Next Steps: The Road Ahead for the COVID-19 Response

Senate Health, Education, Labor, and Pensions Committee

Witness: Rochelle P. Walensky, MD, MPH

Chair Murray, Ranking Member Burr, and distinguished members of the Committee, it is an honor to appear before you today to discuss the Centers for Disease Control and Prevention’s (CDC) ongoing response to the COVID-19 pandemic. It is my privilege to represent CDC, America’s health protection agency. We work 24/7 to prevent illness, save lives, and protect America from threats to health, safety, and security. CDC is proud of its key role in preparedness and response to public health concerns here in the United States and abroad.

Beginning in July 2021, we witnessed steep increases in COVID-19 cases, hospitalizations, and deaths around the nation, due to the spread of the Delta variant. However, in recent weeks we have begun to see a decrease in the numbers in all three of these indicators in nearly all jurisdictions. Yet, as we enter flu season, which has the potential to be severe in part due to reduced population immunity from decreased flu circulation in the last year and a half, and approach the winter holidays, it is as important as ever that we continue to be diligent in vaccination for both flu and COVID-19, masking, and other mitigation efforts to continue the positive trends of these indicators.

We have made incredible strides in vaccinating the U.S population. As of November 1, 2021, about 97.4% of the United States population 65 years and older, 80% of those 18 years and older, 78.1% of those 12 years and older, and nearly 66.8% of the total United States population received at least one dose of a COVID-19 vaccine. These gains are thanks to the tireless efforts of professionals from across the public health, medical, business, and multisectoral levels of government and trusted community leaders who have come together across the country to respond to this pandemic.  But there is still more work to be done to combat the threat of COVID-19.

Where people remain unvaccinated, communities remain vulnerable. We know that those who are unvaccinated have a more than ten-fold greater risk of death than those who are vaccinated. With vaccines readily available across the country, the suffering and loss are nearly entirely avoidable. These vaccines are safe and effective, and high rates of vaccination protect individuals, families, and communities from severe disease, hospitalizations, and death from COVID-19.

While the Delta variant is currently responsible for more than 99 percent of new cases, CDC continues to monitor all variants circulating in the United States to improve our understanding of the evolution of SARS-CoV-2 and the impact of emerging variants on critical medical countermeasures, including vaccines and treatments. A strong genomic surveillance infrastructure enables rapid detection of emerging variants and timely sharing of data and information to support public health decision making at all levels. CDC continues to work closely with public health laboratories across the United States to strengthen genomic sequencing and bioinformatics capacity as an integral component of our public health system.

Vaccination remains a safe and highly effective tool in bringing this pandemic to an end. CDC is constantly monitoring emerging data on the transmission of SARS-CoV-2 and vaccine effectiveness, including against hospitalization, severe illness, and death. While breakthrough cases are expected to occur, COVID-19 vaccines continue to be highly effective, and there is clear evidence that vaccination results in less severe illness, fewer hospitalizations, and fewer deaths. In August 2021, data showed that people who were unvaccinated had 6.1 times greater risk of testing positive for COVID-19 and 11.3 times greater risk of dying from COVID-19 than people who were fully vaccinated.

CDC closely monitors and regularly updates data on COVID-19 vaccine effectiveness for duration of protection, level of protection against variants by risk groups, and infection and severe disease or hospitalization. With the emergence of Delta as the predominant variant circulating in the United States, and as the duration since vaccination increases, we have seen some decrease in vaccine effectiveness against infection. However, there has been little change in vaccine effectiveness against hospitalization and death, for which vaccines remain strongly protective. For example, a recent study found that even though COVID-19 vaccines offer less protection against infection with the Delta variant than previous variants, people not fully vaccinated still had almost five times the risk of getting infected when compared to fully vaccinated people.

CDC has a comprehensive strategy for monitoring all aspects of breakthrough infections and illness, a strategy that was implemented at the time that COVID-19 vaccination began in the United States. Immediately after the introduction of the vaccine, national case surveillance was an important component of CDC’s strategy to rapidly identify cases of breakthrough illness. These data continue to be monitored to identify signals for unexpected presentations of infections or illnesses in vaccinated persons. States continue to report these data to CDC; however, this system does not answer all of the questions we and our public health partners in the field have about vaccine effectiveness. For example, it does not capture many of the breakthrough infections that are asymptomatic or mild and that do not require medical attention.

In addition, case surveillance alone does not provide enough data to understand the clinical spectrum and severity of breakthrough disease. To fully monitor and investigate all aspects of breakthrough infection, including breakthrough cases that do not lead to hospitalization, CDC uses enhanced surveillance and vaccine effectiveness study platforms that can more fully detect and describe the frequency of mild cases as well as severe cases, and that can track whether these variables are changing over time. CDC is collaborating with multiple states to link immunization records to case reporting, so as to compare the incidence of infections among the vaccinated with the incidence among those who are unvaccinated. Both case surveillance and these study platforms allow CDC to continuously monitor and provide updated information on breakthrough infections and vaccine effectiveness on the CDC COVID Data Tracker Website. In addition to monitoring vaccine effectiveness, CDC is reviewing data as they become available to compare infection induced immune responses with vaccine induced immune responses and their protection against reinfection, breakthrough infections, and variants.

Having data that show continued vaccine effectiveness is an important tool in our efforts to build vaccine confidence. CDC created the Vaccinate with Confidence strategic framework to build trust, empower healthcare workers, and engage communities and individuals. CDC publishes numerous resources online to increase vaccine confidence, including information on how to address misinformation and tailor messaging for specific audiences. CDC also advances vaccine equity by funding a wide variety of partners who vaccine confidence among racial and ethnic minority groups and in rural communities.

One example of why CDC’s vaccine confidence building work is so critical is reflected in our efforts to increase vaccine uptake during or prior to pregnancy. The accumulating evidence has shown that infection during pregnancy can be dangerous both to the pregnant person and to the child, and that COVID-19 vaccines are safe in those who are pregnant or are considering pregnancy. Despite the proven benefits of vaccination, as of October 21, 2021, only 34.6 percent of those who are pregnant have been fully vaccinated either during pregnancy or prior to getting pregnant, and the data are even more alarming in Black and Hispanic populations, where only 19.2 and 30 percent of pregnant people are vaccinated, respectively. This leaves far too many people at risk of severe illness, adverse pregnancy and neonatal outcomes, and death from COVID-19. CDC is assessing reasons for vaccine hesitancy in these and other disproportionately affected populations, and CDC is disseminating safety information rapidly and broadly on our website, through social media, and our partners to increase vaccine confidence across the United States.

Following the meetings of the Food and Drug Administration’s (FDA) Vaccines and Related Biological Products Advisory Committee (VRBPAC) and of CDC’s Advisory Committee on Immunization Practices (ACIP) in September and October, CDC recommended booster doses of the Pfizer, Moderna, and Janssen vaccines for certain populations. Before making these decisions, CDC carefully examined the latest data and conducted robust discussions around booster shots.

The data show vaccines generally remain effective in preventing hospitalization and severe disease in the United States. Still, recent evidence suggests they are less effective in preventing infection or milder symptomatic illness due to waning immunity over time, and in the setting of the more highly transmissible Delta variant. Emerging evidence shows that vaccine effectiveness against COVID-19 infections is decreasing over time, including among healthcare and other frontline workers. Booster shots will help provide continued protection against severe disease in those populations who are especially at risk for severe COVID-19. It is important to note, that even with boosters, we expect to continue to see some breakthrough cases, and we are well equipped to monitor these post-booster vaccination breakthrough cases using the same surveillance systems we currently have in place.

Booster shots are currently available at many local retail pharmacies and from other healthcare professionals enrolled in the CDC COVID-19 Vaccination Program. In addition, CDC has launched the Federal Long-Term Care COVID-19 Vaccine Access Campaign to support any long-term care setting that requests assistance with accessing COVID-19 vaccine boosters for their residents and staff.

Unfortunately, from June to August of this year, the case rate among children increased ten-fold, and hospitalization rates among children increased almost 400% from June 25, 2021, to September 11, 2021, although it has declined to an increase of 101% as of October 30, 2021.

Tragically, hundreds of children have died, including nearly 100 elementary school aged children 5 – 11. It is important to recognize that even cases that do not result in severe illness or death can be devastating, so it remains critical that we continue with our prevention efforts and quickly scale up vaccination for eligible children.

The data are clear that vaccination is as effective at protecting children as it is at protecting adults. Data from August 2021 showed that rates of COVID-19–associated emergency department (ED) visits and hospital admissions for children and adolescents with confirmed COVID-19 were highest in the states with lowest vaccination coverage, whereas in the states with the highest coverage, COVID-19 ED visits and the rate of hospital admissions among children and adolescents were lowest. Vaccinating eligible adults and children against COVID- 19 remains the most effective prevention strategy to help schools safely maintain full-time in- person learning as well as extracurricular activities and sports. CDC’s ACIP met on November 2, 2021 to review data on safety and effectiveness of the Pfizer-BioNTech vaccine for children ages 5 to 11 years old. I am so pleased to report that CDC now recommends the vaccine for this population, and we have been hard at work to plan for possible distribution of these childhood vaccines so we will be ready to put shots in arms right away.

Testing is an integral part of our strategy to make schools safe. Screening testing identifies infected people, including those without symptoms who may be contagious, so that measures can be taken to prevent further transmission. A modeling study found that weekly screening testing of students, teachers, and staff can reduce in-school infection by an estimated 50 percent. Another study found that, among five programs with regular screening testing (at least weekly) of most students and staff in the fall of 2020, one-third to two-thirds of total COVID-19 cases identified in the schools were found through screening.¹ “Test to stay” is a practice comprised of regular testing and contact tracing to allow close contacts to remain in the classroom, while maintaining other layered prevention strategies, such as universal masking, to reduce the spread of COVID-19. CDC views “test to stay” as a promising practice, and we are working with multiple jurisdictions to evaluate the effectiveness of this approach. When all of this is done in coordination with other prevention measures—such as universal and correct indoor masking — the results are clear: schools can safely provide in-person learning. To support these efforts, in April, CDC provided $10 billion for screening testing to help schools reopen safely, and more than $2 billion to scale up testing in underserved populations.

CDC is leading two additional activities to improve testing: (1) Operation Expanded Testing is focused on school-based testing for K-12 students and on supporting testing for students and staff at Historically Black Colleges and Universities, and (2) Increased Community Access to Testing aims to improve access to testing in communities at increased risk of COVID- 19and provide surge capacity during times of sudden increase in testing demand.

On September 24, CDC published three reports highlighting the importance of COVID- 19 prevention measures in schools to protect students, teachers, and staff and keep schools open. The first report showed schools without in-school mask requirements were 3.5 times more likely to have a COVID-19 outbreak than schools with an in-school mask requirement.² The second report showed that while 96 percent of schools have offered in-person learning during the 2021- 2022 school year, COVID-19 continues to cause disruptions (e.g., closures due to COVID-19 outbreaks) that have affected more than 900,000 students.³ The third report showed that counties without school mask requirements experienced larger increases in pediatric COVID-19 case rates after the start of school compared with counties that had school mask requirements.⁴ These findings reinforce the importance of following CDC guidance to limit the spread of COVID-19 in K-12 schools, including universal mask wearing indoors; vaccinating all eligible students, teachers, and staff; improving ventilation; testing; physical distancing; and cohorting people into small groups to limit the number of students, teachers, and staff that come in contact with each other.

The COVID-19 pandemic has further brought social and racial injustice and inequity to the forefront of public health. While in the early stages of the pandemic, significant percentages of COVID-19 case reports lacked race and ethnicity information, we have since made significant progress, and as of early October we now have race information for 3 out of 4 COVID-19 cases (75%) and ethnicity information for 2 out of 3 (67%) cases. Our National Vital Statistics System captures race and ethnicity data for more than 99% of COVID-19 deaths; CDC’s enhanced hospitalization surveillance system, COVID-NET, includes these data more than 98% of the time; and cumulative race and ethnicity completeness in CDC’s National Syndromic Surveillance Program for emergency departments stands at 92% and 82%, respectively. The result is a layered surveillance approach that includes robust and dynamic data on multiple aspects of the pandemic, yielding actionable information on health disparities and equity to inform the nation’s response.

Data continue to show the disproportionate impact of COVID-19 on racial and ethnic minority populations, as well as other population groups, such as people living in rural or frontier areas, people experiencing homelessness, pregnant people, essential and frontline workers, people with disabilities, people with substance use disorders, people who are incarcerated, and non-U.S.-born persons.

CDC has released several studies examining vaccination rates in certain population groups to monitor disparities and track progress towards health equity. The research highlighted the hidden and ongoing additional tragedies and disparities that both fueled and are the result of the COVID-19 pandemic.

For example, a study that used data from CDC’s Vaccine Safety Datalink (VSD) from December 2020 through May 2021 found that vaccination coverage among racial and ethnic groups was highest in non-Hispanic Asian and non-Hispanic White persons and lowest in Hispanic and Black persons. Last month, CDC released a study that found COVID-19 vaccination coverage was lower among United States adults with a disability than among those without a disability, even though adults with a disability reported less hesitancy to getting vaccinated. However, adults with a disability anticipated or experienced more difficulty obtaining a COVID-19 vaccination than did those without a disability. Further, CDC released a study in October 2021 on COVID-19 related orphanhood. Approximately 1 out of 500 children in the United States has experienced COVID-19-associated orphanhood or death of a grandparent caregiver. Children who are members of racial and ethnic minority populations accounted for 65% of those who lost a primary caregiver due to the pandemic, despite being only 39% of the overall US population. Collectively, these findings highlight the need to continue monitoring demographic and social factors affecting vaccine access and to prioritize efforts to ensure equitable access to vaccines.

These data indicate that additional work lies ahead to achieve greater and more equitable vaccination rates in certain population groups. CDC continues to collaborate closely with state, local, tribal, and territorial partners to address these disparities. The Federal Retail Pharmacy Program has helped to increase COVID-19 vaccination coverage in communities across the country. As of October 27, 2021, more than 152 million doses have been administered and reported by retail pharmacies in the United States, which includes approximately 8 million doses administered through the Pharmacy Partnership for Long Term Care Program. Overall, 44 percent of the doses administered through the program have gone to a person from a racial or ethnic minority group (among people with known race or ethnicity).

CDC is also partnering with the Health Resources and Services Administration (HRSA) to accelerate direct distribution of COVID-19 vaccines in select HRSA-funded federally qualified health centers (FQHCs) to ensure under-resourced communities and disproportionately affected groups are equitably vaccinated. As of October 27, 2021, more than 21 million doses have been delivered to over 1,400 health centers.

In addition to publishing and disseminating State of Vaccine Confidence Insights Reports biweekly,⁵ CDC is providing financial and technical assistance to state, local, territorial and community-based partners to increase the percentage of all US residents who are fully vaccinated regardless of race/ethnicity, income, place of residence, or other social factors. To support the work of health departments and community organizations across the United States, CDC published the COVID-19 Vaccination Field Guide, which outlines selected strategies to help increase vaccine confidence and uptake and which includes examples from communities currently using these strategies. The evidence-based strategies address common barriers to getting a COVID-19 vaccine, which are structural, behavioral, or informational.

CDC continues to add functionality and additional information to our COVID Data Tracker. This includes the COVID Data Tracker Health Equity Data page, launched earlier this year, which presents CDC’s health equity-related data relevant to selected populations and place- based groups identified in the CDC COVID-19 Response Health Equity Strategy. Over the summer of 2021, CDC made updates to the Data Tracker to provide more detailed insights related to race, age, gender, disability, pregnancy, and more for cases, death, and vaccination coverage, including vaccine confidence. CDC remains committed to conducting all our work through a lens of health equity.

In closing, I want to emphasize that despite the current downward trend in cases, hospitalizations, and deaths, we must stay diligent with our mitigation efforts. As the holidays approach, these strategies and tools will allow us to look forward to being with our families and to connect with one another safely, but we must all do our part. I urge our nation to prepare for the upcoming flu season by getting the flu shot, and if you haven’t already, by getting the COVID-19 vaccine. Those who are eligible should also get their COVID-19 booster. For convenience, people can ask their provider to get both shots, flu and COVID-19, at the same time. Vaccination remains one of the best tools we have to end this pandemic. It will require sustained efforts from all stakeholders and across all levels of government and most importantly individuals making the decision to get vaccinated to protect themselves, their loved ones, and their communities. We are at a critical juncture in the response. If we all commit to sustaining the proven mitigation measures that we know work, we can save thousands of lives and return to more of a sense of normalcy in our school, work and communities.

Lastly, we also must continue to focus on how we can better prepare for the future. We must make investments now to address the long-standing vulnerabilities in our public health system and the conditions that led to disproportionate burden of COVID-19 illness and death in some communities. I am committed to working with Congress to find common ground to support our public health system to make meaningful strides toward achieving health security for all Americans.