Protecting the Editorial Independence of the CDC From Politics | Global Health | JAMA | JAMA Network
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Viewpoint
September 22, 2020

Protecting the Editorial Independence of the CDC From Politics

Author Affiliations
  • 1Departments of Pediatrics, Obstetrics and Gynecology, and Epidemiology, University of Florida College of Medicine and College of Public Health and Health Professions, Gainesville
  • 2Coalition for Global Hepatitis Elimination Task Force for Global Health, Decatur, Georgia
  • 3Department of Family and Preventive Medicine, Emory University School of Medicine, and Emory Rollins School of Public Health, Atlanta, Georgia
JAMA. Published online September 22, 2020. doi:10.1001/jama.2020.19646

Beginning September 11, 2020, media sources reported that political appointees within the US Department of Health and Human Services (HHS) have demanded the ability to review and revise scientific reports on the coronavirus disease 2019 (COVID-19) pandemic published in Morbidity and Mortality Weekly Report (MMWR), published by the Centers for Disease Control and Prevention (CDC).1,2 According to these sources, reviews by political appointees have sometimes led to delays in publication and changes in language in certain reports. Whether this is true is unclear, but these reports are consistent with other reports of the actions of political appointees and their attempts to influence the scientific process.3 As former editors in chief of MMWR, we believe these media reports raise serious concerns that in the midst of the COVID-19 pandemic, scientific reports published in MMWR might have been delayed or altered for political purposes. These concerns threaten the credibility of MMWR, an essential source of information to help counteract the pandemic.

Since 1961, when CDC began publishing MMWR, the publication has been considered to be the “voice of CDC,” with a focus on communicating timely, authoritative, accurate, and objective scientific reports to guide public health action. The publication has broad readership including public health practitioners, epidemiologists, physicians and other health care professionals, other scientists, educators, and laboratory workers, among others. MMWR reports are also closely followed and amplified by the news media. In addition to reports published weekly, CDC releases MMWR reports on an urgent basis for immediate dissemination of information on disease outbreaks and other health threats. MMWR also publishes comprehensive articles that delineate CDC science-based recommendations for prevention and treatment, including recommendations from the Advisory Committee on Immunization Practices (ACIP), an external federal advisory committee of experts that provides recommendations to CDC regarding vaccines.

As with all scientific manuscripts authored by CDC professionals or published by CDC, submissions to MMWR undergo a rigorous internal peer review clearance process by epidemiologists, laboratorians, and other technical experts.4 The goal of this process is to ensure that the content incorporates relevant input from experts across the agency and is scientifically valid and technically accurate.5 The extent of this internal review process depends on the range of issues covered, the complexity of the science, and the potential effects of the findings. Typically this process takes about 4 weeks,5 although it is expedited when urgent release of a report is needed.

MMWR serves a critical role in providing up-to-date information during the COVID-19 pandemic. This is consistent with the role it has had during previous public health crises.6 For example, in 1981, a report of 5 cases of Pneumocystis carinii (now P jiroveci) pneumonia among previously healthy young men in Los Angeles was published in MMWR, which prompted reporting of additional cases and subsequent identification of AIDS. In 2001, following intentional exposures to anthrax sent through the mail, MMWR was used to update health care clinicians and organizations, public health professionals, and the public regarding the investigation and guidelines for clinical diagnosis and management. In 2003, when the virus causing severe acute respiratory syndrome (SARS) emerged and spread throughout the world, MMWR published reports that alerted the nation to the course of the epidemic, clinical manifestations, diagnostic testing, and methods to prevent transmission.6 During 2016-2018, MMWR reported the emergence of the Zika epidemic in the Americas with guidance for obstetricians and pediatricians for care of Zika-exposed pregnant women and their infants.7

MMWR is highly cited in the medical literature: in 2019, MMWR weekly had the highest number of citations of any journal in the epidemiology category, according to Google Scholar, and the MMWR series has a 2019 journal impact factor of 13.6. In addition, commentaries on MMWR articles of prime interest are often published in leading journals.8

Large disease outbreaks usually generate high levels of public concern, including among elected officials and their staff. Thus, HHS and others in the executive branch frequently have a keen interest in MMWR articles. Many controversial and sensitive issues have been published in MMWR, including HIV, anthrax, SARS, Ebola, and Zika. To address the administration’s interest at the time of those publications, CDC has shared the topics of upcoming reports with health officials in HHS; however, the actual reports were not reviewed or shared outside of CDC. During the 20 years of collective experience of the authors of this Viewpoint and spanning 5 presidential administrations, CDC leadership maintained a stringent firewall to ensure MMWR editorial independence and to guard against political interference. Decisions about what to publish and when were based on the science and public health needs. Thus, while the science of public health is essential for informing decisions of elected officials, it has long been recognized that for the scientific reports of MMWR to be respected and trusted, they must be free of political influence.

Whether the allegations regarding political appointees delaying or altering MMWR articles are true is unknown. However, even the perception that MMWR reports could be delayed or altered for political purposes is damaging to the reputation of CDC. These allegations could undermine the confidence of readers in the scientific integrity of MMWR reports that are relied on by large audiences in the US and globally. At a time when the scientific integrity in government health agencies has been questioned,3 MMWR needs to remain a trusted venue for publication. Preservation of MMWR as an essential source of information for public health action has important implications for the COVID-19 epidemic. Once COVID-19 vaccines are licensed by the US Food and Drug Administration (FDA), official recommendations for their use developed by the ACIP are expected to be published in MMWR, as they were during the 2009 H1N1 influenza pandemic.9 Any perception that these recommendations are inappropriately influenced by political considerations—or any other considerations aside from scientific evidence—could hinder delivery of COVID-19 vaccines by clinicians and acceptance of vaccines by the public.

To address the COVID-19 epidemic and other threats to the nation’s health, prompt action is needed. First, HHS leadership, not just CDC staff, needs to affirm its commitment to preserving the integrity of CDC science, including publications in MMWR. Second, CDC leadership can review and, when indicated, strengthen measures for ensuring the editorial independence of MMWR to prevent future political interference. Third, the MMWR editorial board, a highly respected group of experts in medicine and public health, can assist in these efforts by reviewing these measures and advising additional options to ensure the continued quality and scientific integrity of MMWR.

The COVID-19 pandemic has placed great demands on local, state, and federal public health officials and on health care systems. Health professionals and the public they serve deserve information from CDC based on the best available science. For nearly 60 years, MMWR has served as a trusted source of public health information. Now more than ever, it is imperative to ensure that the public’s trust in MMWR as the voice of CDC is maintained.

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Article Information

Corresponding Author: Sonja A. Rasmussen, MD, MS, University of Florida, 1600 SW Archer Rd, PO Box 100296, Gainesville, FL 32610 (sonja.rasmussen@peds.ufl.edu).

Published Online: September 22, 2020. doi:10.1001/jama.2020.19646

Conflict of Interest Disclosures: Dr Rasmussen reports serving as an unpaid guest researcher at the CDC and also receives NIH and CDC funding for unrelated work. Dr Ward reports receiving NIH funding for unrelated work. Dr Goodman reports receiving grants and personal fees from CDC and HRSA funding for unrelated work; and owns stock in Johnson & Johnson; Procter & Gamble; and Merck & Company.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent those of any institutions with which they are currently or have been formerly affiliated.

Additional Contributions: We acknowledge Mary Lou Lindegren, MD, MPH, San Diego, California, for helpful comments on earlier versions of the manuscript.

Additional Information: The authors served as editors in chief of MMWR: Dr Rasmussen from 2015 to 2018, Dr Ward from 1998 to 2005, and Dr Goodman from 1988 to 1998.

References
1.
Diamond  D. Trump officials interfered with CDC reports on Covid-19. Politico. Published September 11, 2020. Accessed September 15, 2020. https://www.politico.com/news/2020/09/11/exclusive-trump-officials-interfered-with-cdc-reports-on-covid-19-412809
2.
Schultz  M. Trump aides review CDC coronavirus reports to better align with president's upbeat messaging: report. Fox News. Published September 13, 2020. Accessed September 15, 2020. https://www.foxnews.com/politics/trump-aides-review-cdc-coronavirus-reports-to-better-align-with-presidents-messaging-report
3.
Goodman  JL, Borio  L.  Finding effective treatments for COVID-19: scientific integrity and public confidence in a time of crisis.   JAMA. 2020;323(19):1899-1900. doi:10.1001/jama.2020.6434PubMedGoogle ScholarCrossref
4.
CDC. Morbidity and Mortality Weekly Report (MMWR) Recommendations and Reports/Surveillance Summaries Instructions for authors. Updated November 8, 2018. Accessed September 16, 2020. https://www.cdc.gov/mmwr/author_guide_rrss.html
5.
Cono  J, Jaffe  H.  The CDC clearance process: supporting quality science.   Am J Public Health. 2015;105(6):e1-e2. doi:10.2105/AJPH.2015.302691PubMedGoogle ScholarCrossref
6.
Shaw  FE, Goodman  RA, Lindegren  ML, Ward  JW; Centers for Disease Control and Prevention (CDC).  A history of MMWR.   MMWR Suppl. 2011;60(4):7-14.PubMedGoogle Scholar
7.
CDC. MMWR Zika reports. Updated July 17, 2020. Accessed September 15, 2020. https://www.cdc.gov/mmwr/zika_reports.html
8.
Grohskopf  LA, Liburd  LC, Redfield  RR.  Addressing influenza vaccination disparities during the COVID-19 pandemic.   JAMA. 2020;324(11):1029-1030. doi:10.1001/jama.2020.15845PubMedGoogle ScholarCrossref
9.
National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC).  Use of influenza A (H1N1) 2009 monovalent vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009.   MMWR Recomm Rep. 2009;58(RR-10):1-8.PubMedGoogle Scholar
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    3 Comments for this article
    EXPAND ALL
    Journal Reputation is Established by Scientific Creativity and Destroyed by Political Interference
    Michael McAleer, PhD(Econometrics),Queen's | Asia University, Taiwan
    It is difficult to disagree with the commanding viewpoint written by experts and former Editors-in-Chief of a leading journal in epidemiology that is published by the CDC, Morbidity and Mortality Weekly Report (MMWR).

    If and when political appointees within the US Department of Health and Human Services (HHS), or anywhere else interfere in the editorial process, it should be made clear in the lead footnote and throughout each and every article that is published in the journal, with names wherever appropriate.

    A journal's reputation can take many years to be established through innovative scientific creativity, but it can easily be destroyed, even with
    a hint of non-scientific interference.

    Nothing does this more easily and speedily than political interference, which is anathema to scientific progress and creativity, especially when accurate information is essential during the COVID-19 pandemic.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Protecting MMWR is CRUCIAL
    Kathleen Lohr, Phd, MA, MPhil | Retired Distinguished Fellow Emeritus (Health Services Research)
    Just a thank you for getting this article out quickly and convincingly. Any meddling with MMWR would be an incalculable loss to the US, and the world, of honest, well-researched, and well-reported information critical for adequate public health here and globally.
    CONFLICT OF INTEREST: None Reported
    Yes But
    David Deterly, BSPh | Drug Therapy Consultant
    Appoint the best people, but no one should think this is a "job" for life. No one is perfect and we should realize there is always room for conjecture. First attribute should be to not take criticism personally. Evaluate that which is being analyzed or questioned and respond appropriately if at all. Above all, don't respond on social media. Hopefully these appointed positions will not be based on the "good old boy" criteria but on absolute experience and expertise in the field.
    CONFLICT OF INTEREST: None Reported
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