Answering the Call: The Response of Centers for Disease Control and Prevention’s Federal Public Health Nursing Workforce to the COVID-19 Pandemic

Many public health challenges face our world today, including systemic racism, the opioid epidemic, and the COVID-19 pandemic. Nurses are well-qualified and well-positioned to respond to these challenges, as nurses represent 50% of the global health workforce and are leaders not only in clinical settings but also in public health.¹ The professions of nursing and public health have been closely intertwined since the founding of the modern-day nursing profession by Florence Nightingale, a pioneer in the field of epidemiology.²

Nursing incorporates many tenets of public health. Nurses are taught to view individuals within the context of their communities and to consider each patient’s social determinants of health in the provision of care. Nurses have in-depth knowledge of disease and wellness and are trained to plan, implement, and evaluate health interventions based upon health assessment at both the individual and population levels. In addition, nurses are trusted professionals who communicate and educate patients and communities about important health messages related to disease prevention and wellness promotion while considering cultural implications. The purpose of this editorial is to describe the contributions of nurses at the US Centers for Disease Control and Prevention (CDC) during the COVID-19 pandemic, and to generate a call to action to support the need for a strong public health nursing workforce.

NURSES AT THE CENTERS FOR DISEASE CONTROL AND PREVENTION

Nurses are integral to the workforce of many health care organizations, including state and local health departments and the CDC, the public health agency of our nation. The CDC aims to protect the US population from disease and disability by conducting scientific research and surveillance that provides health information to the public and responds to new and emerging health threats.³ Nurses at the CDC perform a variety of roles, serving as clinicians, health scientists, epidemiologists, public health advisors, nurse consultants, and communication and education specialists. Nurses fulfill leadership and managerial roles at various levels within the agency. In addition, many CDC nurses are commissioned officers of the US Public Health Service (USPHS), one of the eight active-duty uniformed services of this nation. Of more than 6100 Commissioned Corps officers in the USPHS, nurses comprise the largest percentage of health professionals.⁴ Nurses have also been part of CDC’s Epidemic Intelligence Service program, a globally recognized fellowship program renowned for its response efforts to investigate outbreaks of infectious disease and environmental and occupational health and safety issues throughout the program’s 70-year history.⁵

RESPONSE TO THE COVID-19 PANDEMIC

Since the onset of the COVID-19 pandemic, the nursing profession has been in the world’s spotlight as nurses have been on the front lines providing care for COVID-19 patients, performing key functions in state and local health departments, and preventing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission in health care facilities, workplaces, and communities.⁶ At the CDC, nurses have been at the forefront of CDC’s response to the pandemic. The CDC and Agency for Toxic Substances and Disease Registry Nurses’ Work Group (CNWG), a group of nurses that provide expertise and support to nurses throughout the agency, have assisted in disseminating and fulfilling requests for deployments to support the COVID-19 response at CDC.

The CDC activated the Incident Management System for the 2019 COVID response in January 2020. As a part of this response, an application called Emergency Operations Management System tracks the work hours of employees, fellows, and contractors who contribute to the response. The CNWG maintains an administrative list of all CDC nurses who are a part of the CNWG membership, although not all nurses who work at CDC are members of CNWG. Using information from Emergency Operations Management System and CNWG’s administrative list, we determined that, among 190 CNWG members, 146 (76.8%) were deployed on the COVID-19 response at some time between January 21, 2020, and September 18, 2021. Together, they logged more than 24 600 person-days and nearly 198 000 person-hours on the response.

Nurses contributed to multiple COVID-19 task forces supporting the agency’s response through COVID-19 deployments. Except for Commissioned Corps officers, all deployments were voluntary; agency Commissioned Corps officers were also deployed across the country on behalf of the Office of the Assistant Secretary for Preparedness and Response. The following roles and contributions of CDC nurses parallel the work of dedicated public health nurses at state and local health departments:

Responding to Clinical Inquiries

CDC’s COVID-19 response deployed clinicians, including CDC nurses, to answer clinical inquiries 24 hours per day. The call center initially answered questions related to the clinical determination of persons under investigation, collection and shipping of specimens to CDC, and contact tracing. As transmission of SARS-CoV-2 accelerated in communities, the call center began fielding questions from frontline clinicians and health departments regarding guidance about COVID-19 testing and available assays, treatment, underlying medical conditions, risk mitigation, serological viral indicators, and viral shedding. CDC clinicians provided real-time consultation for inquiries related to a wide variety of topics. Most inquiries came from clinical sites in which clinicians inquired about exposure risk, regarding both their own safety and transmission risk to patients.⁷ In addition, frequent inquiries included risk assessment after a known or potential exposure, implementing the correct return-to-work strategy for exposed personnel, isolation and quarantine guidance, and guidance on personal protective equipment (PPE) use in a health care setting. CDC nurses also participated in a series of clinical outreach and communication activity calls to educate health care providers.

Creating Guidelines to Reduce Transmission Risk

Throughout the COVID-19 response, multidisciplinary teams, including nurses, created guidelines for health care settings, correctional institutions, schools and childcare facilities, businesses and workplaces, and many other community settings. CDC nurses organized calls with CDC’s partners and webinars to answer questions to help schools, businesses and workplaces, and communities make key decisions about safely resuming operations by incorporating COVID-19 mitigation strategies. CDC nurses have developed materials and resources during the COVID-19 response, including guidance that helps people understand what actions they can take to reduce the risk of COVID-19 as well as accompanying toolkits to help operationalize the guidance. For example, CDC nurses were vital contributors in the development of telehealth guidelines to reduce the risk of exposure to SARS-CoV-2 in health care personnel, patients, and communities.

Providing Personal Protective Equipment Guidance

The COVID-19 pandemic created an unprecedented need for respirators as well as immediate guidance and information dissemination related to the use, disinfection, reuse, and optimization of respiratory protection devices for health care and public safety workers. The National Personal Protective Technology Laboratory team located within the National Institute for Occupational Safety and Health includes scientists, nurses, and engineers who conduct research on PPE and promote proper respirator selection, maintenance, and use. In addition, this group fielded questions related to PPE via e-mail, which was a critical extension of the CDC’s COVID-19 response. This team provided responses to more than 7000 inquiries over 19 months from the public regarding PPE.

Leading Vaccine Distribution and Monitoring Safety

CDC nurses worked with state, tribal, local, and territorial health departments to facilitate the roll-out and distribution of COVID-19 vaccines to priority groups by providing oversight and coordinating field teams in assigned regions. CDC nurses also contributed to the development of COVID-19 vaccine training and educational materials for health professionals, including online training modules and guidance for vaccine transportation, storage, preparation, and administration. In addition, nurses were deployed to the CDC’s Vaccine Task Force to monitor the safety of the COVID-19 vaccines through the Vaccine Adverse Event Reporting System, the Myocarditis Outcomes After mRNA COVID-19 Vaccination Investigation Team, and v-safe, a smart phone‒based app that contains links to Web-based surveys where individuals can report any adverse effects after vaccination.⁸ On the Vaccine Task Force, nurses reviewed and replied to vaccine-related inquiries; performed abstraction of medical records for reports of adverse events, including myocarditis and cerebral sinus venous thrombosis; and called clinicians to conduct surveys about myocarditis. In addition, nurses provided clinical support and helped coordinate and develop standard operating procedures for the CDC’s COVID-19 v-safe pregnancy registry. Nurses called pregnant people to assess pregnancy outcomes following vaccination; data from the v-safe pregnancy registry directly informed clinical guidance for COVID-19 vaccination during pregnancy.

Serving as Health Department Liaison Officers

Several CDC nurses worked as health department liaison officers, serving as the primary conduit and resource for state, tribal, local, and territorial public health agencies as well as other federal partners across the nation, including Health and Human Services, Assistant Secretary for Preparedness and Response, and Federal Emergency Management Agency. Health department liaison officers provided guidance, resources, and tools necessary to meet the needs of various partners in several areas, including contact tracing, case investigation, COVID-19 vaccination, and testing access. They also helped address the safety and health of those at increased risk for severe COVID-19 illness and those at increased risk of acquiring or transmitting COVID-19.

Providing Protection for the Workforce

Workforce protection for emergency response activities is coordinated through the Office of Safety, Security, and Asset Management. This office’s Occupational Health Clinic (OHC) permanent staff of 10 registered or advanced practice nurses, two physicians, and support staff play a pivotal role in ensuring the health and safety of those involved in responses. With the surge in response activities because of COVID-19, the OHC required additional health care and public health staff. In the last year, the OHC provided medical clearances for multiple responses, including COVID-19, polio, Ebola, wildfires, hurricanes, and Operation Allies Welcome, which supported the evacuation of US citizens and Afghanistan nationals to the United States.⁹ Civil servant health care professionals and USPHS officers, most of whom were registered and advanced practice nurses, deployed to the OHC to support the increased demand. More than 5000 medical clearances have been completed during the pandemic thus far, all response and critical laboratory staff are monitored daily for illness, and COVID-19‒symptomatic or ‒positive staff are monitored and provided medical advice. In addition, COVID-19 and influenza vaccination clinics ran simultaneously, administering thousands of vaccines to CDC staff, contractors, and other federal employees. Polymerase chain reaction testing for SARS-CoV-2 was also instituted and available to all employees.

Leading and Supporting Field Deployments

CDC nurses also supported diverse field deployments, many of which included leadership roles. These influential leadership positions included providing clinical and epidemiological support in tribal nations and leading outbreak investigations in settings such as medical centers, summer camps, and households. In state, tribal, local, and territorial offices throughout the United States, CDC nurses were involved with contact tracing in federal prisons and early repatriation missions. In addition, they conducted infection-control assessments of long-term-care facilities, screened for COVID-19 symptoms at international airports, and supported health departments. CDC nurses also served as Career Epidemiology Field Officers¹⁰ and field team leads, coordinating communication between CDC field and headquarters teams, local and state public health officials, laboratories, and medical staff. They developed standard operating procedures and served as subject matter experts for a variety of topics ranging from infection prevention and control to specimen collection in long-term-care facilities, mass testing sites, and as part of large state-led surveys.

Other Roles

Other roles included but were not limited to serving as quarantine medical officers, performing phlebotomy and collecting nasal swab specimens for epidemiological investigations, providing analytic support, addressing vaccine hesitancy, and improving vaccine confidence. Nurses also contributed to scientific studies by conducting qualitative interviews with public health workers to assess the effects of the COVID-19 pandemic on their mental health. Many nurses published high-impact articles in journals, including CDC’s Morbidity and Mortality Weekly Report and New England Journal of Medicine.^11–14

In summary, CDC nurses served in a variety of capacities, including roles in clinical practice, surveillance, data analysis, public education, and leadership, all of which significantly contributed the federal COVID-19 response. Although it is important to highlight the various roles of nurses within CDC, recognizing the work of nurses beyond the federal level is crucial in understanding the broader impact of the nursing profession in efforts against the COVID-19 pandemic. Nurses have continuously and courageously provided patient care at the bedside. They have also served within local and state public health agencies and departments as policy experts, contact tracers, researchers, epidemiologists, nurse consultants, and patient advocates. In this capacity, nurses have provided the necessary care and resources to underserved communities who may otherwise go without proper health care follow-up or guidance. As such, nurses, both those in clinical settings and those in public health, have been essential in efforts to curb this pandemic.

A CALL TO ACTION

The COVID-19 pandemic has increased the visibility of both the nursing and the public health professions and has highlighted the incredible, multifaceted roles that nurses have in responding to public health crises. However, the COVID-19 pandemic has exposed vulnerabilities in our public health systems globally and nationally at the federal, state, and local levels rooted in a lack of public health investment, which has contributed to a shortage of public health nurses.^15,16 The current public health nursing workforce is insufficiently sized to adequately address a pandemic, much less prevent and address underlying causes that have contributed to COVID-19 mortality and morbidity, such as chronic diseases and health inequalities.^17,18 It is estimated that the United States has about half of the public health nurses needed to meet the public health needs of our nation.^17,18 Consequences of a shrinking public health nurse workforce can compromise the ability of health departments to respond effectively during crises such as the COVID-19 pandemic and can exacerbate other public health issues that existed before the pandemic. The heavy toll of the COVID-19 pandemic can be felt by nurses worldwide. Many nurses fighting the pandemic on the front lines are exhausted and burned out.^19,20 Prioritizing and protecting the health and mental well-being of nurses will strengthen nurse resilience, which is essential for sustaining the nursing workforce.²⁰

Crises, like a pandemic, can prompt change. It is essential that we emerge from the COVID-19 pandemic with a reimagined and stronger public health system. The American Nursing Association and National Academy of Medicine have called on all levels of government to increase funding to further develop the public health nursing workforce.^15,16,21 In addition, nursing education curricula need to incorporate more content and clinical practicum hours related to public health. Although the American Association of Colleges of Nursing has guidelines for incorporating population-focused and public health concepts into curricula, most nursing programs heavily focus on acute care content with almost all clinical practicum hours occurring in acute care or hospital settings.²² The emphasis on acute care in nursing education is perpetuated by this same focus on the National Licensure Examination. As a result, many nurses do not even consider careers in public health.

Nurses are trained to be communicators, critical thinkers, innovators, and leaders. The value and contribution that these skills, paired with clinical experience and compassion, bring to the field of public health cannot be overstated. Throughout the COVID-19 response, nurses have consistently answered the call with a resounding “Yes,” performing jobs that blend clinical knowledge, science, and public health.

It is essential to invest in strengthening the public health nurse workforce; leverage the skills of nurses in public health surveillance, program management, and policy development; and elevate nurses as leaders. We need a strong public health nurse workforce, especially at the local and state levels, but also at the federal level. As demonstrated through work in the COVID-19 pandemic, nurses are critically needed to protect and promote the health of all individuals and communities in our world. No pandemic—neither the current COVID-19 pandemic nor future pandemics—will be conquered without the leadership and vital contributions of nurses at every level.