A Blog by Jonathan Low


Aug 4, 2021

Are the CDC's Confusing Communications Contributing To Vaccine Hesitancy?

The CDC has failed to take a strategic approach to communications about the pandemic, responding to events through multiple spokespeople and too frequently changing its guidance. 

It's task has been made more difficult by the efforts of right wing politicians and media to undermine anti-Covid initiatives in hopes of weakening the current administration. But until the agency establishes a longer term focus on how to communicate what it is doing and why, its changes of direction will cause the public to tune out its messages, making them more susceptible to misinformation. JL 

Zeynep Tufekci comments in the New York Times:

A pandemic is a communications emergency as much as a medical crisis. Effective communication (means): Avoid sending mixed messages from multiple experts, releasing information too late, taking paternalistic attitudes, failing to counter rumors and myths in real time, engaging in public power struggles causing confusion. Epidemics spread exponentially, so delayed responses make problems worse. If the response to a crisis comes after many are already aware of it, it leaves them confused if they look to the C.D.C. for guidance, and vulnerable to misinformation if they do not.

“Be first, be right, be credible,” are among the most important principles for health authorities to follow in a crisis, the Centers for Disease Control and Prevention shared in a pamphlet on crisis communication in 2018.

To meet those goals, the report advises, avoid sending mixed messages from multiple experts, releasing information too late, taking paternalistic attitudes, failing to counter rumors and myths in real time and engaging in public power struggles and causing confusion.

Last week, as agency officials announced new mask guidelines and set the nation on edge, I had to wonder if they had swapped their “do list” and their “avoid list.”

The C.D.C. faces three major problems.

The first is reality: a sustained campaign of misinformation against vaccines and other public health measures, originating mostly with right-wing commentators and politicians, and a new media environment that has upended traditional information flows.

Second, the C.D.C. is still mired in the fog of pandemic, with too little data, collected too slowly, leaving it chasing epidemic waves and trying to make sense of information from other countries. Epidemics spread exponentially, so delayed responses make problems much worse. If the response to a crisis comes after many people are already aware of it brewing, it leaves them confused and fearful if they look to the C.D.C. for guidance, and vulnerable to misinformation if they do not.

Third, the agency is simply not doing a good job at what the pamphlet advises: being first, right and credible, and avoiding mixed messaging, delays and confusion.

It’s hard not to have sympathy for its predicament. The previous administration undermined the C.D.C., and anti-vaxxers’ deliberate misinformation assault has not made the agency’s job any easier. The digital public sphere operates fast and furious, and that’s difficult for traditional institutions to keep up with or to counter.

All this makes it even more important that the C.D.C. properly handle what’s under its control.

The response to the Delta variant has been too slow. Data from other countries made it clear months ago that it posed a great threat. Unfortunately, the United States already doesn’t collect the kind of systematic data needed on many important indicators. Making things worse, in early May, the C.D.C. stopped tracking breakthrough infections among the vaccinated unless they were hospitalized or worse, even though the reason for continued surveillance is to see and understand changes in an outbreak as early as possible.

June passed with little change in the government’s response, despite multiple technical papers from Public Health England showing that the Delta variant was much more transmissible and possibly more severe, and that it was able to cause more breakthrough infections among the vaccinated. Detailed contact tracing from Singapore also showed that some of the vaccinated were transmitting. It was clear something had changed. Severe outbreaks were occurring wherever Delta swept through, leaving millions dead in countries with few vaccinated people, and increasing caseloads and hospitalizations even in countries with substantial vaccination levels.

Throughout June and July, I felt the same out-of-body experience I had in February 2020, when Covid-19 devastated Wuhan and Milan, while Americans acted as if it would somehow miss them.

Even with the natural immunity from previous outbreaks, with less than half the country fully vaccinated at the beginning of this summer, tens of millions of Americans were vulnerable — and the unvaccinated include large swathes of disadvantaged groups, like minorities and working poor, not just ideological anti-vaxxers.

Questions also swirled around how to better protect the immunocompromised and the elderly who can remain more vulnerable even when vaccinated, and how to open schools as safely as possible for children under 12 who cannot be vaccinated.

Yet the government waited to react.

Meanwhile, infections in the United States ticked up as the Delta variant swept through places with fewer vaccinated people. Hospitals were filling up again. The piling up of anecdotes made it obvious that more vaccinated people were getting infected since the variant hit.

How many? How sick? How infectious? What to do? The answers came late, in a trickle and in a manner that was more confusing than illuminating.

On July 21, the White House’s chief medical adviser, Anthony Fauci, told CNBC that Delta was “clearly different” than previous variants, with an extraordinary capacity for transmitting from person to person, and that fully vaccinated people might want to consider wearing masks indoors. However, just one day later, the C.D.C.’s director, Rochelle Walensky, asserted again that wearing masks for the vaccinated was an “individual choice,” saying that the vaccinated enjoyed “exceptional levels of protection.” Then on July 25, Dr. Fauci confirmed that bringing back mask mandates was “under active consideration.

Just two days later, on July 27, Dr. Walensky addressed the issue again, but now with a very different message: Delta was behaving very differently, she said, and the C.D.C. was now recommending even the fully vaccinated wear masks indoors in public places wherever transmission rates were “substantial.”

All this was fairly confusing for the public especially since it was already many weeks after the agency should have reacted. A pandemic requires a forceful, quick, clear and unified response from public health authorities.

In announcing changes in mask recommendations Dr. Walensky notably said that vaccinated people who became infected had viral loads similar to those of unvaccinated people who got sick, and could “forward transmit with the same capacity as an unvaccinated person.”

That vaccinated people with breakthrough infections could sometimes transmit the virus wasn’t particularly surprising given the data and anecdotes that had accumulated. However, that they had “the same capacity” to transmit it as an unvaccinated person certainly was, including to many experts. It was the kind of claim that was clearly going to alarm tens of millions of vaccinated people, and needed to be delivered with maximum clarity and context.

Instead we got a stark lesson in how not to communicate.

First, the data that the C.D.C. said it based its decision on wasn’t released right away — leaving both experts and ordinary people to try to piece together what was being said.

The Associated Press, on the same day as Dr. Walensky’s news conference, quoted her as saying the level of virus in infected vaccinated people was “indistinguishable” from the level of virus in the noses and throats of unvaccinated people. The news report also noted that the data the C.D.C. had based its new decision on was unpublished, and had “emerged over the last couple of days from over 100 samples from several states and one other country.”

Which ones and where?

The updated C.D.C. guidelines pointed to a single reference on this question, which was a preprint looking at health care workers in India who became infected after receiving vaccines not approved for use in the United States. In many studies, viral load is ascertained through examining a measure from PCR testing called the cycle threshold or CT. While useful, because the cycle threshold is a proxy and a snapshot, it needs to be interpreted with caution. Still, the study from India wasn’t even between those who were vaccinated and those who were not, but among vaccinated workers infected with different variants. That the more transmissible Delta had a higher viral load than other variants had already been reported.

Two days later, based on slides leaked from the C.D.C. and a federal health official who spoke on condition of anonymity, The Washington Post reported that the American outbreak that the agency used to base its new guidelines on was in Provincetown, Mass.

Finally, on July 30, the C.D.C. released its epidemiological study of the Provincetown outbreak.

In a seashore town with about 3,000 residents, the vast majority of whom were vaccinated, and 60,000 summer visitors, the C.D.C. noted more than 450 infections between July 3 and 17. Health officials later traced more than 960 cases to gatherings in Provincetown. Attendees said it rained a lot during those two weeks, driving more people to crowded, poorly ventilated bars and restaurants, probably worsening the spread.

The data showed what had been documented elsewhere: Delta was sometimes able to infect the vaccinated, although there were only seven hospitalizations and no deaths. Most common symptoms were cough, headache, sore throat.

The cycle threshold numbers among vaccinated and unvaccinated cases were indeed similar, suggesting similar viral loads — at least when the test was taken. However, since there was no follow-up to measure actual transmission events it was unclear how much the vaccinated contributed to the spread. Or did the unvaccinated infect most people in the outbreak, including the vaccinated? It is also hard to draw broader conclusions from such nonsystematic and limited data. People who get tested are likely to be more sick, for example, so they probably have higher viral loads to begin with, and thus are probably not fully representative of those who are vaccinated but infected. All this means that the cycle threshold value may be useful, but it’s just one piece of the puzzle without contextual data — suggestive but not conclusive.

On July 31, a more systematic study from Singapore showed that viral load from Delta could get high but that it quickly peaked and then crashed in breakthrough cases among the vaccinated — as their immune system responded to quickly clear the virus. The potential infectious period lingered much longer in the unvaccinated.

The Provincetown study was certainly useful. It provided one more example of how well the vaccines worked in preventing severe disease or worse, but also of the need to take Delta seriously: to expand vaccine mandates, speed up formal approval of vaccines, work hard at increasing vaccinations and urge the use of masks for everyone, especially in crowded, poorly ventilated indoor spaces in areas where infections are high and vaccinations are low.

However, by itself, the study should not have been presented as the primary cause for the alarm it set off, and the public certainly should not have been left waiting many days for the data itself while details leaked out in dribs and drabs, often through anonymous sources.

Some in the administration lashed out at the media coverage of it all. Administration officials, again anonymously, said they were worried that this might contribute to vaccine hesitancy by making it sound as if vaccines don’t make a difference.

I’ll be first to say that the media can and should do a better job. But the administration’s job is to make sure the message they send is clear, timely, loud and unified, not just to get angry at factors beyond their control.

How else could this have played out? Ideally, with better data and earlier response. The C.D.C. should start tracking more breakthrough cases, and do much more systematic data collection including cluster and contact-tracing while the pandemic continues to rage. Yes, such infrastructure cannot be built overnight, but we have to start from where we are.

The C.D.C. also needs to better take into account the sociological effects of its guidance. Recently, Dr. Walensky attributed the current rise in infections to the unvaccinated, saying: “Unvaccinated people took off their masks as well. And that’s what led us to where we are today.” However, as many pointed out at the time, those who are not eager to get vaccinated were not going to be eager to keep on their masks. And a grocery store or a club cannot be expected to enforce masking selectively, so the practical effect of that guidance change was to undermine masking in general. Getting mad at the public for not following public health advice might be understandable at the individual level, but the agency should focus on how to broaden trust and facilitate better behaviors for everyone.

The nation should have waited a bit more before lifting indoor mask guidelines, tying changes to concrete benchmarks like vaccination and infection rates, especially given the vulnerability of the immunocompromised and children who are ineligible for vaccination.

Most important, the C.D.C. can follow the principles it espouses — organize and coordinate the release of information, back up recommendations with solid research, and move as quickly as possible to respond to crises. The C.D.C. should have news conferences weekly, or even a few times a week, with a consistent spokesperson and a team of experts to answer technical questions. If officials feel the media has been misleading, then they should quickly hold a news conference and explain why.

The Epidemic Intelligence Service unit of the C.D.C. has a core principle that needs to remain at the forefront of everything the administration does: A pandemic is a communications emergency as much as it is a medical crisis. Effective communication is much more than choosing the right words. It needs a wholesale approach starting with clarity of purpose, a realistic assessment of where things are including factors outside the agency’s control, collection and presentation of detailed data when possible and an open acknowledgment of uncertainty and underlying reasoning when precautionary steps are being advised. The agency must have a laser focus on what it can do with what it has, despite the challenges, rather than looking for justifications for what doesn’t work well — even if those exist. So remember, C.D.C.: Be first, be right and be credible. The conditions may not be ideal, but that’s the job.


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