WASHINGTON – If the scientists at the US Centers for Disease Control and Prevention had their way, to curb the spread of Covid-19 right now, nearly every US school would cancel football, wrestling, band and loads of other mainstay school activities.
In another piece of guidance, the CDC tells people who’ve recovered from Covid-19 that they can leave their homes after five days — and while they are out and about for the next five days, they should avoid being around more than 80% of the US public.
Dr. William Schaffner, an adviser to the CDC for four decades, said it’s “unlikely, unreasonable, and unrealistic” to think Americans will follow either of the agency’s suggestions.
“Making public health recommendations — they are not a platonic ideal,” Schaffner added. “They have to work in the real world.”
Such out-of-touch advice has been a hallmark of many CDC recommendations long before the pandemic began, and the agency needs to do better, said current and former health officials and physicians who have worked with the CDC on health guidance.
“As we say in Tennessee, that dog won’t hunt,” said Schaffner, an infectious disease expert at Vanderbilt University Medical Center.
Over the past few weeks, the agency has faced criticism for issuing guidance that was confusing or seemed counterintuitive. In this case, the criticism is different; the concern is that CDC staffers, while hardworking, smart, and well-intentioned, don’t always consider whether Americans will — or even can — follow their advice.
CDC Director Dr. Rochelle Walensky was asked about the two pieces of guidance. In a statement, Walensky said the agency “prioritized academics over athletics because of the increased risks involved in some extracurricular sports.? When followed, our school guidance has been incredibly effective.? In the fall, 99 percent of schools were able to remain open during the intense delta wave of COVID.”
Part of the problem, Schaffner and others say, is that CDC scientists are sometimes stuck in a bubble.
“You’ve got nerds — literally science nerds — who are writing these things,” said Dr. Otis Brawley, who worked with the CDC on cancer guidance while he was chief medical officer at the American Cancer Society from 2007 to 2018.
Brawley added, though, that the CDC is often in a tough spot. For example, it’s clear there have been documented Covid-19 outbreaks among choirs, and so on the one hand, it makes sense to advise schools to stay away from singing. But on the other hand, it’s unrealistic to think that schools would cancel band, choir and school musicals now or at any other period of high transmission.
“I really feel for the people at the CDC,” he said. “They’re damned if they do, and they’re damned if they don’t.”
CDC’s school guidance
As part of its guidance last updated on January 6, the CDC advised schools to “cancel or hold high-risk sports and extra-curricular activities virtually” any time a community has a “high” Covid-19 transmission rate.
The guidance links to a CDC map that indicates more than 99% of US counties are currently experiencing high transmission.
The CDC gives football and wrestling as examples of high-risk sports and says that “high-risk extracurricular activities are those in which increased exhalation occurs, such as activities that involve singing, shouting, band, or exercise, especially when conducted indoors.”
Paul Imhoff, president of The School Superintendents Association, said while schools have gone to great lengths to curb the spread of Covid-19, he doesn’t know of any schools that have cancelled activities such as football or band or choir. Such activities, he said, are “important to students’ mental health.”
“As schools are making decisions about having choir and band and wrestling, it’s about making sure our kids are healthy in every way. I think everyone’s doing their best to take care of the whole child,” said Imhoff, a school superintendent in Ohio.
In her statement, Walensky said the CDC “developed our school guidance knowing school administrators, teachers and parents were looking to us at CDC to get their children back in the enriching environment of the classroom and it was a priority to get our children back to school safely,” adding that “vaccines are available for school-aged children, which adds another layer of protection and enhances the school guidance.”
At a January 7 media briefing, Greta Massetti, chief of the CDC’s Field Epidemiology and Prevention Branch, said the guidance was “intended to really protect that critical in-person learning time.” She added that the guidance “is really one piece of a layered prevention strategy that schools can use. CDC continues to recommend layered prevention, including universal masking, including screening, testing, and a variety of other strategies.”
Schaffner, however, questioned why the CDC would advise schools to cancel extracurriculars that involve shouting when children shout on a regular basis.
“I could take you by the hand and say, ‘let’s walk through three grammar schools.’ What we’d see is kids shouting in the hallways. That’s what kids do,” said Schaffner, a liaison representative to the CDC’s Advisory Committee on Immunization Practices.
CDC’s isolation guidance
In its isolation and quarantine guidance, which was last updated January 9, the agency tells people that if they have Covid-19, they should isolate themselves for five days following the onset of symptoms or a positive test. After that, they can end isolation if they’re fever-free without the use of medication and other symptoms have improved.
That advice links to a CDC page that lists conditions that make people more likely to become severely ill with Covid-19. Many of the conditions are very common, such as being overweight or suffering from depression, certain heart conditions or cancer.
The Computational Epidemiology Lab at Boston Children’s Hospital estimates that more than 80% of Americans have at least one of the conditions on the CDC’s list, according to an analysis the group did.
Schaffner questioned the practicality of avoiding 80% of the people around you.
“How do you know if people have heart conditions or diabetes? How are you supposed to figure that out? Can you recognize everyone who is pregnant or has sickle cell or are former smokers?” he said, naming some of the conditions on the CDC’s list of whom to avoid.
When asked about the advice at the briefing, Walensky said the agency was asking people to “avoid your family members or others who might be immunocompromised, avoid visiting grandma or a nursing home.”
‘Round, red tomatoes’
When considering the CDC’s school and isolation guidance, Glen Nowak thinks back to a foodborne illness outbreak that occurred in 2008, while he was the CDC’s head of media relations.
It was unclear exactly what had made people sick, but one of the possible culprits was tomatoes, so Nowak says the agency’s scientists wanted to tell Americans to stop eating tomatoes.
Nowak says he told the scientists that this was quite broad, considering that tomatoes are a very common food. He says he asked his colleagues to be more specific — was there a particular type or source of tomatoes that Americans should avoid?
“I got an answer back — they said ’round, red tomatoes.’ I told them that wasn’t actionable,” Nowak said. The warning about tomatoes was scrapped altogether, and the red round vegetable ended up not being the cause of the outbreak after all — it turned out to be jalapeño and serrano peppers.
Nowak said when he worked at the CDC from 1999 to 2012, scientists repeatedly developed guidance without thinking through the next step: Is it possible to follow the advice we’ve written? If so, what exactly would someone need to do?
“It was a constant challenge. It came up during a lot of circumstances,” said Nowak, co-director of the Center for Health & Risk Communication at the University of Georgia.
“Scientists and experts have a really hard time seeing the world through the lens of everyday people,” he added.
Shifting the lens
One way to shift that lens is to seek input from outside groups, but that’s been more difficult during the pandemic, when the agency has had to move more swiftly. Spokespersons for the superintendents’ association and the National Association of Secondary School Principals said the CDC did not reach out to them to confer about the guidance on school sports and extra-curricular activities.
A federal health official familiar with how the CDC develops its guidelines said the agency should also make better use of its own communication specialists.
“There simply is not a seat at the table for communicators when it comes to actually developing guidance,” the official said, adding that CDC communication specialists would “take into account whether the guidance that’s being developed is truly practical.”
The official asked to speak anonymously because they were not authorized to speak on this issue.
Brawley noted that the pandemic has posed unusual challenges when issuing guidance.
He said under normal circumstances, experts will first gather all the relevant studies on a particular topic and then debate — sometimes for months — what the best advice to the public would be, and also consult outsiders to get their input.
“When I was at the American Cancer Society, when we sat down to write lung cancer guidelines, it took a group of 14 people almost a year to come up with the wording. And then we tested the wording on focus groups, working with doctors and nurses and lay people to try to figure out if we were communicating effectively,” he said. “The CDC doesn’t have time to do that.”
Brawley, now a professor at Johns Hopkins University, said there’s an alternative to the way CDC issued their guidance. For example, if schools aren’t ready to cancel football or choir, then the CDC could just explain that those are high-risk activities, without directly advising against them.
He said it would be important to explain the research that shows these are high-risk activities, something the CDC doesn’t do on their site now.
“I would put in the studies, because I have a sense that a large part of the American lay population doesn’t appreciate how we come up with these rules. This isn’t just a couple of people in Atlanta making these up in their offices at the CDC. The rules are based on real observations in real populations,” he said.
But he added that the CDC still would likely come under fire for its guidance, at least from some people.
“There’s no way the CDC can win,” he said.
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