Ann Bauer, a researcher who studies Tylenol and autism, felt queasy with anxiety in the weeks leading up to the White House’s much-anticipated autism announcement.

In August, Bauer and her colleagues published an analysis of 46 previous studies on Tylenol, autism, and attention-deficit/hyperactivity disorder. Many found no link between the drug and the conditions, while some suggested Tylenol might occasionally exacerbate other potential causes of autism, such as genetics.

Bauer, an epidemiologist at the University of Massachusetts-Lowell, and her team called for more judicious use of the drug until the science is settled.

On Monday, President Donald Trump stood beside Health and Human Services Secretary Robert F. Kennedy Jr. for what he called a “historic” announcement on autism. “If you’re pregnant, don’t take Tylenol, and don’t give it to the baby after the baby is born,” Trump said. “There are certain groups of people that don’t take vaccines and don’t take any pills that have no autism,” he added, without providing evidence. “They pump so much stuff into those beautiful little babies, it’s a disgrace.”

A fact sheet released alongside the White House briefing cited Bauer’s analysis. But she was alarmed by Trump’s comments. If prenatal Tylenol has any association, which it may not, it would help account for only a fraction of cases, she said. Further, research has not deeply examined Tylenol risks in young children, and many rigorous studies refute a link between vaccines and autism.

Bauer worries such statements will cut both ways: People may put themselves at risk to avoid vaccines and Tylenol, the only safe painkiller for use during pregnancy. And she frets that scientists might outright reject her team’s measured concerns about Tylenol in a backlash against misleading remarks from Trump and other members of his “Make America Healthy Again” movement.

“I’m really concerned about how this message is going to play out,” she said. “It’s a sound-bite universe, and everyone wants a simple solution.”

Autism experts at the Centers for Disease Control and Prevention were neither consulted for the White House’s long-awaited autism announcement nor asked to review a draft of the findings and recommendations, CDC scientists told KFF Health News, which agreed not to identify them because they fear retaliation.

“Typically, we’d be asked to provide information and review the report for accuracy, but we’ve had absolutely no contact with anyone,” one CDC researcher said. “It is very unusual.”

Trump and Kennedy promised this year that under their leadership the federal government would swiftly figure out what causes autism. Scientists who work in the field have been skeptical, noting that decades of research has shown that no single drug, chemical, or other environmental factor is strongly linked to the developmental disorder. In addition, both Trump and Kennedy have repeated the scientifically debunked notion that childhood vaccines may cause autism.

Helen Tager-Flusberg, director of the Center for Autism Research Excellence at Boston University, called Trump’s comments dangerous. Fevers can harm the mother and the developing fetus, she said, adding that fevers are more strongly associated with autism than Tylenol.

In an emailed response to queries, HHS spokesperson Andrew Nixon said, “We are using gold-standard science to get to the bottom of America’s unprecedented rise in autism rates.”

White House spokesperson Kush Desai wrote, “President Trump pledged to address America’s rising rate of autism, and to do so with Gold Standard Science.”

Had CDC scientists been allowed to brief Kennedy, they say they would have cautioned that simple fixes won’t make a dent in the number of autism cases in the United States: As many as 1 in 31 8-year-old children had autism spectrum disorder in 2022.

Systemic changes, such as regulations on air pollution, which has been linked to asthma and developmental disabilities including autism, and assistance for parents of disabled children, could improve lives for far more Americans with autism and other conditions than actions taken by the Trump administration on Sept. 22, researchers say.

One federal action is to consider updating the label on Tylenol and to “encourage clinicians to exercise their best judgment in use of acetaminophen for fevers and pain in pregnancy by prescribing the lowest effective dose for the shortest duration.” The American College of Obstetricians and Gynecologists already recommends acetaminophen “as needed, in moderation, and after consultation with a doctor.”

‘Political Crusade’

Despite Kennedy’s many years of speaking about autism, he rarely cites credible autism research or expert recommendations, Tager-Flusberg said. Instead, Kennedy repeats fringe, scientifically debunked theories linking vaccines to autism, despite rigorous studies published in peer-reviewed journals that refute a link.

At the Sept. 22 briefing, Trump said he spoke with Kennedy about autism 20 years ago: “We understood a lot more than a lot of people who studied it,” he said. Ahead of Trump’s first term in 2017, Kennedy said he met with the president to consider a commission on vaccine safety and autism. It didn’t happen then. But soon after Kennedy was confirmed as health secretary, he called autism “preventable,” pointed to “environmental toxins,” and contradicted the results of a CDC study finding that the main driver of rising autism diagnoses was that doctors increasingly recognize the disorder.

At a televised Cabinet meeting in April, Kennedy told Trump, “By September, we will know what has caused the autism epidemic and we’ll be able to eliminate those exposures.”

“You stop taking something, you stop eating something, or maybe it’s a shot,” Trump replied.

“He is on a political crusade,” Tager-Flusberg said of Kennedy, adding that vaccines, Tylenol, aluminum, and food dyes make for simple targets to rally against. “We know genetics is the most significant risk factor,” she said, “but you can’t blame Big Pharma for genetics, and you can’t build a political movement on genetics research and ride to victory.”

“RFK makes our work harder,” said Peter Hotez, a vaccine researcher and the author of a book about his autistic daughter, “Vaccines Did Not Cause Rachel’s Autism.” He said the book stemmed from conversations with Kennedy in 2017, in which Hotez shared studies pinpointing more than a hundred genes linked to autism, and research into the complex interplay between genetics, biological processes, and things that children and fetuses encounter during development.

“I sat down with him and explained what the science says, but he was unwilling or incapable of thinking deeply about it,” Hotez said. “He is extremely careless.”

In addition to its focus on Tylenol, the White House said it would move to update “prescribing information” on leucovorin — a medication related to the B vitamin folate — to reflect its use as an autism treatment. A small clinical trial in 2012-13 suggested the drug may help treat language problems in some children with autism. Tager-Flusberg said the findings warrant further study but clarified these were “old data, not a breakthrough.”

Likewise, studies finding a modest association between autism and prolonged Tylenol use were published years ago. Researchers have suggested the medicine might occasionally exacerbate factors associated with autism, such as genetics and oxidative stress, a biological condition that occurs for a variety of reasons that scientists are still unraveling.

Still, these studies couldn’t rule out the possibility that fevers prompting women to take Tylenol, rather than the medicine itself, might instead be to blame. Fevers and infections — including those prevented by vaccines — have also been linked to autism.

Nonetheless, Bauer’s recommendation would be to pause before taking acetaminophen while pregnant — blanket advice that doctors give for all medications during that period, but which may be ignored. “Try to alleviate discomfort in some other ways, like with a cold compress, hydration, or massage, before taking it,” Bauer said.

She welcomed the White House’s motion to consider labeling Tylenol to emphasize judicious use of the drug but worries about how the MAHA movement might distort a careful message. On Sept. 2, the right-wing news outlet One America News Network posted an interview with newly appointed CDC vaccine adviser Robert Malone, writing that Malone “speculates RFK Jr. may have an important announcement this month regarding a potential link between Tylenol, multiple vaccinations and autism in children.”

“I was sick to my stomach,” Bauer said, concerned that Kennedy would link her study to discredited theories, causing doctors and scientists to reject her far more measured work.

‘The Boy Who Cried Wolf’

Several medical and scientific associations have called for Kennedy’s removal or resignation. Many scientists are skeptical of what he says because much of it has been misleading or wrong. For example, he’s said HIV isn’t the only cause of AIDS (it is), that antidepressant drugs cause mass shootings (they don’t), that older adults don’t have severe autism (some do), that the measles vaccine causes brain swelling (it doesn’t), that covid vaccines were the deadliest vaccines ever made (they aren’t), that vaccines aren’t safety-tested (they are), and that vaccines contribute to autism (they don’t).

“This is like the boy who cried wolf,” said Brian Lee, an epidemiologist at Drexel University. “One day he might be right about something and Americans who are not prone to conspiracies won’t trust it because it’s coming from RFK’s mouth. And that could be a problem.”

What’s more, the Trump administration is eroding scientists’ ability to probe the safety of pharmaceuticals, said Robert Steinbrook, head of health research at Public Citizen, a nonprofit consumer protection group.

“Public Citizen is very supportive of research on medications that could be linked to diseases,” he said. “But it needs to be through an open process, which looks at scientific evidence, and which doesn’t cherry-pick studies to support a preconceived point of view.”

Steinbrook said the administration has undermined his confidence in the government’s ability to conduct credible work. The Food and Drug Administration has held less than a third the number of advisory committee meetings this year as it did last, meaning fewer opportunities for experts to discuss research on the risks and benefits of drugs. The Trump administration has fired hundreds of career scientists at the CDC and FDA and cut millions of dollars in research funds, including to projects studying autism.

In early September, the CDC issued an unusual contract with the Rensselaer Polytechnic Institute to analyze datasets for signs that vaccinated children were more likely to have autism. Unlike with other research initiatives, the CDC didn’t post an open call for applications in advance. This allows agency experts to review proposals and select studies best designed to answer the question at hand.

CDC researchers told KFF Health News that experts in the agency’s autism and disability group weren’t aware of the contract or asked to review the proposal. That’s important, they said, because researchers digging through data to find clues about autism must show how they’ll rule out biological and environmental exposures that muddy the results, and ensure that children have been accurately diagnosed. One researcher said, “It absolutely looks like Kennedy has subverted the grantmaking process.”

The CDC and HHS did not respond to KFF Health News’ requests for information on the grant, including through a Freedom of Information Act request.

The new vaccine study is separate from Kennedy’s autism data-science initiative, which was posted as an open call at the National Institutes of Health. “The hope is that something good comes of it, and that the government won’t cherry-pick or censor what scientists find out,” Lee said.

Bauer said she didn’t apply to be part of the initiative because of Kennedy’s outsize presence at HHS.

“I would not take his funding because it could take away from the credibility of my study,” she said, “in the same way that taking money from pharmaceutical companies does."

As measles surged in Texas early this year, the Trump administration’s actions sowed fear and confusion among CDC scientists that kept them from performing the agency’s most critical function — emergency response — when it mattered most, an investigation from KFF Health News shows.

The outbreak soon became the worst the United States has endured in over three decades.

In the month after Donald Trump took office, his administration interfered with Centers for Disease Control and Prevention communications, stalled the agency’s reports, censored its data, and abruptly laid off staff. In the chaos, CDC experts felt restrained from talking openly with local public health workers, according to interviews with seven CDC officials with direct knowledge of events, as well as local health department emails obtained by KFF Health News through public records requests.

“CDC hasn’t reached out to us locally,” Katherine Wells, the public health director in Lubbock, Texas, wrote in a Feb. 5 email exchange with a colleague two weeks after children with measles were hospitalized in Lubbock. “My staff feels like we are out here all alone,” she added.

A child would die before CDC scientists contacted Wells.

“All of us at CDC train for this moment, a massive outbreak,” one CDC researcher told KFF Health News, which agreed not to name CDC officials who fear retaliation for speaking with the press. “All this training and then we weren’t allowed to do anything.”

Delays have catastrophic consequences when measles spreads in undervaccinated communities, like many in West Texas. If a person with measles is in the same room with 10 unvaccinated people, nine will be infected, researchers estimate. If those nine go about their lives in public spaces, numbers multiply exponentially.

The outbreak that unfolded in West Texas illustrates the danger the country faces under the Trump administration as vaccination rates drop, misinformation flourishes, public health budgets are cut, and science agencies are subject to political manipulation.

While the Trump administration stifled CDC communications, health secretary Robert F. Kennedy Jr. fueled doubt in vaccines and exaggerated the ability of vitamins to ward off disease. Suffering followed: The Texas outbreak spread to New Mexico, Oklahoma, Kansas, Colorado, and Mexico’s Chihuahua state — at minimum. Together these linked outbreaks have sickened more than 4,500 people, killed at least 16, and levied exorbitant costs on hospitals, health departments, and those paying medical bills.

“This is absolutely outrageous,” said Jennifer Nuzzo, director of the Pandemic Center at Brown University. “When you’re battling contagious diseases, time is everything.”

‘The CDC Is “Stressed” Currently’

Wells was anxious the moment she learned that two unvaccinated children hospitalized in late January had the measles. Hospitals are legally required to report measles cases to health departments and the CDC, but Wells worried many children weren’t getting tested.

“I think this may be very large,” she wrote in a Feb. 3 email to the Texas Department of State Health Services. Wells relayed in another email what she’d learned from conversations around town: “According to one of the women I spoke with 55 children were absent from one school on 1/24. The women reported that there were sick children with measles symptoms as early as November.”

In that email and others, Wells asked state health officials to put her in touch with CDC experts who could answer complicated questions on testing, how to care for infants exposed to measles, and more. What transpired was a plodding game of telephone.

One email asked whether clinics could decontaminate rooms where people with measles had just been if the clinics were too small to follow the CDC’s recommendation to keep those rooms empty for two hours.

“Would it be possible to arrange a consultation with the CDC?” Wells wrote on Feb. 5.

“It never hurts to ask the CDC,” said Scott Milton, a medical officer at the Texas health department. About 25 minutes later, he told Wells that an information specialist at the CDC had echoed the guidelines advising two hours.

“I asked him to escalate this question to someone more qualified,” Milton wrote. “Of course, we know the CDC is ‘stressed’ currently.”

Local officials resorted to advice from doctors and researchers outside the government, including those at the Immunization Partnership, a Texas nonprofit.

“The CDC had gone dark,” said Terri Burke, executive director of the partnership. “We had anticipated a measles outbreak, but we didn’t expect the federal government to be in collapse when it hit.”

Technically, the Trump administration’s freeze on federal communications had ended Feb. 1. However, CDC scientists told KFF Health News that they could not speak freely for weeks after.

“There was a lot of confusion and nonanswers over what communications were allowed,” one CDC scientist said.

Georges Benjamin, executive director of the American Public Health Association, said the situation was not unique to measles. “Like most public health organizations, we weren’t able to get ahold of our program people in February,” he said. Information trickled out through the CDC’s communications office, but CDC scientists gave no press briefings and went dark on their closest partners across the country. “The CDC was gagged,” he said.

Through private conversations, Benjamin learned that CDC experts were being diverted to remove information from websites to comply with executive orders. And they were afraid to resume communication without a green light from their directors or the Department of Health and Human Services as they watched the Trump administration lay off CDC staffers in droves.

“It’s not that the CDC was delinquent,” Benjamin said. “It’s that they had their hands tied behind their backs.”

To work on the ground, the CDC needs an invitation from the state. But Anne Schuchat, a former CDC deputy director, said that during her 33 years with the agency, federal health officials didn’t need special permission to talk freely with local health departments during outbreaks. “We would always offer a conversation and ask if there’s anything we could do,” she said.

Lara Anton, a press officer at the Texas health department, said the state never prevented the CDC from calling county officials. To learn more about the state’s correspondences with the CDC, KFF Health News filed a public records request to the Texas health department. The department refused to release the records. Anton called the records “confidential under the Texas Health and Safety Code.”

Anton said the state sent vaccines, testing supplies, and staff to assist West Texas in the early weeks of February. That’s corroborated in emails from the South Plains Public Health District, which oversees Gaines County, the area hit hardest by measles.

“Texas will try to handle what it needs to before it goes to the CDC,” Zach Holbrooks, the health district’s executive director, told KFF Health News.

Responding to an outbreak in an undervaccinated community, however, requires enormous effort. To keep numbers from exploding, public health workers ideally would notify all people exposed to an infected person and ask them to get vaccinated immediately if they weren’t already. If they declined, officials would try to persuade them to avoid public spaces for three weeks so that they wouldn’t spread measles to others.

Holbrooks said this was nearly impossible. Cases were concentrated in close-knit Mennonite communities where people relied on home remedies before seeking medical care. He said many people didn’t want to be tested, didn’t want to name their contacts, and didn’t want to talk with the health department. “It doesn’t matter what resources I have if people won’t avail themselves of it,” Holbrooks said.

Historically, Mennonites faced persecution in other countries, making them leery of interacting with authorities, Holbrooks said. A backlash against covid restrictions deepened that mistrust.

Another reason Mennonites may seek to avoid authorities is that some live in the U.S. illegally, having immigrated to Texas from Canada, Mexico, and Bolivia in waves over the past 50 years. Locals guess the population of Seminole, the main city in Gaines County, is far larger than the U.S. Census count.

“I have no idea how many cases we might have missed, since I don’t know how many people are in the community,” Holbrooks said. “There’s a lot of people in the shadows out here.”

Public health experts say the situation in Gaines sounds tough but familiar. Measles tends to take hold in undervaccinated communities, and therefore public health workers must overcome mistrust, misinformation, language barriers, and more.

About 450 people — including local health officials, CDC scientists, nurses, and volunteers — helped control a measles outbreak sparked in an Eastern European immigrant community in Clark County, Washington, in 2018.

Alan Melnick, Clark County’s public health director, said his team spoke with hundreds of unvaccinated people who were exposed. “We were calling them basically every day to see how they were doing and ask them not to go out in public,” he said.

Melnick spoke with CDC scientists from the start, and the intensity of the response was buoyed by emergency declarations by the county and the state. Within a couple of months, the outbreak was largely contained. No one died, and only two people were hospitalized.

In New York, hundreds of people in the city’s health department responded to a larger measles outbreak in 2018 and 2019 concentrated among Orthodox Jewish communities. The work included meeting with dozens of rabbis and distributing booklets to nearly 30,000 households to combat vaccine misinformation.

The effort cost more than $7 million, but Jane Zucker, New York City’s assistant health commissioner at the time, said it yielded immense savings. The average medical bill for measles hospitalizations is roughly $18,500, according to data from prior outbreaks. Then there’s the cost of diverting hospital resources, of children missing school, of parents staying home from work to care for sick kids, and the lasting toll of some measles infections, including deafness or worse.

“I don’t think there’s a price tag to put on a child’s death that would otherwise be prevented,” Zucker said.

Local health departments in West Texas were understaffed from the start. About 18 people work at the South Plains health department, which oversees four vast rural counties. About 50 staff the department in Lubbock, where patients were hospitalized and health workers struggled to figure out who was exposed. In mid-February, Wells emailed a colleague: “I’m so overwhelmed.”

A Death Ignites a Response

On Feb. 26, Texas announced that a 6-year-old child had died of measles. Wells heard from CDC scientists for the first time the following day. Also that day, the CDC issued a brief notice on the outbreak. The notice recommended vaccines, but it worried public health specialists because it also promoted vitamin A as a treatment under medical supervision.

In emails, Texas health officials privately discussed how the CDC’s notice might exacerbate a problem: Doctors were treating children with measles for toxic levels of vitamin A, suggesting that parents were delaying medical care and administering the supplements at home. A local Lubbock news outlet reported on a large drugstore where vitamin A supplements and cod liver oil, which contains high levels of vitamin A, were “flying off the shelf.”

Too much vitamin A can cause liver damage, blindness, and dire abnormalities during fetal development.

Milton worried that parents were listening to misinformation from anti-vaccine groups — including one founded by Kennedy — that diminished the need for vaccination by inaccurately claiming that vitamin A staved off the disease’s worst outcomes.

“How many people will choose Vitamin A and not a vaccine because it appears to them there are two options?” Milton asked in an email.

Scientists at the CDC privately fretted, too. “HHS pressed us to insert vitamin A into all of our communications with clinicians and health officials,” one CDC scientist told KFF Health News, referring to the agency’s notices and alerts. “If pregnant women took too much vitamin A during the outbreak, their babies could be profoundly disabled. We haven’t seen those babies born yet.”

Another CDC official said they’ve had to “walk a fine line” between protecting the public based on scientific evidence and aligning with HHS.

While CDC scientists held their tongues, Kennedy exaggerated the power of nutrition and vitamin A while furthering mistrust in vaccines. “We’re providing vitamin A,” Kennedy said in an interview on Fox News. “There are many studies, some showing 87% effectiveness,” he claimed, “against serious disease and death.”

The studies Kennedy referenced were conducted in low-income countries where children are malnourished. Evidence suggests that vitamin A supplementation is seldom useful against measles in the United States, because deficiency is exceedingly rare.

Kennedy deflected criticism from those who call him anti-vaccine, saying that any parent in Texas who wants a measles vaccine can get one. He followed this with dangerously inaccurate statements. “There are adverse events from the vaccine. It does cause deaths every year,” he said. “It causes all the illnesses that measles itself causes, encephalitis and blindness, et cetera.” There is no evidence that measles vaccines “cause deaths every year.” Scores of studies show that the vaccine doesn’t cause encephalitis, that most potential side effects resolve quickly on their own, and serious adverse reactions are far rarer than measles complications.

In another interview, Kennedy said, “The MMR vaccine contains a lot of aborted fetus debris.” The measles, mumps, and rubella, or MMR, vaccine does not contain an iota of fetal cells.

HHS spokesperson Andrew Nixon and spokespeople at the CDC did not respond to queries from KFF Health News.

‘Staff Are Exhausted’

Despite national attention after the country’s first measles death in a decade, West Texas was overwhelmed. In late February and March, hospital administrators and health officials exchanged emails about how to lobby for resources.

“Local hospitals are at capacity,” wrote Jeffrey Hill, a senior vice president at the University Medical Center Health System in Lubbock. “The state reports emergency funds that typically cover a response like the measles outbreak are not available from the federal government right now,” he added.

“I am writing to express our urgent need for additional staff and funding,” Ronald Cook, medical director for Lubbock, said in an email, drafted with other Lubbock health authorities, to the deputy city manager. “Our Capacity is Stretched Thin: The health department has been operating seven days a week since February 2nd. Staff are exhausted.”

The city of Lubbock fronted money to help the local health department hire temporary staff. The state did not provide money, but it asked the CDC to send epidemiologists. Some came to Texas in early March. Then Texas requested federal funds.

None arrived, even as the outbreak approached 500 cases. It spread to Mexico when an unvaccinated Mennonite child returned home after visiting family in Seminole. This would fuel the largest outbreak Mexico has seen in decades, with at least 3,700 cases and 13 deaths in the state of Chihuahua.

Then another child in West Texas died of measles.

In a rare moment of openness, CDC scientist David Sugarman mentioned the outbreak at a vaccine advisory meeting in late April. “There are quite a number of resource requests coming in, in particular from Texas,” Sugarman said. “We are scraping to find the resources and personnel needed to provide support to Texas and other jurisdictions.”

Federal funds arrived in Texas on May 21, said Anton, the state health department spokesperson. By then, the crisis was fading. The outbreak seemed to have burned until every unvaccinated person in Seminole was infected, said Richard Eby, a doctor at Permian Regional Medical Center who treated some measles patients. Hundreds, if not thousands, of cases have probably gone undetected, he said. “A lot of people presumed their kids had measles,” he said, “and didn’t see the need to confirm it.”

On Aug. 18, health officials declared the West Texas outbreak over, but the consequences of the catastrophe will be lasting.

The outbreaks it sparked across the U.S. and Mexico are still spreading.

More are inevitable, Nuzzo said. A growing number of parents are deciding not to vaccinate their kids, worried over unfounded rumors about the shots. Misinformation is flourishing, especially after Kennedy fired vaccine experts who advise the CDC and replaced them with doctors and researchers on the fringes of the scientific establishment. For example, one of his recent appointees, Robert Malone, blamed the deaths of children with measles on “medical mismanagement,” without evidence.

At the same time, states are downsizing programs for emergency response, disease surveillance, and immunization after the Trump administration clawed back more than $11 billion in public health funds earlier this year.

Amid Lubbock’s toughest months, Wells sent an email to the department’s exhausted staff. “The future is uncertain, and I know this is an unsettling time for many of us,” she wrote. “Every day we show up and do our jobs is an act of resilience.”

The Trump administration’s cancellation of $766 million in contracts to develop mRNA vaccines against potential pandemic flu viruses is the latest blow to national defense, former health security officials said. They warned that the U.S. could be at the mercy of other countries in the next pandemic.

“The administration’s actions are gutting our deterrence from biological threats,” said Beth Cameron, a senior adviser to the Brown University Pandemic Center and a former director at the White House National Security Council. “Canceling this investment is a signal that we are changing our posture on pandemic preparedness,” she added, “and that is not good for the American people.”

Flu pandemics killed up to 103 million people worldwide last century, researchers estimate.

In anticipation of the next big one, the U.S. government began bolstering the nation’s pandemic flu defenses during the George W. Bush administration. These strategies were designed by the security council and the Biomedical Advanced Research and Development Authority at the Department of Health and Human Services, among other agencies. The plans rely on rolling out vaccines rapidly in a pandemic. Moving fast hinges on producing vaccines domestically, ensuring their safety, and getting them into arms across the nation through the public health system.

The Trump administration is undermining each of these steps as it guts health agencies, cuts research and health budgets, and issues perplexing policy changes, health security experts said.

Since President Donald Trump took office, at least half of the security council’s staff have been laid off or left, and the future of BARDA is murky. The nation’s top vaccine adviser, Peter Marks, resigned under pressure in March, citing “the unprecedented assault on scientific truth.”

Most recently, Trump’s clawback of funds for mRNA vaccine development put Americans on shakier ground in the next pandemic. “When the need hits and we aren’t ready, no other country will come to our rescue and we will suffer greatly,” said Rick Bright, an immunologist and a former BARDA director.

Countries that produced their own vaccines in the covid-19 pandemic had first dibs on the shots. While the United States, home to Moderna and Pfizer, rolled out second doses of mRNA vaccines in 2021, hundreds of thousands of people in countries that didn’t manufacture vaccines died waiting for them.

The most pertinent pandemic threat today is the bird flu virus H5N1. Researchers around the world were alarmed when it began spreading among cattle in the U.S. last year. Cows are closer to humans biologically than birds, indicating that the virus had evolved to thrive in cells like our own.

As hundreds of herds and dozens of people were infected in the U.S., the Biden administration funded Moderna to develop bird flu vaccines using mRNA technology. As part of the agreement, the U.S. government stipulated it could purchase doses in advance of a pandemic. That no longer stands.

Researchers can make bird flu vaccines in other ways, but mRNA vaccines are developed much more quickly because they don’t rely on finicky biological processes, such as growing elements of vaccines in chicken eggs or cells kept alive in laboratory tanks.

Time matters because flu viruses mutate constantly, and vaccines work better when they match whatever variant is circulating.

Developing vaccines within eggs or cells can take 10 months after the genetic sequence of a variant is known, Bright said. And relying on eggs presents an additional risk when it comes to bird flu because a pandemic could wipe out billions of chickens, crashing egg supplies.

Decades-old methods that rely on inactivated flu viruses are riskier for researchers and time-consuming. Still the Trump administration invested $500 million into this approach, which was largely abandoned by the 1980s after it caused seizures in children.

“This politicized regression is baffling,” Bright said.

A bird flu pandemic may begin quietly in the U.S. if the virus evolves to spread between people but no one is tested at first. Indeed, the Centers for Disease Control and Prevention’s dashboard suggests that only 10 farmworkers have been tested for the bird flu since March. Because of their close contact with cattle and poultry, farmworkers are at highest risk of infection.

As with many diseases, only a fraction of people with the bird flu become severely sick. So the first sign that the virus is widespread might be a surge in hospital cases.

“We’d need to immediately make vaccines,” said Angela Rasmussen, a virologist at the University of Saskatchewan in Canada.

The U.S. government could scale up production of existing bird flu vaccines developed in eggs or cells. However, these vaccines target an older strain of H5N1 and their efficacy against the virus circulating now is unknown.

In addition to the months it takes to develop an updated version within eggs or cells, Rasmussen questioned the ability of the government to rapidly test and license updated shots, with a quarter of HHS staff gone. If the Senate approves Trump’s proposed budget, the agency faces about $32 billion in cuts.

Further, the Trump administration’s cuts to biomedical research and its push to slash grant money for overhead costs could undermine academic hospitals, rendering them unable to conduct large clinical trials. And its cuts to the CDC and to public health funds to states mean that fewer health officials will be available in an emergency.

“You can’t just turn this all back on,” Rasmussen said. “The longer it takes to respond, the more people die.”

Researchers suggest other countries would produce bird flu vaccines first. “The U.S. may be on the receiving end like India was, where everyone — rich people, too — got vaccines late,” said Achal Prabhala, a public health researcher in India at medicines access group AccessIBSA.

He sits on the board of a World Health Organization initiative to improve access to mRNA vaccines in the next pandemic. A member of the initiative, the company Sinergium Biotech in Argentina, is testing an mRNA vaccine against the bird flu. If it works, Sinergium will share the intellectual property behind the vaccine with about a dozen other groups in the program from middle-income countries so they can produce it.

The Coalition for Epidemic Preparedness Innovations, an international partnership headquartered in Norway, is providing funds to research groups developing rapid-response vaccine technology, including mRNA, in South Korea, Singapore, and France. And CEPI committed up to $20 million to efforts to prepare for a bird flu pandemic. This year, the Indian government issued a call for grant applications to develop mRNA vaccines for the bird flu, warning it “poses a grave public health risk.”

Pharmaceutical companies are investing in mRNA vaccines for the bird flu as well. However, Prabhala says private capital isn’t sufficient to bring early-stage vaccines through clinical trials and large-scale manufacturing. That’s because there’s no market for bird flu vaccines until a pandemic hits.

Limited supplies means the United States would have to wait in line for mRNA vaccines made abroad. States and cities may compete against one another for deals with outside governments and companies, like they did for medical equipment at the peak of the covid pandemic.

“I fear we will once again see the kind of hunger games we saw in 2020,” Cameron said.

In an email response to queries, HHS communications director Andrew Nixon said, “We concluded that continued investment in Moderna’s H5N1 mRNA vaccine was not scientifically or ethically justifiable.” He added, “The decision reflects broader concerns about the use of mRNA platforms—particularly in light of mounting evidence of adverse events associated with COVID-19 mRNA vaccines.”

Nixon did not back up the claim by citing analyses published in scientific journals.

In dozens of published studies, researchers have found that mRNA vaccines against covid are safe. For example, a placebo-controlled trial of more than 30,000 people in the U.S. found that adverse effects of Moderna’s vaccine were rare and transient, whereas 30 participants in the placebo group suffered severe cases of covid and one died.

More recently, a study revealed that three of nearly 20,000 people who got Moderna’s vaccines and booster had significant adverse effects related to the vaccine, which resolved within a few months. Covid, on the other hand, killed four people during the course of the study.

As for concerns about the heart issue, myocarditis, a study of 2.5 million people who got at least one dose of Pfizer’s mRNA vaccine revealed about 2 cases per 100,000 people. Covid causes 10 to 105 myocarditis cases per 100,000.

Nonetheless, HHS Secretary Robert F. Kennedy Jr., who founded an anti-vaccine organization, has falsely called covid shots “the deadliest vaccine ever made.” And without providing evidence, he said the 1918 flu pandemic “came from vaccine research.”

Politicized mistrust in vaccines has grown. Far more Republicans said they trust Kennedy to provide reliable information on vaccines than their local health department or the CDC in a recent KFF poll: 73% versus about half.

Should the bird flu become a pandemic in the next few years, Rasmussen said, “we will be screwed on multiple levels.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

JACKSON, Miss. — Storm clouds hung low above a community center in Jackson, where pastor Andre Devine invited people inside for lunch. Hoagies with smoked turkey and ham drew the crowd, but several people lingered for free preventive health care: tests for HIV and other diseases, flu shots, and blood pressure and glucose monitoring.

Between greetings, Devine, executive director of the nonprofit group Hearts for the Homeless, commiserated with his colleagues about the hundreds of thousands of dollars their groups had lost within a couple of weeks, swept up in the Trump administration’s termination of research dollars and clawback of more than $11 billion from health departments across the country.

Devine would have to scale back food distribution for people in need. And his colleagues at the nonprofit health care group My Brother’s Keeper were worried they’d have to shutter the group’s mobile clinic — an RV offering HIV tests, parked beside the community center that morning. Several employees had already been furloughed and the cuts kept coming, said June Gipson, CEO of My Brother’s Keeper.

“People can’t work without being paid,” she said.

The directors of other community-based groups in Mississippi, Alabama, Louisiana, and Tennessee told KFF Health News they too had reduced their spending on HIV testing and outreach because of delayed or slashed federal funds — or they were making plans to do so, anticipating cuts to come.

Scaling back these efforts could prove tragic, Gipson said. Without an extra boost of support to get tested or stay on treatment, many people living with HIV will grow sicker and stand a greater chance of infecting others.

President Donald Trump, in his first term, promised to end America’s HIV epidemic — and he put the resources of the federal government behind the effort. This time, he has deployed the powers of his office to gut funding, abandoning those communities at highest risk of HIV.

Trump’s earlier efforts targeted seven Southern states, including Mississippi, where funds went to community groups and health departments that tailor interventions to historically underserved communities that face discrimination and have less access to quality education, health care, stable income, and generational wealth. Such factors help explain why Black people accounted for 38% of HIV diagnoses in the United States in 2023, despite representing only 14% of the population, and also why half of the country’s new HIV infections occur in the South.

Now, Trump is undermining HIV efforts by barring funds from programs built around diversity, equity, and inclusion. A Day One executive order said they represent “immense public waste and shameful discrimination.”

Since then, his administration has cut millions of dollars in federal grants to health departments, universities, and nonprofit organizations that do HIV work. And in April, it eliminated half of the Centers for Disease Control and Prevention’s 10 HIV branch offices, according to an email to grant recipients, reviewed by KFF Health News, from the director of the CDC’s Division of HIV Prevention. The layoffs included staff who had overseen the rollout of HIV grants to health departments and community-based groups, like My Brother’s Keeper.

The CDC provides more than 90% of all federal funding for HIV prevention — about $1 billion annually. The Trump administration’s May 2 budget proposal for fiscal 2026 takes aim at DEI initiatives, including in its explanation for cutting $3.59 billion from the CDC. Although the proposal doesn’t mention HIV prevention specifically, the administration’s drafted plan for HHS, released mid-April, eliminates all prevention funding at the CDC, as well as funding for Trump’s initiative to end the epidemic.

Eliminating federal funds for HIV prevention would lead to more than 143,000 additional people in the U.S. becoming infected with HIV within five years, and about 127,000 additional people who die of AIDS-related causes, according to estimates from the Foundation for AIDS Research, a nonprofit known as amfAR. Excess medical costs would exceed $60 billion, it said.

Eldridge Dwayne Ellis, the coordinator of the mobile testing clinic at My Brother’s Keeper, said curbing the group’s services goes beyond HIV.

“People see us as their only outlet, not just for testing but for confidential conversations, for a shoulder to cry on,” he said. “I don’t understand how someone, with the stroke of a pen, could just haphazardly write off the health of millions.”

Quiet Tears

Ellis came into his role in the mobile clinic haphazardly, when he worked as a construction worker. Suddenly dizzy and unwell on a job, a co-worker suggested he visit the organization’s brick-and-mortar clinic nearby. He later applied for a position with My Brother’s Keeper, inspired by its efforts to give people support to help themselves.

For example, Ellis described a young man who visited the mobile clinic recently who had been kicked out of his home and was sleeping on couches or on the street. Ellis thought of friends he’d known in similar situations that put them at risk of HIV by increasing the likelihood of transactional sex or substance use disorders.

When a rapid test revealed HIV, the young man fell silent. “The quiet tears hurt worse — it’s the dread of mortality,” Ellis said. “I tried to be as strong as possible to let him know his life is not over, that this wasn’t a death sentence.”

Ellis and his team enrolled the man into HIV care that day and stayed in touch. Otherwise, Ellis said, he might not have had the means or fortitude to seek treatment on his own and adhere to daily HIV pills. Not only is that deadly for people with HIV, it’s bad for public health. HIV experts use the phrase “treatment as prevention” because most new infections derive from people who aren’t adhering to treatment well enough to be considered virally suppressed — which keeps the disease from spreading.

Only a third of people living with HIV in Mississippi were virally suppressed in 2022. Nationally, that number is about 65%. That’s worse than in eastern and southern Africa, where 78% of people with HIV aren’t spreading the virus because they’re on steady treatment.

My Brother’s Keeper is one of many groups improving such numbers by helping people get tested and stay on medication. But the funding cuts in Washington have curtailed their work. The first loss was a $12 million grant from the National Institutes of Health, not even two years into a 10-year project. “Programs based primarily on artificial and non-scientific categories, including amorphous equity objectives, are antithetical to the scientific inquiry,” the NIH said in a letter reviewed by KFF Health News.

My Brother’s Keeper then lost a CDC award to reduce health disparities — a grant channeled through the Mississippi state health department — that began with the group’s work during the covid pandemic but had broadened to screening and care for HIV, heart disease, and diabetes. These are some of the maladies that account for why low-income Black people in the Deep South die sooner, on average, than those who are white. According to a recent study, the former’s life expectancy was just 68 years in 2021, on par with the average in impoverished nations like Rwanda and Myanmar.

The group then lost CDC funding that covered the cost of laboratory work to detect HIV, chlamydia, gonorrhea, and syphilis in patients’ blood samples. Mississippi has the highest rate of sexually transmitted diseases among states, in part because people spread infections when they aren’t tested and treated.

“The labs are $200 to $600 per person,” Gipson said, “so now we can’t do that without passing the cost to the patient, and some can’t pay.”

Two other CDC grants on HIV prevention, together worth $841,000, were unusually delayed.

Public health specialists close to the CDC, who spoke on condition of anonymity because they fear retaliation, said they were aware of delays in HIV prevention funding, despite court orders to unfreeze payments for federal grants in January and February. “The faucet was being turned off at a higher level than at the CDC,” one specialist said. The delays have now been compounded, they said, by the gutting of that agency’s HIV workforce in April.

“I know of many organizations reliant on subcontracted federal funds who have not been paid for the work they’ve done, or whose funding has been terminated,” said Dafina Ward, executive director of the Southern AIDS Coalition.

To reach the underserved, these groups offer food, housing assistance, bus passes, disease screening, and a sense of community. A network of the groups was fostered, in part, by Trump’s initiative to end the epidemic. And it showed promise: From 2017 to 2022, new HIV infections decreased by 21% in the cities and the Southern states it targeted.

Disparities in infections were still massive, with the rate of HIV diagnoses about eight times as high for Black people as white people, and the South remained hardest hit. Ward was hopeful at the start of this year, however, as testing became more widespread and HIV prevention drugs — called preexposure prophylaxis, or PrEP — slowly gained popularity. But her outlook has shifted and she fears that grassroots organizations might not weather the funding turmoil.

“We’re seeing an about-face of what it means to truly work towards ending HIV in this country,” she said.

A Closed Clinic

Southeast of Jackson, in Hattiesburg, Sean Fortenberry tears up as he walks into a small room used until recently for HIV testing. He has kept his job at Mississippi’s AIDS Services Coalition by shifting his role but agonizes about the outcome. When Fortenberry tested positive for HIV in 2007, he said, his family and doctor saved his life.

“I never felt that I was alone, and that was really, really important,” he said. “Other people don’t have that, so when I came across this position, I was gung-ho. I wanted to help.”

But the coalition froze its HIV testing clinic and paused mobile testing at homeless shelters, colleges, and churches late last year. Kathy Garner, the group’s executive director, said the Mississippi health department — which funds the coalition with CDC’s HIV prevention dollars — told her to pause outreach in October before the state renewed the group’s annual HIV prevention contract.

Kendra Johnson, communicable diseases director at Mississippi’s health department, said that delays in HIV prevention funds were initially on the department’s end because it was short on administrative staff. Then Trump took office. “We were working with our federal partners to ensure that our new objectives were in line with new HIV prevention activities,” Johnson said. “And we ran into additional delays due to paused communications at the federal level.”

The AIDS coalition remains afloat largely because of federal money from the Ryan White HIV/AIDS Program for treatment and from the Department of Housing and Urban Development. “If most of these federal dollars are cut, we would have to close,” Garner said.

The group provides housing or housing assistance to roughly 400 people each year. Research shows that people in stable housing adhere much better to HIV treatment and are far less likely to die than unhoused people with HIV.

Funding cuts have shaken every state, but the South is acutely vulnerable when it comes to HIV, said Gregorio Millett, director of public policy at amfAR. Southern states have the highest level of poverty and a severe shortage of rural clinics, and several haven’t expanded Medicaid so that more low-income adults have health insurance.

Further, Southern states aren’t poised to make up the difference. Alabama, Louisiana, Kentucky, Mississippi, and Missouri put zero state funds into HIV prevention last year, according to NASTAD, an association of public health officials who administer HIV and hepatitis programs. In contrast, about 40% of Michigan’s HIV prevention budget is provided by the state, 50% of Colorado’s HIV prevention budget, and 88% of New York’s.

“When you are in the South, you need the federal government,” said Gipson, from My Brother’s Keeper. “When we had slavery, we needed the federal government. When we had the push for civil rights, we needed the federal government. And we still need the federal government for health care,” she said. “The red states are going to suffer, and we’re going to start suffering sooner than anyone else.”

‘So Goes Mississippi’

When asked about cuts and delays to HIV prevention funding, the CDC directed queries to HHS. The department’s director of communications, Andrew Nixon, replied in an email: “Critical HIV/AIDS programs will continue under the Administration for a Healthy America (AHA) as a part of Secretary [Robert F.] Kennedy’s vision to streamline HHS to better serve the American people.”

Nixon did not reply to a follow-up question on whether the Trump administration considers HIV prevention critical.

On April 4, Gipson received a fraction of her delayed HIV prevention funds from the CDC. But Gipson said she was afraid to hire back staff amid the turmoil.

Like the directors of many other community organizations, Gipson is going after grants from foundations and companies. Pharmaceutical firms such as Gilead and GSK that produce HIV drugs are among the largest contributors of non-governmental funds for HIV testing, prevention, and care, but private funding for HIV has never come close to the roughly $40 billion that the federal government allocated to HIV annually.

“If the federal government withdraws some or all of its support, the whole thing will collapse,” said Alice Riener, CEO of the community-based organization CrescentCare in Louisiana. “What you see in Mississippi is the beginning of that, and what’s so concerning is the infrastructure we’ve built will collapse quickly but take decades to rebuild.”

Southern health officials are reeling from cuts because state budgets are already tight. Mississippi’s state health officer, Daniel Edney, spoke with KFF Health News on the day the Trump administration terminated $11 billion in covid-era funds intended to help states improve their public health operations. “There’s not a lot of fat, and we’re cutting it to the bone right now,” Edney said.

Mississippi needed this boost, Edney said, because the state ranks among the lowest in health metrics including premature death, access to clinical care, and teen births. But Edney noted hopeful trends: The state had recently moved from 50th to 49th worst in health rankings, and its rate of new HIV cases was dropping.

“The science tells us what we need to do to identify and care for patients, and we’re improving,” he said. “But trends can change very quickly on us, so we can’t take our foot off the gas pedal.”

If that happens, researchers say, the comeback of HIV will go unnoticed at first, as people at the margins of society are infected silently before they’re hospitalized. As untreated infections spread, the rise will eventually grow large enough to make a dent in national statistics, a resurgence that will cost lives and take years, if not decades, to reverse.

Outside the community center on that stormy March morning, pastor Devine lamented not just the loss of his grant from the health department, but a $1 billion cut to food distribution programs at the U.S. Department of Agriculture. He rattled off consequences he feared: People relying on food assistance would be forced to decide between buying groceries, paying bills, or seeing a doctor, driving them further into poverty, into emergency rooms, into crime.

Deja Abdul-Haqq, a program director at My Brother’s Keeper, nodded along as he spoke. “So goes Mississippi, so goes the rest of the United States,” Abdul-Haqq said. “Struggles may start here, but they spread.”

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Some private schools have shut down because of a rapidly escalating measles outbreak in West Texas. Local health departments are overstretched, pausing other important work as they race to limit the spread of this highly contagious virus.

Since the outbreak emerged three weeks ago, the Texas health department has confirmed 90 cases with 16 hospitalizations, as of Feb. 21. Most of those infected are under age 18. Officials suspect that nine additional measles cases reported in New Mexico, across the border from the epicenter of the Texas outbreak in Gaines County, are linked to the Texas outbreak. Ongoing investigations seek to confirm that connection.

Health officials worry they’re missing cases. Undetected infections bode poorly for communities because doctors and health officials can’t contain transmission if they can’t identify who is infected.

“This is the tip of the iceberg,” said Rekha Lakshmanan, chief strategy officer for The Immunization Partnership in Houston, a nonprofit that advocates for vaccine access. “I think this is going to get a lot worse before it gets better.”

An unknown number of parents may not be taking sick children to clinics where they could be tested, said Katherine Wells, the public health director in Lubbock, Texas. “If your kids are responding to fever reducers and you’re keeping hydrated, some people may keep them at home,” she said.

Most unvaccinated people will contract measles if they’re exposed to the airborne virus, which can linger for up to two hours indoors. Those infected can spread the disease before they have symptoms. Around 1 in 5 people with measles end up hospitalized, 1 in 10 children develop ear infections that can lead to permanent hearing loss, and about 1 in 1,000 children die from respiratory and neurological conditions.

Gaines has a large Mennonite population, which often shuns vaccinations. “We respect everyone’s right to vaccinate or not get vaccinated,” said Albert Pilkington, CEO of the Seminole Hospital District, in the heart of the county, in an interview with Texas Standard. “That’s just what it means to be an American, right?”

Local health officials have been trying to persuade the parents of unvaccinated children to protect their kids by bringing them to pop-up clinics offering measles vaccines.

“Some people who were on the fence, who thought measles wasn’t something their kids would see, are recalculating and coming forward for vaccination,” Wells said.

Local health departments are also operating mobile testing units outside schools in an attempt to detect infections before they spread. They’re staffing clinics that can provide treatment prophylactically for infants exposed to the virus, who are too young for vaccination. Local health officials are advising day care centers on how to protect young children and babies, and educating school nurses on how to spot signs of the disease.

“I am putting 75% of my staff on this outbreak,” Wells said. Although Lubbock isn’t at the center of the outbreak, people infected have sought treatment there. “If someone infected was in the [emergency room], we need to identify everyone who was in that ER within two hours of that visit, notify them, and find out if they were vaccinated.”

Local health departments in rural areas are notoriously underfunded. Wells said the workload has meant pressing pause on other programs, such as one providing substance abuse education.

Zach Holbrooks, executive director of the South Plains Public Health District, which includes Gaines, said health officials were following Centers for Disease Control and Prevention guidelines, as of last year, by advising schools to keep unvaccinated children home for 21 days if they shared a classroom or the cafeteria with someone infected. This means that many parents may need to stay home from work to care for their kids.

“A lot of private schools have closed down because of a high number of sick children,” Holbrooks said.

The burden of measles outbreaks multiplies as the disease spreads. Curbing a 2018 outbreak in Washington state with 72 cases cost about $2.3 million, in addition to $76,000 in medical costs, and an estimated $1 million in economic losses due to illness, quarantines, and caregiving.

Public health researchers expect such outbreaks to become larger and more common because of scores of laws around the U.S. — pending and recently passed — that ultimately lower vaccine rates by allowing parents to exempt their children from vaccine requirements at public schools and some private schools.

Such policies are coupled with misinformation about childhood vaccination now platformed at the highest levels of government. The new director of the Department of Health and Human Services, Robert F. Kennedy Jr., has erroneously blamed vaccines for autism, pointing to discredited theories shown to be untrue by more than a dozen scientific studies.

In Kennedy’s first week on the job, HHS postponed an important meeting of the CDC’s Advisory Committee on Immunization Practices, without saying when it would resume. In addition, the CDC’s letter template to school principals, advising unvaccinated children to remain home from school for 21 days if they’ve been exposed to the measles virus, is no longer on the agency’s website. An old version remains posted on its archive.

As a rule, at least 95% of people need to be vaccinated against measles for a community to be well protected. That threshold is high enough to protect infants too young for the vaccine, people who can’t take the vaccine for medical reasons, and anyone who doesn’t mount a strong, lasting immune response to it. Last school year, the number of kindergartners exempted from a vaccine requirement was higher than ever reported before, according to the CDC.

In Gaines, exemptions were far higher than the national average, approaching 20% in 2023-24. Gaines has one of the lowest rates of childhood vaccination in Texas. At a local public school district in the community of Loop, only 46% of kindergarten students have gotten vaccines that protect against measles.

Amid an outbreak that displays the toll of measles in under-vaccinated pockets of America, Texas lawmakers have filed about 25 bills in this year’s legislative session that could limit vaccination further. Lakshmanan said the public — the majority of whom believe in the benefits of measles vaccination — should contact their representatives about the danger of such decisions. Her group and others offer resources to get involved.

“We’ve got children winding up in the hospital, and yet lawmakers who’ve got their blinders on,” she said, referring to pending policies that will erode vaccination rates. “It’s just mind-blowing.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Sonya Stokes, an emergency room physician in the San Francisco Bay Area, braces herself for a daily deluge of patients sick with coughs, soreness, fevers, vomiting, and other flu-like symptoms.

She’s desperate for information, but the Centers for Disease Control and Prevention, a critical source of urgent analyses of the flu and other public health threats, has gone quiet in the weeks since President Donald Trump took office.

“Without more information, we are blind,” she said.

Flu has been brutal this season. The CDC estimates at least 24 million illnesses, 310,000 hospitalizations, and 13,000 deaths from the flu since the start of October. At the same time, the bird flu outbreak continues to infect cattle and farmworkers. But CDC analyses that would inform people about these situations are delayed, and the CDC has cut off communication with doctors, researchers, and the World Health Organization, say doctors and public health experts.

“CDC right now is not reporting influenza data through the WHO global platforms, FluNet [and] FluID, that they’ve been providing information [on] for many, many years,” Maria Van Kerkhove, interim director of epidemic and pandemic preparedness at the WHO, said at a Feb. 12 press briefing.

“We are communicating with them,” she added, “but we haven’t heard anything back.”

On his first day in office, President Donald Trump announced the U.S. would withdraw from the WHO.

A critical analysis of the seasonal flu selected for distribution through the CDC’s Health Alert Network has stalled, according to people close to the CDC. They asked not to be identified because of fears of retaliation. The network, abbreviated as HAN, is the CDC’s main method of sharing urgent public health information with health officials, doctors, and, sometimes, the public.

A chart from that analysis, reviewed by KFF Health News, suggests that flu may be at a record high. About 7.7% of patients who visited clinics and hospitals without being admitted had flu-like symptoms in early February, a ratio higher than in four other flu seasons depicted in the graph. That includes 2003-04, when an atypical strain of flu fueled a particularly treacherous season that killed at least 153 children.

Without a complete analysis, however, it’s unclear whether this tidal wave of sickness foreshadows a spike in hospitalizations and deaths that hospitals, pharmacies, and schools must prepare for. Specifically, other data could relay how many of the flu-like illnesses are caused by flu viruses — or which flu strain is infecting people. A deeper report might also reveal whether the flu is more severe or contagious than usual.

“I need to know if we are dealing with a more virulent strain or a coinfection with another virus that is making my patients sicker, and what to look for so that I know if my patients are in danger,” Stokes said. “Delays in data create dangerous situations on the front line.”

Although the CDC’s flu dashboard shows a surge of influenza, it doesn’t include all data needed to interpret the situation. Nor does it offer the tailored advice found in HAN alerts that tells health care workers how to protect patients and the public. In 2023, for example, a report urged clinics to test patients with respiratory symptoms rather than assume cases are the flu, since other viruses were causing similar issues that year.

“This is incredibly disturbing,” said Rachel Hardeman, a member of the Advisory Committee to the Director of the CDC. On Feb. 10, Hardeman and other committee members wrote to acting CDC Director Susan Monarez asking the agency to explain missing data, delayed studies, and potentially severe staff cuts. “The CDC is vital to our nation’s security,” the letter said.

Several studies have also been delayed or remain missing from the CDC’s preeminent scientific publication, the Morbidity and Mortality Weekly Report. Anne Schuchat, a former principal deputy director at the CDC, said she would be concerned if there was political oversight of scientific material: “Suppressing information is potentially confusing, possibly dangerous, and it can backfire.”

CDC spokesperson Melissa Dibble declined to comment on delayed or missing analyses. “It is not unexpected to see flu activity elevated and increasing at this time of the year,” she said.

A draft of one unpublished study, reviewed by KFF Health News, that has been withheld from the MMWR for three weeks describes how a milk hauler and a dairy worker in Michigan may have spread bird flu to their pet cats. The indoor cats became severely sick and died. Although the workers weren’t tested, the study says that one of them had irritated eyes before the cat fell ill — a common bird flu symptom. That person told researchers that the pet “would roll in their work clothes.”

After one cat became sick, the investigation reports, an adolescent in the household developed a cough. But the report says this young person tested negative for the flu, and positive for a cold-causing virus.

Corresponding CDC documents summarizing the cat study and another as-yet unpublished bird flu analysis said the reports were scheduled to be published Jan. 23. These were reviewed by KFF Health News. The briefing on cats advises dairy farmworkers to “remove clothing and footwear, and rinse off any animal biproduct residue before entering the household to protect others in the household, including potentially indoor-only cats.”

The second summary refers to “the most comprehensive” analysis of bird flu virus detected in wastewater in the United States.

Jennifer Nuzzo, director of the Pandemic Center at Brown University, said delays of bird flu reports are upsetting because they’re needed to inform the public about a worsening situation with many unknown elements. Citing “insufficient data” and “high uncertainty,” the United Kingdom raised its assessment of the risk posed by the U.S. outbreak on dairies.

“Missing and delayed data causes uncertainty,” Nuzzo said. “It also potentially makes us react in ways that are counterproductive.”

Another bird flu study slated for January publication showed up in the MMWR on Feb. 13, three weeks after it was expected. It revealed that three cattle veterinarians had been unknowingly infected last year, based on the discovery of antibodies against the bird flu virus in their blood. One of the veterinarians worked in Georgia and South Carolina, states that haven’t reported outbreaks on dairy farms.

The study provides further evidence that the United States is not adequately detecting cases in cows and people. Nuzzo said it also highlights how data can supply reassuring news. Only three of 150 cattle veterinarians had signs of prior infections, suggesting that the virus doesn’t easily spread from the animals into people. More than 40 dairy workers have been infected, but they generally have had more sustained contact with sick cattle and their virus-laden milk than veterinarians.

Instead, recently released reports have been about wildfires in California and Hawaii.

“Interesting but not urgent,” Nuzzo said, considering the acute fire emergencies have ended. The bird flu outbreak, she said, is an ongoing “urgent health threat for which we need up-to-the-minute information to know how to protect people.”

“The American public is at greater risk when we don’t have information on a timely basis,” Schuchat said.

This week, a federal judge ordered the CDC and other health agencies to “restore” datasets and websites that the organization Doctors for America had identified in a lawsuit as having been altered. Further, the judge ordered the agencies to “identify any other resources that DFA members rely on to provide medical care” and restore them by Feb. 14.

In their letter, CDC advisory committee members requested an investigation into missing data and delayed reports. Hardeman, an adviser who is a health policy expert at the University of Minnesota, said the group didn’t know why data and scientific findings were being withheld or removed. Still, she added, “I hold accountable the acting director of the CDC, the head of HHS, and the White House.”

Hardeman said the Trump administration has the power to disband the advisory committee. She said the group expects that to happen but proceeded with its demands regardless.

“We want to safeguard the rigor of the work at the CDC because we care deeply about public health,” she said. “We aren’t here to be silent.”

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A measles outbreak is growing in a Texas county with dangerously low vaccination rates.

In late January, two school-age children from Gaines County were hospitalized with measles. Since an estimated 1 in 5 people with the disease end up in the hospital, the two cases suggested a larger outbreak.

As of Feb. 6, there were 12 confirmed cases and health officials expected an additional six, said Zach Holbrooks, executive director of the South Plains Public Health District, which includes Gaines. The department is investigating many other potential cases among close contacts, he said, in hopes of treating people quickly and curbing the spread of the virus.

Public health practitioners warn such outbreaks will become more common because of scores of laws around the U.S. — pending and passed — that ultimately lower vaccine rates. Many of the measures allow parents to more easily exempt their children from school vaccine requirements, and a swell of vaccine misinformation has led to record rates of exemptions.

As Robert F. Kennedy Jr., one of the most influential purveyors of dangerous vaccine misinformation, prepares to take the helm of the Department of Health and Human Services, researchers say such bills have a higher chance of passing and that more parents will refuse vaccines because of false information spread at the highest levels of government.

“Mr. Kennedy has been an opponent of many health-protecting and life-saving vaccines, such as those that prevent measles and polio,” scores of Nobel Prize laureates wrote in a letter to the Senate. Having him head HHS, they wrote, “would put the public’s health in jeopardy.”

Most people who aren’t protected by vaccination will get measles if exposed. Gaines County has one of the lowest rates of childhood vaccination in Texas. At a local public school district in the community of Loop, only 46% of kindergarten students have gotten vaccines against measles, mumps, and rubella. Vaccination rates may be even lower at private schools and within homeschool groups, which don’t always report the information.

Holbrooks’ team is scrambling to track transmission, ensure that kids and babies seek prompt care, and offer measles vaccines to anyone who hasn’t yet gotten them.

“We are going to see more kids infected. We will see more families taking time off from work. More kids in the hospital,” said Rekha Lakshmanan, chief strategy officer for The Immunization Partnership in Houston, a nonprofit that advocates for vaccine access. “This is the tip of the iceberg.”

As a rule, at least 95% of people need to be vaccinated against measles for a community to be well protected. That threshold is high enough to protect infants too young for the vaccine, people who can’t take the vaccine for medical reasons, and anyone who doesn’t mount a strong, lasting immune response to it.

Measles is extremely contagious, so health workers preemptively treated infants too young to be vaccinated who had shared the emergency room with children later diagnosed with the virus, said Katherine Wells, public health director in Lubbock, Texas. Some children from Gaines were hospitalized in that county. The disease can cause severe complications, and about one of every thousand children with measles die.

An outbreak among a largely unvaccinated population in Samoa in 2019 and 2020 caused 83 deaths, mainly among children, and more than 5,700 cases. Kennedy, who peddles misinformation about measles vaccines, had visited the island earlier on a trip arranged by a Samoan anti-vaccine influencer, according to a 2021 blog post by Kennedy.

Without evidence, Kennedy cast doubt on the fact that measles caused the tragedy in Samoa. “We don’t know what was killing them,” he said at his first confirmation hearing. Samoa’s top health official denounced this evasion as “a complete lie,” in an interview with The Associated Press.

Last school year, the number of kindergartners exempted from a vaccine requirement — 3.3% — was higher than ever reported before, according to the Centers for Disease Control and Prevention. Numbers were far higher than that in Gaines County, where nearly 1 in 5 children in kindergarten had a vaccine exemption for philosophical or religious reasons in 2023-24.

Over the past couple of years, several states have allowed more parents to obtain exemptions. Already, about 25 bills have been filed in the 2025 Texas legislative session that could limit vaccination in various ways.

“We’re seeing a level of momentum this legislative session that we’ve never seen in the past,” Lakshaman said. Changes are afoot at the local level, too. For example, a school board in the Houston area voted to remove references to vaccines in its curriculum. “There is a top-down and bottom-up assault on these protections,” Lakshaman said.

About 80% of the public believes that the benefits of the measles, mumps, and rubella vaccines outweigh the risks, according to a 2025 KFF poll.

“Lawmakers who put forth dangerous policies need to know the people they hear from don’t represent the majority,” Lakshaman said. Her group offers resources on its website to help people influence decisions on vaccination policies.

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The Trump administration has intervened in the release of important studies on the bird flu, as an outbreak escalates across the United States.

One of the studies would reveal whether veterinarians who treat cattle have been unknowingly infected by the bird flu virus. Another report documents cases in which people carrying the virus might have infected their pet cats.

The studies were slated to appear in the official journal of the Centers for Disease Control and Prevention, the Morbidity and Mortality Weekly Report. The distinguished journal has been published without interruption since 1952.

Its scientific reports have been swept up in an “immediate pause” on communications by federal health agencies ordered by Dorothy Fink, the acting secretary of the Department of Health and Human Services. Fink’s memo covers “any document intended for publication,” she wrote, “until it has been reviewed and approved by a presidential appointee.” It was sent on President Donald Trump’s first full day in office.

That’s concerning, former CDC officials said, because a firewall has long existed between the agency’s scientific reports and political appointees.

“MMWR is the voice of science,” said Tom Frieden, a former CDC director and the CEO of the nonprofit organization Resolve to Save Lives.

“This idea that science cannot continue until there’s a political lens over it is unprecedented,” said Anne Schuchat, a former principal deputy director at the CDC. “I hope it’s going to be very short-lived, but if it’s not short-lived, it’s censorship.”

White House officials meddled with scientific studies on covid-19 during the first Trump administration, according to interviews and emails collected in a 2022 report from congressional investigators. Still, the MMWR came out as scheduled.

“What’s happening now is quite different than what we experienced in covid, because there wasn’t a stop in the MMWR and other scientific manuscripts,” Schuchat said.

Neither the White House nor HHS officials responded to requests for comment. CDC spokesperson Melissa Dibble said, “This is a short pause to allow the new team to set up a process for review and prioritization.”

News of the interruption hit suddenly last week, just as Fred Gingrich, executive director of the American Association of Bovine Practitioners, a group for veterinarians specializing in cattle medicine, was preparing to hold a webinar with members. He planned to disclose the results of a study he helped lead, slated for publication in the MMWR later that week. Back in September, about 150 members had answered questions and donated blood for the study. Researchers at the CDC analyzed the samples for antibodies against the bird flu virus, to learn whether the veterinarians had been unknowingly infected earlier last year.

Although it would be too late to treat prior cases, the study promised to help scientists understand how the virus spreads from cows to people, what symptoms it causes, and how to prevent infection. “Our members were very excited to hear the results,” Gingrich said.

Like farmworkers, livestock veterinarians are at risk of bird flu infections. The study results could help protect them. And having fewer infections would lessen the chance of the H5N1 bird flu virus evolving within a person to spread efficiently between people — the gateway to a bird flu pandemic.

At least 67 people have tested positive for the bird flu in the U.S., with the majority getting the virus from cows or poultry. But studies and reporting suggest many cases have gone undetected, because testing has been patchy.

Just before the webinar, Gingrich said, the CDC informed him that because of an HHS order, the agency was unable to publish the report last week or communicate its findings. “We had to cancel,” he said.

Another bird flu study slated to be published in the MMWR last week concerns the possibility that people working in Michigan’s dairy industry infected their pet cats. These cases were partly revealed last year in emails obtained by KFF Health News. In one email from July 22, an epidemiologist pushed to publish the group’s investigation to “inform others about the potential for indirect transmission to companion animals.”

Jennifer Morse, medical director at the Mid-Michigan District Health Department and a scientist on the pending study, said she got a note from a colleague last week saying that “there are delays in our publication — outside of our control.”

A person close to the CDC, speaking on the condition of anonymity because of concerns about reprisal, expected the MMWR to be on hold at least until Feb. 6. The journal typically posts on Thursdays, and the HHS memo says the pause will last through Feb. 1.

“It’s startling,” Frieden said. He added that it would become dangerous if the reports aren’t restored. “It would be the equivalent of finding out that your local fire department has been told not to sound any fire alarms,” he said.

In addition to publishing studies, the MMWR keeps the country updated on outbreaks, poisonings, and maternal mortality, and provides surveillance data on cancer, heart disease, HIV, and other maladies. Delaying or manipulating the reports could harm Americans by stunting the ability of the U.S. government to detect and curb health threats, Frieden said.

The freeze is also a reminder of how the first Trump administration interfered with the CDC’s reports on covid, revealed in emails detailed in 2022 by congressional investigators with the House Select Subcommittee on the Coronavirus Crisis. That investigation found that political appointees at HHS altered or delayed the release of five reports and attempted to control several others in 2020.

In one instance, Paul Alexander, then a scientific adviser to HHS, criticized a July 2020 report on a coronavirus outbreak at a Georgia summer camp in an email to MMWR editors, which was disclosed in the congressional investigation. “It just sends the wrong message as written and actually reads as if to send a message of NOT to re-open,” he wrote. Although the report’s data remained the same, the CDC removed remarks on the implications of the findings for schools.

Later that year, Alexander sent an email to then-HHS spokesperson Michael Caputo citing this and another example of his sway over the reports: “Small victory but a victory nonetheless and yippee!!!”

Schuchat, who was at the CDC at the time, said she had never experienced such attempts to spin or influence the agency’s scientific reports in more than three decades with the agency. She hopes it won’t happen again. “The MMWR cannot become a political instrument,” she said.

Gingrich remains hopeful that the veterinary study will come out soon. “We’re an apolitical organization,” he said. “Maintaining open lines of communication and continuing research with our federal partners is critical as we fight this outbreak.”

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Keith Poulsen’s jaw dropped when farmers showed him images on their cellphones at the World Dairy Expo in Wisconsin in October. A livestock veterinarian at the University of Wisconsin, Poulsen had seen sick cows before, with their noses dripping and udders slack.

But the scale of the farmers’ efforts to treat the sick cows stunned him. They showed videos of systems they built to hydrate hundreds of cattle at once. In 14-hour shifts, dairy workers pumped gallons of electrolyte-rich fluids into ailing cows through metal tubes inserted into the esophagus.

“It was like watching a field hospital on an active battlefront treating hundreds of wounded soldiers,” he said.

Nearly a year into the first outbreak of the bird flu among cattle, the virus shows no sign of slowing. The U.S. government failed to eliminate the virus on dairy farms when it was confined to a handful of states, by quickly identifying infected cows and taking measures to keep their infections from spreading. Now at least 845 herds across 16 states have tested positive.

Experts say they have lost faith in the government’s ability to contain the outbreak.

“We are in a terrible situation and going into a worse situation,” said Angela Rasmussen, a virologist at the University of Saskatchewan in Canada. “I don’t know if the bird flu will become a pandemic, but if it does, we are screwed.”

To understand how the bird flu got out of hand, KFF Health News interviewed nearly 70 government officials, farmers and farmworkers, and researchers with expertise in virology, pandemics, veterinary medicine, and more.

Together with emails obtained from local health departments through public records requests, this investigation revealed key problems, including a deference to the farm industry, eroded public health budgets, neglect for the safety of agriculture workers, and the sluggish pace of federal interventions.

Case in point: The U.S. Department of Agriculture this month announced a federal order to test milk nationwide. Researchers welcomed the news but said it should have happened months ago — before the virus was so entrenched.

“It’s disheartening to see so many of the same failures that emerged during the covid-19 crisis reemerge,” said Tom Bollyky, director of the Global Health Program at the Council on Foreign Relations.

Far more bird flu damage is inevitable, but the extent of it will be left to the Trump administration and Mother Nature. Already, the USDA has funneled more than $1.7 billion into tamping down the bird flu on poultry farms since 2022, which includes reimbursing farmers who’ve had to cull their flocks, and more than $430 million into combating the bird flu on dairy farms. In coming years, the bird flu may cost billions of dollars more in expenses and losses. Dairy industry experts say the virus kills roughly 2 to 5% of infected dairy cows and reduces a herd’s milk production by about 20%.

Worse, the outbreak poses the threat of a pandemic. More than 60 people in the U.S. have been infected, mainly by cows or poultry, but cases could skyrocket if the virus evolves to spread efficiently from person to person. And the recent news of a person critically ill in Louisiana with the bird flu shows that the virus can be dangerous.

Just a few mutations could allow the bird flu to spread between people. Because viruses mutate within human and animal bodies, each infection is like a pull of a slot machine lever.

“Even if there’s only a 5% chance of a bird flu pandemic happening, we’re talking about a pandemic that probably looks like 2020 or worse,” said Tom Peacock, a bird flu researcher at the Pirbright Institute in the United Kingdom, referring to covid-19. “The U.S. knows the risk but hasn’t done anything to slow this down,” he added.

Beyond the bird flu, the federal government’s handling of the outbreak reveals cracks in the U.S. health security system that would allow other risky new pathogens to take root, too. “This virus may not be the one that takes off,” said Maria Van Kerkhove, director of the emerging diseases group at the World Health Organization. “But this is a real fire exercise right now, and it demonstrates what needs to be improved.”

A Slow Start

It may have been a grackle, a goose, or some other wild bird that infected a cow in northern Texas. In February, the state’s dairy farmers took note when cows stopped making milk. They worked alongside veterinarians to figure out why. In less than two months, veterinary researchers identified the highly pathogenic H5N1 bird flu virus as the culprit.

Long listed among pathogens with pandemic potential, the bird flu’s unprecedented spread among cows marked a worrying shift. It had evolved to thrive in animals that are more like people biologically than birds.

After the USDA announced the dairy outbreak on March 25, control shifted from farmers, veterinarians, and local officials to state and federal agencies. Collaboration disintegrated almost immediately.

Farmers worried the government might block their milk sales or even demand sick cows be killed, like poultry are, said Kay Russo, a livestock veterinarian in Fort Collins, Colorado.

Instead, Russo and other veterinarians said, they were dismayed by inaction. The USDA didn’t respond to their urgent requests to support studies on dairy farms — and for money and confidentiality policies to protect farmers from financial loss if they agreed to test animals.

The USDA announced that it would conduct studies itself. But researchers grew anxious as weeks passed without results. “Probably the biggest mistake from the USDA was not involving the boots-on-the-ground veterinarians,” Russo said.

Will Clement, a USDA senior adviser for communications, said in an email: “Since first learning of H5N1 in dairy cattle in late March 2024, USDA has worked swiftly and diligently to assess the prevalence of the virus in U.S. dairy herds.” The agency provided research funds to state and national animal health labs beginning in April, he added.

The USDA didn’t require lactating cows to be tested before interstate travel until April 29. By then, the outbreak had spread to eight other states. Farmers often move cattle across great distances, for calving in one place, raising in warm, dry climates, and milking in cooler ones. Analyses of the virus’s genes implied that it spread between cows rather than repeatedly jumping from birds into herds.

Milking equipment was a likely source of infection, and there were hints of other possibilities, such as through the air as cows coughed or in droplets on objects, like work boots. But not enough data had been collected to know how exactly it was happening. Many farmers declined to test their herds, despite an announcement of funds to compensate them for lost milk production.

“There is a fear within the dairy farmer community that if they become officially listed as an affected farm, they may lose their milk market,” said Jamie Jonker, chief science officer at the National Milk Producers Federation, an organization that represents dairy farmers. To his knowledge, he added, this hasn’t happened.

Speculation filled knowledge gaps. Zach Riley, head of the Colorado Livestock Association, said wild birds may be spreading the virus to herds across the country, despite scientific data suggesting otherwise. Riley said farmers were considering whether to install “floppy inflatable men you see outside of car dealerships” to ward off the birds.

Advisories from agriculture departments to farmers were somewhat speculative, too. Officials recommended biosecurity measures such as disinfecting equipment and limiting visitors. As the virus kept spreading throughout the summer, USDA senior official Eric Deeble said at a press briefing, “The response is adequate.”

The USDA, the Centers for Disease Control and Prevention, and the Food and Drug Administration presented a united front at these briefings, calling it a “One Health” approach. In reality, agriculture agencies took the lead.

This was explicit in an email from a local health department in Colorado to the county’s commissioners. “The State is treating this primarily as an agriculture issue (rightly so) and the public health part is secondary,” wrote Jason Chessher, public health director in Weld County, Colorado. The state’s leading agriculture county, Weld’s livestock and poultry industry produces about $1.9 billion in sales each year.

Patchy Surveillance

In July, the bird flu spread from dairies in Colorado to poultry farms. To contain it, two poultry operations employed about 650 temporary workers — Spanish-speaking immigrants as young as 15 — to cull flocks. Inside hot barns, they caught infected birds, gassed them with carbon dioxide, and disposed of the carcasses. Many did the hazardous job without goggles, face masks, and gloves.

By the time Colorado’s health department asked if workers felt sick, five women and four men had been infected. They all had red, swollen eyes — conjunctivitis — and several had such symptoms as fevers, body aches, and nausea.

State health departments posted online notices offering farms protective gear, but dairy workers in several states told KFF Health News that they had none. They also said they hadn’t been asked to get tested.

Studies in Colorado, Michigan, and Texas would later show that bird flu cases had gone under the radar. In one analysis, eight dairy workers who hadn’t been tested — 7% of those studied — had antibodies against the virus, a sign that they had been infected.

Missed cases made it impossible to determine how the virus jumped into people and whether it was growing more infectious or dangerous. “I have been distressed and depressed by the lack of epidemiologic data and the lack of surveillance,” said Nicole Lurie, an executive director at the international organization the Coalition for Epidemic Preparedness Innovations, who served as assistant secretary for preparedness and response in the Obama administration.

Citing “insufficient data,” the British government raised its assessment of the risk posed by the U.S. dairy outbreak in July from three to four on a six-tier scale.

Virologists around the world said they were flabbergasted by how poorly the United States was tracking the situation. “You are surrounded by highly pathogenic viruses in the wild and in farm animals,” said Marion Koopmans, head of virology at Erasmus Medical Center in the Netherlands. “If three months from now we are at the start of the pandemic, it is nobody’s surprise.”

Although the bird flu is not yet spreading swiftly between people, a shift in that direction could cause immense suffering. The CDC has repeatedly described the cases among farmworkers this year as mild — they weren’t hospitalized. But that doesn’t mean symptoms are a breeze, or that the virus can’t cause worse.

“It does not look pleasant,” wrote Sean Roberts, an emergency services specialist at the Tulare County, California, health department in an email to colleagues in May. He described photographs of an infected dairy worker in another state: “Apparently, the conjunctivitis that this is causing is not a mild one, but rather ruptured blood vessels and bleeding conjunctiva.”

Over the past 30 years, half of around 900 people diagnosed with bird flu around the world have died. Even if the case fatality rate is much lower for this strain of the bird flu, covid showed how devastating a 1% death rate can be when a virus spreads easily.

Like other cases around the world, the person now hospitalized with the bird flu in Louisiana appears to have gotten the virus directly from birds. After the case was announced, the CDC released a statement saying, “A sporadic case of severe H5N1 bird flu illness in a person is not unexpected.”

‘The Cows Are More Valuable Than Us‘

Local health officials were trying hard to track infections, according to hundreds of emails from county health departments in five states. But their efforts were stymied. Even if farmers reported infected herds to the USDA and agriculture agencies told health departments where the infected cows were, health officials had to rely on farm owners for access.

“The agriculture community has dictated the rules of engagement from the start,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “That was a big mistake.”

Some farmers told health officials not to visit and declined to monitor their employees for signs of sickness. Sending workers to clinics for testing could leave them shorthanded when cattle needed care. “Producer refuses to send workers to Sunrise [clinic] to get tested since they’re too busy. He has pinkeye, too,” said an email from the Weld, Colorado, health department.

“We know of 386 persons exposed – but we know this is far from the total,” said an email from a public health specialist to officials at Tulare’s health department recounting a call with state health officials. “Employers do not want to run this through worker’s compensation. Workers are hesitant to get tested due to cost,” she wrote.

Jennifer Morse, medical director of the Mid-Michigan District Health Department, said local health officials have been hesitant to apply pressure after the backlash many faced at the peak of covid. Describing the 19 rural counties she serves as “very minimal-government-minded,” she said, “if you try to work against them, it will not go well.”

Rural health departments are also stretched thin. Organizations that specialize in outreach to farmworkers offered to assist health officials early in the outbreak, but months passed without contracts or funding. During the first years of covid, lagging government funds for outreach to farmworkers and other historically marginalized groups led to a disproportionate toll of the disease among people of color.

Kevin Griffis, director of communications at the CDC, said the agency worked with the National Center for Farmworker Health throughout the summer “to reach every farmworker impacted by H5N1.” But Bethany Boggess Alcauter, the center’s director of public health programs, said it didn’t receive a CDC grant for bird flu outreach until October, to the tune of $4 million. Before then, she said, the group had very limited funds for the task. “We are certainly not reaching ‘every farmworker,’” she added.

Farmworker advocates also pressed the CDC for money to offset workers’ financial concerns about testing, including paying for medical care, sick leave, and the risk of being fired. This amounted to an offer of $75 each. “Outreach is clearly not a huge priority,” Boggess said. “I hear over and over from workers, ‘The cows are more valuable than us.’”

The USDA has so far put more than $2.1 billion into reimbursing poultry and dairy farmers for losses due to the bird flu and other measures to control the spread on farms. Federal agencies have also put $292 million into developing and stockpiling bird flu vaccines for animals and people. In a controversial decision, the CDC has advised against offering the ones on hand to farmworkers.

“If you want to keep this from becoming a human pandemic, you focus on protecting farmworkers, since that’s the most likely way that this will enter the human population,” said Peg Seminario, an occupational health researcher in Bethesda, Maryland. “The fact that this isn’t happening drives me crazy.”

Nirav Shah, principal deputy director of the CDC, said the agency aims to keep workers safe. “Widespread awareness does take time,” he said. “And that’s the work we’re committed to doing.”

As Trump comes into office in January, farmworkers may be even less protected. Trump’s pledge of mass deportations will have repercussions, said Tania Pacheco-Werner, director of the Central Valley Health Policy Institute in California, whether they happen or not.

Many dairy and poultry workers are living in the U.S. without authorization or on temporary visas linked to their employers. Such precarity made people less willing to see doctors about covid symptoms or complain about unsafe working conditions in 2020. Pacheco-Werner said, “Mass deportation is an astronomical challenge for public health.”

Not ‘Immaculate Conception’

A switch flipped in September among experts who study pandemics as national security threats. A patient in Missouri had the bird flu, and no one knew why. “Evidence points to this being a one-off case,” Shah said at a briefing with journalists. About a month later, the agency revealed it was not.

Antibody tests found that a person who lived with the patient had been infected, too. The CDC didn’t know how the two had gotten the virus, and the possibility of human transmission couldn’t be ruled out.

Nonetheless, at an October briefing, Shah said the public risk remained low and the USDA’s Deeble said he was optimistic that the dairy outbreak could be eliminated.

Experts were perturbed by such confident statements in the face of uncertainty, especially as California’s outbreak spiked and a child was mysteriously infected by the same strain of virus found on dairy farms.

“This wasn’t just immaculate conception,” said Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies. “It came from somewhere and we don’t know where, but that hasn’t triggered any kind of reset in approach — just the same kind of complacency and low energy.”

Sam Scarpino, a disease surveillance specialist in the Boston area, wondered how many other mysterious infections had gone undetected. Surveillance outside of farms was even patchier than on them, and bird flu tests are hard to get.

Although pandemic experts had identified the CDC’s singular hold on testing for new viruses as a key explanation for why America was hit so hard by covid in 2020, the system remained the same. All bird flu tests must go through the CDC, even though commercial and academic diagnostic laboratories have inquired about running tests themselves since April. The CDC and FDA should have tried to help them along months ago, said Ali Khan, a former top CDC official who now leads the University of Nebraska Medical Center College of Public Health.

As winter sets in, the bird flu becomes harder to spot because patient symptoms may be mistaken for the seasonal flu. Flu season also raises a risk that the two flu viruses could swap genes if they infect a person simultaneously. That could form a hybrid bird flu that spreads swiftly through coughs and sneezes.

A sluggish response to emerging outbreaks may simply be a new, unfortunate norm for America, said Bollyky, at the Council on Foreign Relations. If so, the nation has gotten lucky that the bird flu still can’t spread easily between people. Controlling the virus will be much harder and costlier than it would have been when the outbreak was small. But it’s possible.

Agriculture officials could start testing every silo of bulk milk, in every state, monthly, said Poulsen, the livestock veterinarian. “Not one and done,” he added. If they detect the virus, they’d need to determine the affected farm in time to stop sick cows from spreading infections to the rest of the herd — or at least to other farms. Cows can spread the bird flu before they’re sick, he said, so speed is crucial.

Curtailing the virus on farms is the best way to prevent human infections, said Jennifer Nuzzo, director of the Pandemic Center at Brown University, but human surveillance must be stepped up, too. Every clinic serving communities where farmworkers live should have easy access to bird flu tests — and be encouraged to use them. Funds for farmworker outreach must be boosted. And, she added, the CDC should change its position and offer farmworkers bird flu vaccines to protect them and ward off the chance of a hybrid bird flu that spreads quickly.

The rising number of cases not linked to farms signals a need for more testing in general. When patients are positive on a general flu test — a common diagnostic that indicates human, swine, or bird flu — clinics should probe more deeply, Nuzzo said.

The alternative is a wait-and-see approach in which the nation responds only after enormous damage to lives or businesses. This tack tends to rely on mass vaccination. But an effort analogous to Trump’s Operation Warp Speed is not assured, and neither is rollout like that for the first covid shots, given a rise in vaccine skepticism among Republican lawmakers.

Change may instead need to start from the bottom up — on dairy farms, still the most common source of human infections, said Poulsen. He noticed a shift in attitudes among farmers at the Dairy Expo: “They’re starting to say, ‘How do I save my dairy for the next generation?’ They recognize how severe this is, and that it’s not just going away.”

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Bird flu cases have more than doubled in the country within a few weeks, but researchers can’t determine why the spike is happening because surveillance for human infections has been patchy for seven months.

Just this week, California reported its 15th infection in dairy workers and Washington state reported seven probable cases in poultry workers.

Hundreds of emails from state and local health departments, obtained in records requests from KFF Health News, help reveal why. Despite health officials’ arduous efforts to track human infections, surveillance is marred by delays, inconsistencies, and blind spots.

Several documents reflect a breakdown in communication with a subset of farm owners who don’t want themselves or their employees monitored for signs of bird flu.

For instance, a terse July 29 email from the Weld County Department of Public Health and Environment in Colorado said, “Currently attempting to monitor 26 dairies. 9 have refused.”

The email tallied the people on farms in the state who were supposed to be monitored: “1250+ known workers plus an unknown amount exposed from dairies with whom we have not had contact or refused to provide information.”

Other emails hint that cases on dairy farms were missed. And an exchange between health officials in Michigan suggested that people connected to dairy farms had spread the bird flu virus to pet cats. But there hadn’t been enough testing to really know.

Researchers worldwide are increasingly concerned.

“I have been distressed and depressed by the lack of epidemiologic data and the lack of surveillance,” said Nicole Lurie, formerly the assistant secretary for preparedness and response in the Obama administration.

Bird flu viruses have long been on the short list of pathogens with pandemic potential. Although they have been around for nearly three decades in birds, the unprecedented spread among U.S. dairy cattle this year is alarming: The viruses have evolved to thrive within mammals. Maria Van Kerkhove, head of the emerging diseases unit at the World Health Organization, said, “We need to see more systemic, strategic testing of humans.”

Refusals and Delays

A key reason for spotty surveillance is that public health decisions largely lie with farm owners who have reported outbreaks among their cattle or poultry, according to emails, slide decks, and videos obtained by KFF Health News, and interviews with health officials in five states with outbreaks.

In a video of a small meeting at Central District Health in Boise, Idaho, an official warned colleagues that some dairies don’t want their names or locations disclosed to health departments. “Our involvement becomes very sketchy in such places,” she said.

“I just finished speaking to the owner of the dairy farm,” wrote a public health nurse at the Mid-Michigan district health department in a May 10 email. “[REDACTED] feels that this may have started [REDACTED] weeks ago, that was the first time that they noticed a decrease in milk production,” she wrote. “[REDACTED] does not feel that they need MSU Extension to come out,” she added, referring to outreach to farmworkers provided by Michigan State University.

“We have had multiple dairies refuse a site visit,” wrote the communicable disease program manager in Weld, Colorado, in a July 2 email.

Many farmers cooperated with health officials, but delays between their visits and when outbreaks started meant cases might have been missed. “There were 4 people who discussed having symptoms,” a Weld health official wrote in another email describing her visit to a farm with a bird flu outbreak, “but unfortunately all of them had either already passed the testing window, or did not want to be tested.”

Jason Chessher, who leads Weld’s public health department, said farmers often tell them not to visit because of time constraints.

Dairy operations require labor throughout the day, especially when cows are sick. Pausing work so employees can learn about the bird flu virus or go get tested could cut milk production and potentially harm animals needing attention. And if a bird flu test is positive, the farm owner loses labor for additional days and a worker might not get paid. Such realities complicate public health efforts, several health officials said.

An email from Weld’s health department, about a dairy owner in Colorado, reflected this idea: “Producer refuses to send workers to Sunrise [clinic] to get tested since they’re too busy. He has pinkeye, too.” Pink eye, or conjunctivitis, is a symptom of various infections, including the bird flu.

Chessher and other health officials told KFF Health News that instead of visiting farms, they often ask owners or supervisors to let them know if anyone on-site is ill. Or they may ask farm owners for a list of employee phone numbers to prompt workers to text the health department about any symptoms.

Jennifer Morse, medical director at the Mid-Michigan District Health Department, conceded that relying on owners raises the risk cases will be missed, but that being too pushy could reignite a backlash against public health. Some of the fiercest resistance against covid-19 measures, such as masking and vaccines, were in rural areas.

“It’s better to understand where they’re coming from and figure out the best way to work with them,” she said. “Because if you try to work against them, it will not go well.”

Cat Clues

And then there were the pet cats. Unlike dozens of feral cats found dead on farms with outbreaks, these domestic cats didn’t roam around herds, lapping up milk that teemed with virus.

In emails, Mid-Michigan health officials hypothesized that the cats acquired the virus from droplets, known as fomites, on their owners’ hands or clothing. “If we only could have gotten testing on the [REDACTED] household members, their clothing if possible, and their workplaces, we may have been able to prove human->fomite->cat transmission,” said a July 22 email.

Her colleague suggested they publish a report on the cat cases “to inform others about the potential for indirect transmission to companion animals.”

Thijs Kuiken, a bird flu researcher in the Netherlands, at the Erasmus Medical Center in Rotterdam, said person-to-cat infections wouldn’t be surprising since felines are so susceptible to the virus. Fomites may have been the cause or, he suggested, an infected — but untested — owner might have passed it on.

Hints of missed cases add to mounting evidence of undetected bird flu infections. Health officials said they’re aware of the problem but that it’s not due only to farm owners’ objections.

Local health departments are chronically understaffed. For every 6,000 people in rural areas, there’s one public health nurse — who often works part-time, one analysis found.

“State and local public health departments are decimated resource-wise,” said Lurie, who is now an executive director at an international organization, the Coalition for Epidemic Preparedness Innovations. “You can’t expect them to do the job if you only resource them once there’s a crisis.”

Another explanation is a lack of urgency because the virus hasn’t severely harmed anyone in the country this year. “If hundreds of workers had died, we’d be more forceful about monitoring workers,” Chessher said. “But a handful of mild symptoms don’t warrant a heavy-handed response.”

All the bird flu cases among U.S. farmworkers have presented with conjunctivitis, a cough, a fever, and other flu-like symptoms that resolved without hospitalization. Yet infectious disease researchers note that numbers remain too low for conclusions — especially given the virus’s grim history.

About half of the 912 people diagnosed with the bird flu over three decades died. Viruses change over time, and many cases have probably gone undetected. But even if the true number of cases — the denominator — is five times as high, said Jennifer Nuzzo, director of the Pandemic Center at Brown University, a mortality rate of 10% would be devastating if the bird flu virus evolved to spread swiftly between people. The case fatality rate for covid was around 1%.

By missing cases, the public health system may be slow to notice if the virus becomes more contagious. Already, delays resulted in missing a potential instance of human-to-human transmission in early September. After a hospitalized patient tested positive for the bird flu virus in Missouri, public health officials learned that a person in the patient’s house had been sick — and recovered. It was too late to test for the virus, but on Oct. 24, the CDC announced that an analysis of the person’s blood found antibodies against the bird flu, signs of a prior infection.

CDC Principal Deputy Director Nirav Shah suggested the two people in Missouri had been separately infected, rather than passing the virus from one to the other. But without testing, it’s impossible to know for certain.

The possibility of a more contagious variant grows as flu season sets in. If someone contracts bird flu and seasonal flu at the same time, the two viruses could swap genes to form a hybrid that can spread swiftly. “We need to take steps today to prevent the worst-case scenario,” Nuzzo said.

The CDC can monitor farmworkers directly only at the request of state health officials. The agency is, however, tasked with providing a picture of what’s happening nationwide.

As of Oct. 24, the CDC’s dashboard states that more than 5,100 people have been monitored nationally after exposure to sick animals; more than 260 tested; and 30 bird flu cases detected. (The dashboard hasn’t yet been updated to include the most recent cases and five of Washington’s reports pending CDC confirmation.)

Van Kerkhove and other pandemic experts said they were disturbed by the amount of detail the agency’s updates lack. Its dashboard doesn’t separate numbers by state, or break down how many people were monitored through visits with health officials, daily updates via text, or from a single call with a busy farm owner distracted as cows fall sick. It doesn’t say how many workers in each state were tested or the number of workers on farms that refused contact.

“They don’t provide enough information and enough transparency about where these numbers are coming from,” said Samuel Scarpino, an epidemiologist who specializes in disease surveillance. The number of detected bird flu cases doesn’t mean much without knowing the fraction it represents — the rate at which workers are being infected.

This is what renders California’s increase mysterious. Without a baseline, the state’s rapid uptick could signal it’s testing more aggressively than elsewhere. Alternatively, its upsurge might indicate that the virus has become more infectious — a very concerning, albeit less likely, development.

The CDC declined to comment on concerns about monitoring. On Oct. 4, Shah briefed journalists on California’s outbreak. The state identified cases because it was actively tracking farmworkers, he said. “This is public health in action,” he added.

Salvador Sandoval, a doctor and county health officer in Merced, California, did not exude such confidence. “Monitoring isn’t being done on a consistent basis,” he said, as cases mounted in the region. “It’s a really worrisome situation.”

KFF Health News regional editor Nathan Payne contributed to this report.

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One evening in May, nursing assistant Debra Ragoonanan’s vision blurred during her shift at a state-run Massachusetts veterans home. As her head spun, she said, she called her husband. He picked her up and drove her to the emergency room, where she was diagnosed with a brain aneurysm.

It was the latest in a drumbeat of health issues that she traces to the first months of 2020, when dozens of veterans died at the Soldiers’ Home in Holyoke, in one of the country’s deadliest covid-19 outbreaks at a long-term nursing facility. Ragoonanan has worked at the home for nearly 30 years. Now, she said, the sights, sounds, and smells there trigger her trauma. Among her ailments, she lists panic attacks, brain fog, and other symptoms of post-traumatic stress disorder, a condition linked to aneurysms and strokes.

Scrutiny of the outbreak prompted the state to change the facility’s name to the Massachusetts Veterans Home at Holyoke, replace its leadership, sponsor a $480 million renovation of the premises, and agree to a $56 million settlement for veterans and families. But the front-line caregivers have received little relief as they grapple with the outbreak’s toll.

“I am retraumatized all the time,” Ragoonanan said, sitting on her back porch before her evening shift. “How am I supposed to move forward?”

Covid killed more than 3,600 U.S. health care workers in the first year of the pandemic. It left many more with physical and mental illnesses — and a gutting sense of abandonment.

What workers experienced has been detailed in state investigations, surveys of nurses, and published studies. These found that many health care workers weren’t given masks in 2020. Many got covid and worked while sick. More than a dozen lawsuits filed on behalf of residents or workers at nursing facilities detail such experiences. And others allege that accommodations weren’t made for workers facing depression and PTSD triggered by their pandemic duties. Some of the lawsuits have been dismissed, and others are pending.

Health care workers and unions reported risky conditions to state and federal agencies. But the federal Occupational Safety and Health Administration had fewer inspectors in 2020 to investigate complaints than at any point in a half-century. It investigated only about 1 in 5 covid-related complaints that were filed officially, and just 4% of more than 16,000 informal reports made by phone or email.

Nursing assistants, health aides, and other lower-wage health care workers were particularly vulnerable during outbreaks, and many remain burdened now. About 80% of lower-wage workers who provide long-term care are women, and these workers are more likely to be immigrants, to be people of color, and to live in poverty than doctors or nurses.

Some of these factors increased a person’s covid risk. They also help explain why these workers had limited power to avoid or protest hazardous conditions, said Eric Frumin, formerly the safety and health director for the Strategic Organizing Center, a coalition of labor unions.

He also cited decreasing membership in unions, which negotiate for higher wages and safer workplaces. One-third of the U.S. labor force was unionized in the 1950s, but the level has fallen to 10% in recent years.

Like essential workers in meatpacking plants and warehouses, nursing assistants were at risk because of their status, Frumin said: “The powerlessness of workers in this country condemns them to be treated as disposable.”

In interviews, essential workers in various industries told KFF Health News they felt duped by a system that asked them to risk their lives in the nation’s moment of need but that now offers little assistance for harm incurred in the line of duty.

“The state doesn’t care. The justice system doesn’t care. Nobody cares,” Ragoonanan said. “All of us have to go right back to work where this started, so that’s a double whammy.”

‘A War Zone’

The plight of health care workers is a problem for the United States as the population ages and the threat of future pandemics looms. Surgeon General Vivek Murthy called their burnout “an urgent public health issue” leading to diminished care for patients. That’s on top of a predicted shortage of more than 3.2 million lower-wage health care workers by 2026, according to the Mercer consulting firm.

The veterans home in Holyoke illustrates how labor conditions can jeopardize the health of employees. The facility is not unique, but its situation has been vividly described in a state investigative report and in a report from a joint oversight committee of the Massachusetts Legislature.

The Soldiers’ Home made headlines in March 2020 when The Boston Globe got a tip about refrigerator trucks packed with the bodies of dead veterans outside the facility. About 80 residents died within a few months.

The state investigation placed blame on the home’s leadership, starting with Superintendent Bennett Walsh. “Mr. Walsh and his team created close to an optimal environment for the spread of COVID-19,” the report said. He resigned under pressure at the end of 2020.

Investigators said that “at least 80 staff members” tested positive for covid, citing “at least in part” the management’s “failure to provide and require the use of proper protective equipment,” even restricting the use of masks. They included a disciplinary letter sent to one nursing assistant who had donned a mask as he cared for a sick veteran overnight in March. “Your actions are disruptive, extremely inappropriate,” it said.

To avoid hiring more caretakers, the home’s leadership combined infected and uninfected veterans in the same unit, fueling the spread of the virus, the report found. It said veterans didn’t receive sufficient hydration or pain-relief drugs as they approached death, and it included testimonies from employees who described the situation as “total pandemonium,” “a nightmare,” and “a war zone.”

Because his wife was immunocompromised, Walsh didn’t enter the care units during this period, according to his lawyer’s statement in a deposition obtained by KFF Health News. “He never observed the merged unit,” it said.

In contrast, nursing assistants told KFF Health News that they worked overtime, even with covid, because they were afraid of being fired if they stayed home. “I kept telling my supervisor, ‘I am very, very sick,’” said Sophia Darkowaa, a nursing assistant who said she now suffers from PTSD and symptoms of long covid. “I had like four people die in my arms while I was sick.”

Nursing assistants recounted how overwhelmed and devasted they felt by the pace of death among veterans whom they had known for years — years of helping them dress, shave, and shower, and of listening to their memories of war.

“They were in pain. They were hollering. They were calling on God for help,” Ragoonanan said. “They were vomiting, their teeth showing. They’re pooping on themselves, pooping on your shoes.”

Nursing assistant Kwesi Ablordeppey said the veterans were like family to him. “One night I put five of them in body bags,” he said. “That will never leave my mind.”

Four years have passed, but he said he still has trouble sleeping and sometimes cries in his bedroom after work. “I wipe the tears away so that my kids don’t know.”

High Demands, Low Autonomy

A third of health care workers reported symptoms of PTSD related to the pandemic, according to surveys between January 2020 and May 2022 covering 24,000 workers worldwide. The disorder predisposes people to dementia and Alzheimer’s. It can lead to substance use and self-harm.

Since covid began, Laura van Dernoot Lipsky, director of the Trauma Stewardship Institute, has been inundated by emails from health care workers considering suicide. “More than I have ever received in my career,” she said. Their cries for help have not diminished, she said, because trauma often creeps up long after the acute emergency has quieted.

Another factor contributing to these workers’ trauma is “moral injury,” a term first applied to soldiers who experienced intense guilt after carrying out orders that betrayed their values. It became common among health care workers in the pandemic who weren’t given ample resources to provide care.

“Folks who don’t make as much money in health care deal with high job demands and low autonomy at work, both of which make their positions even more stressful,” said Rachel Hoopsick, a public health researcher at the University of Illinois at Urbana-Champaign. “They also have fewer resources to cope with that stress,” she added.

People in lower income brackets have less access to mental health treatment. And health care workers with less education and financial security are less able to take extended time off, to relocate for jobs elsewhere, or to shift careers to avoid retriggering their traumas.

Such memories can feel as intense as the original event. “If there’s not a change in circumstances, it can be really, really, really hard for the brain and nervous system to recalibrate,” van Dernoot Lipsky said. Rather than focusing on self-care alone, she pushes for policies to ensure adequate staffing at health facilities and accommodations for mental health issues.

In 2021, Massachusetts legislators acknowledged the plight of the Soldiers’ Home residents and staff in a joint committee report saying the events would “impact their well-being for many years.”

But only veterans have received compensation. “Their sacrifices for our freedom should never be forgotten or taken for granted,” the state’s veterans services director, Jon Santiago, said at an event announcing a memorial for veterans who died in the Soldiers’ Home outbreak. The state’s $56 million settlement followed a class-action lawsuit brought by about 80 veterans who were sickened by covid and a roughly equal number of families of veterans who died.

The state’s attorney general also brought criminal charges against Walsh and the home’s former medical director, David Clinton, in connection with their handling of the crisis. The two averted a trial and possible jail time this March by changing their not-guilty pleas, instead acknowledging that the facts of the case were sufficient to warrant a guilty finding.

An attorney representing Walsh and Clinton, Michael Jennings, declined to comment on queries from KFF Health News. He instead referred to legal proceedings in March, in which Jennings argued that “many nursing homes proved inadequate in the nascent days of the pandemic” and that “criminalizing blame will do nothing to prevent further tragedy.”

Nursing assistants sued the home’s leadership, too. The lawsuit alleged that, in addition to their symptoms of long covid, what the aides witnessed “left them emotionally traumatized, and they continue to suffer from post-traumatic stress disorder.”

The case was dismissed before trial, with courts ruling that the caretakers could have simply left their jobs. “Plaintiff could have resigned his employment at any time,” Judge Mark Mastroianni wrote, referring to Ablordeppey, the nursing assistants’ named representative in the case.

But the choice was never that simple, said Erica Brody, a lawyer who represented the nursing assistants. “What makes this so heartbreaking is that they couldn’t have quit, because they needed this job to provide for their families.”

‘Help Us To Retire’

Brody didn’t know of any cases in which staff at long-term nursing facilities successfully held their employers accountable for labor conditions in covid outbreaks that left them with mental and physical ailments. KFF Health News pored through lawsuits and called about a dozen lawyers but could not identify any such cases in which workers prevailed.

A Massachusetts chapter of the Service Employees International Union, SEIU Local 888, is looking outside the justice system for help. It has pushed for a bill — proposed last year by Judith García, a Democratic state representative — to allow workers at the state veterans home in Holyoke, along with its sister facility in Chelsea, to receive their retirement benefits five to 10 years earlier than usual. The bill’s fate will be decided in December.

Retirement benefits for Massachusetts state employees amount to 80% of a person’s salary. Workers qualify at different times, depending on the job. Police officers get theirs at age 55. Nursing assistants qualify once the sum of their time working at a government facility and their age comes to around 100 years. The state stalls the clock if these workers take off more than their allotted days for sickness or vacation.

Several nursing assistants at the Holyoke veterans home exceeded their allotments because of long-lasting covid symptoms, post-traumatic stress, and, in Ragoonanan’s case, a brain aneurysm. Even five years would make a difference, Ragoonanan said, because, at age 56, she fears her life is being shortened. “Help us to retire,” she said, staring at the slippers covering her swollen feet. “We have bad PTSD. We’re crying, contemplating suicide.”

Certain careers are linked with shorter life spans. Similarly, economists have shown that, on average, people with lower incomes in the United States die earlier than those with more. Nearly 60% of long-term care workers are among the bottom earners in the country, paid less than $30,000 — or about $15 per hour — in 2018, according to analyses by the Department of Health and Human Services and KFF, a health policy research, polling, and news organization that includes KFF Health News.

Fair pay was among the solutions listed in the surgeon general’s report on burnout. Another was “hazard compensation during public health emergencies.”

If employers offer disability benefits, that generally entails a pay cut. Nursing assistants at the Holyoke veterans home said it would halve their wages, a loss they couldn’t afford.

“Low-wage workers are in an impossible position, because they’re scraping by with their full salaries,” said John Magner, SEIU Local 888’s legal director.

Despite some public displays of gratitude for health care workers early in the pandemic, essential workers haven’t received the financial support given to veterans or to emergency personnel who risked their lives to save others in the aftermath of 9/11. Talk show host Jon Stewart, for example, has lobbied for this group for over a decade, successfully pushing Congress to compensate them for their sacrifices.

“People need to understand how high the stakes are,” van Dernoot Lipsky said. “It’s so important that society doesn’t put this on individual workers and then walk away.”

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Headlines are flying after the Department of Agriculture confirmed that the H5N1 bird flu virus has infected dairy cows around the country. Tests have detected the virus among cattle in nine states, mainly in Texas and New Mexico, and most recently in Colorado, said Nirav Shah, principal deputy director at the Centers for Disease Control and Prevention, at a May 1 event held by the Council on Foreign Relations.

A menagerie of other animals have been infected by H5N1, and at least one person in Texas. But what scientists fear most is if the virus were to spread efficiently from person to person. That hasn’t happened and might not. Shah said the CDC considers the H5N1 outbreak “a low risk to the general public at this time.”

Viruses evolve and outbreaks can shift quickly. “As with any major outbreak, this is moving at the speed of a bullet train,” Shah said. “What we’ll be talking about is a snapshot of that fast-moving train.” What he means is that what’s known about the H5N1 bird flu today will undoubtedly change.

With that in mind, KFF Health News explains what you need to know now.

Q: Who gets the bird flu?

Mainly birds. Over the past few years, however, the H5N1 bird flu virus has increasingly jumped from birds into mammals around the world. The growing list of more than 50 species includes seals, goats, skunks, cats, and wild bush dogs at a zoo in the United Kingdom. At least 24,000 sea lions died in outbreaks of H5N1 bird flu in South America last year.

What makes the current outbreak in cattle unusual is that it’s spreading rapidly from cow to cow, whereas the other cases — except for the sea lion infections — appear limited. Researchers know this because genetic sequences of the H5N1 viruses drawn from cattle this year were nearly identical to one another.

The cattle outbreak is also concerning because the country has been caught off guard. Researchers examining the virus’s genomes suggest it originally spilled over from birds into cows late last year in Texas, and has since spread among many more cows than have been tested. “Our analyses show this has been circulating in cows for four months or so, under our noses,” said Michael Worobey, an evolutionary biologist at the University of Arizona in Tucson.

Q: Is this the start of the next pandemic?

Not yet. But it’s a thought worth considering because a bird flu pandemic would be a nightmare. More than half of people infected by older strains of H5N1 bird flu viruses from 2003 to 2016 died. Even if death rates turn out to be less severe for the H5N1 strain currently circulating in cattle, repercussions could involve loads of sick people and hospitals too overwhelmed to handle other medical emergencies.

Although at least one person has been infected with H5N1 this year, the virus can’t lead to a pandemic in its current state. To achieve that horrible status, a pathogen needs to sicken many people on multiple continents. And to do that, the H5N1 virus would need to infect a ton of people. That won’t happen through occasional spillovers of the virus from farm animals into people. Rather, the virus must acquire mutations for it to spread from person to person, like the seasonal flu, as a respiratory infection transmitted largely through the air as people cough, sneeze, and breathe. As we learned in the depths of covid-19, airborne viruses are hard to stop.

That hasn’t happened yet. However, H5N1 viruses now have plenty of chances to evolve as they replicate within thousands of cows. Like all viruses, they mutate as they replicate, and mutations that improve the virus’s survival are passed to the next generation. And because cows are mammals, the viruses could be getting better at thriving within cells that are closer to ours than birds’.

The evolution of a pandemic-ready bird flu virus could be aided by a sort of superpower possessed by many viruses. Namely, they sometimes swap their genes with other strains in a process called reassortment. In a study published in 2009, Worobey and other researchers traced the origin of the H1N1 “swine flu” pandemic to events in which different viruses causing the swine flu, bird flu, and human flu mixed and matched their genes within pigs that they were simultaneously infecting. Pigs need not be involved this time around, Worobey warned.

Q: Will a pandemic start if a person drinks virus-contaminated milk?

Not yet. Cow’s milk, as well as powdered milk and infant formula, sold in stores is considered safe because the law requires all milk sold commercially to be pasteurized. That process of heating milk at high temperatures kills bacteria, viruses, and other teeny organisms. Tests have identified fragments of H5N1 viruses in milk from grocery stores but confirm that the virus bits are dead and, therefore, harmless.

Unpasteurized “raw” milk, however, has been shown to contain living H5N1 viruses, which is why the FDA and other health authorities strongly advise people not to drink it. Doing so could cause a person to become seriously ill or worse. But even then, a pandemic is unlikely to be sparked because the virus — in its current form — does not spread efficiently from person to person, as the seasonal flu does.

Q: What should be done?

A lot! Because of a lack of surveillance, the U.S. Department of Agriculture and other agencies have allowed the H5N1 bird flu to spread under the radar in cattle. To get a handle on the situation, the USDA recently ordered all lactating dairy cattle to be tested before farmers move them to other states, and the outcomes of the tests to be reported.

But just as restricting covid tests to international travelers in early 2020 allowed the coronavirus to spread undetected, testing only cows that move across state lines would miss plenty of cases.

Such limited testing won’t reveal how the virus is spreading among cattle — information desperately needed so farmers can stop it. A leading hypothesis is that viruses are being transferred from one cow to the next through the machines used to milk them.

To boost testing, Fred Gingrich, executive director of a nonprofit organization for farm veterinarians, the American Association of Bovine Practitioners, said the government should offer funds to cattle farmers who report cases so that they have an incentive to test. Barring that, he said, reporting just adds reputational damage atop financial loss.

“These outbreaks have a significant economic impact,” Gingrich said. “Farmers lose about 20% of their milk production in an outbreak because animals quit eating, produce less milk, and some of that milk is abnormal and then can’t be sold.”

The government has made the H5N1 tests free for farmers, Gingrich added, but they haven’t budgeted money for veterinarians who must sample the cows, transport samples, and file paperwork. “Tests are the least expensive part,” he said.

If testing on farms remains elusive, evolutionary virologists can still learn a lot by analyzing genomic sequences from H5N1 viruses sampled from cattle. The differences between sequences tell a story about where and when the current outbreak began, the path it travels, and whether the viruses are acquiring mutations that pose a threat to people. Yet this vital research has been hampered by the USDA’s slow and incomplete posting of genetic data, Worobey said.

The government should also help poultry farmers prevent H5N1 outbreaks since those kill many birds and pose a constant threat of spillover, said Maurice Pitesky, an avian disease specialist at the University of California-Davis.

Waterfowl like ducks and geese are the usual sources of outbreaks on poultry farms, and researchers can detect their proximity using remote sensing and other technologies. By zeroing in on zones of potential spillover, farmers can target their attention. That can mean routine surveillance to detect early signs of infections in poultry, using water cannons to shoo away migrating flocks, relocating farm animals, or temporarily ushering them into barns. “We should be spending on prevention,” Pitesky said.

Q: OK it’s not a pandemic, but what could happen to people who get this year’s H5N1 bird flu?

No one really knows. Only one person in Texas has been diagnosed with the disease this year, in April. This person worked closely with dairy cows, and had a mild case with an eye infection. The CDC found out about them because of its surveillance process. Clinics are supposed to alert state health departments when they diagnose farmworkers with the flu, using tests that detect influenza viruses, broadly. State health departments then confirm the test, and if it’s positive, they send a person’s sample to a CDC laboratory, where it is checked for the H5N1 virus, specifically. “Thus far we have received 23,” Shah said. “All but one of those was negative.”

State health department officials are also monitoring around 150 people, he said, who have spent time around cattle. They’re checking in with these farmworkers via phone calls, text messages, or in-person visits to see if they develop symptoms. And if that happens, they’ll be tested.

Another way to assess farmworkers would be to check their blood for antibodies against the H5N1 bird flu virus; a positive result would indicate they might have been unknowingly infected. But Shah said health officials are not yet doing this work.

“The fact that we’re four months in and haven’t done this isn’t a good sign,” Worobey said. “I’m not super worried about a pandemic at the moment, but we should start acting like we don’t want it to happen.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Rates of routine childhood vaccination hit a 10-year low in 2023. That, according to the Centers for Disease Control and Prevention, puts about 250,000 kindergartners at risk for measles, which often leads to hospitalization and can cause death. In recent weeks, an infant and two young children have been hospitalized amid an ongoing measles outbreak in Philadelphia that spread to a day care center.

It’s a dangerous shift driven by a critical mass of people who now reject decades of science backing the safety and effectiveness of childhood vaccines. State by state, they’ve persuaded legislators and courts to more easily allow children to enter kindergarten without vaccines, citing religious, spiritual, or philosophical beliefs.

Growing vaccine hesitancy is just a small part of a broader rejection of scientific expertise that could have consequences ranging from disease outbreaks to reduced funding for research that leads to new treatments. “The term ‘infodemic’ implies random junk, but that’s wrong,” said Peter Hotez, a vaccine researcher at Baylor College of Medicine in Texas. “This is an organized political movement, and the health and science sectors don’t know what to do.”

Changing views among Republicans have steered the relaxation of childhood vaccine requirements, according to the Pew Research Center. Whereas nearly 80% of Republicans supported the rules in 2019, fewer than 60% do today. Democrats have held steady, with about 85% supporting. Mississippi, which once boasted the nation’s highest rates of childhood vaccination, began allowing religious exemptions last summer. Another leader in vaccination, West Virginia, is moving to do the same.

An anti-science movement picked up pace as Republican and Democratic perspectives on science diverged during the pandemic. Whereas 70% of Republicans said that science has a mostly positive impact on society in 2019, less than half felt that way in a November poll from Pew. With presidential candidates lending airtime to anti-vaccine messages and members of Congress maligning scientists and pandemic-era public health policies, the partisan rift will likely widen in the run-up to November’s elections.

Dorit Reiss, a vaccine policy researcher at the University of California Law San Francisco, draws parallels between today’s backlash against public health and the early days of climate change denial. Both issues progressed from nonpartisan, fringe movements to the mainstream once they appealed to conservatives and libertarians, who traditionally seek to limit government regulation. “Even if people weren’t anti-vaccine to start with,” Reiss said, “they move that way when the argument fits.”

Even certain actors are the same. In the late ’90s and early 2000s, a libertarian think tank, the American Institute for Economic Research, undermined climate scientists with reports that questioned global warming. The same institute issued a statement early in the pandemic, grandly called the “Great Barrington Declaration.” It argued against measures to curb the disease and advised everyone — except the most vulnerable — to go about their lives as usual, regardless of the risk of infection. Tedros Adhanom Ghebreyesus, director-general of the World Health Organization, warned that such an approach would overwhelm health systems and put millions more at risk of disability and death from covid. “Allowing a dangerous virus that we don’t fully understand to run free is simply unethical,” he said.

Another group, the National Federation of Independent Business, has fought regulatory measures to curb climate change for over a decade. It moved on to vaccines in 2022 when it won a Supreme Court case that overturned a government effort to temporarily require employers to mandate that workers either be vaccinated against covid or wear a face mask and test on a regular basis. Around 1,000 to 3,000 covid deaths would have been averted in 2022 had the court upheld the rule, one study estimates.

Politically charged pushback may become better funded and more organized if public health becomes a political flashpoint in the lead-up to the presidential election. In the first few days of 2024, Florida’s surgeon general, appointed by Republican presidential candidate and Florida Gov. Ron DeSantis, called for a halt to use of mRNA covid vaccines as he echoed DeSantis’ incorrect statement that the shots have “not been proven to be safe and effective.” And vaccine skeptic Robert F. Kennedy Jr., who is running for president as an independent, announced that his campaign communications would be led by Del Bigtree, the executive director of one of the most well-heeled anti-vaccine organizations in the nation and host of a conspiratorial talk show. Bigtree posted a letter on the day of the announcement rife with misinformation, such as a baseless rumor that covid vaccines make people more prone to infection. He and Kennedy frequently pair health misinformation with terms that appeal to anti-government ideologies like “medical freedom” and “religious freedom.”

A product of a Democratic dynasty, Kennedy’s appeal appears to be stronger among Republicans, a Politico analysis found. DeSantis said he would consider nominating Kennedy to run the FDA, which approves drugs and vaccines, or the CDC, which advises on vaccines and other public health measures. Another Republican candidate for president, Vivek Ramaswamy, vowed to gut the CDC should he win.

Today’s anti-science movement found its footing in the months before the 2020 elections, as primarily Republican politicians rallied support from constituents who resented pandemic measures like masking and the closure of businesses, churches, and schools. Then-President Donald Trump, for example, mocked Joe Biden for wearing a mask at the presidential debate in September 2020. Democrats fueled the politicization of public health, too, by blaming Republican leaders for the country’s soaring death rates, rather than decrying systemic issues that rendered the U.S. vulnerable, such as underfunded health departments and severe economic inequality that put some groups at far higher risk than others. Just before Election Day, a Democratic-led congressional subcommittee released a report that called the Trump administration’s pandemic response “among the worst failures of leadership in American history.”

Republicans launched a subcommittee investigation into the pandemic that sharply criticizes scientific institutions and scientists once seen as nonpartisan. On Jan. 8 and 9, the group questioned Anthony Fauci, a leading infectious disease researcher who has advised both Republican and Democratic presidents. Without evidence, committee member Marjorie Taylor Greene (R-Ga.) accused Fauci of supporting research that created the coronavirus in order to push vaccines: “He belongs in jail for that,” Greene, a vaccine skeptic, said. “This is like a, more of an evil version of science.”

Taking a cue from environmental advocacy groups that have tried to fight strategic and monied efforts to block energy regulations, Hotez and other researchers say public health needs supporters knowledgeable in legal and political arenas. Such groups might combat policies that limit public health power, advise lawmakers, and provide legal counsel to scientists who are harassed or called before Congress in politically charged hearings. Other initiatives aim to present the scientific consensus clearly to avoid both-sidesism, in which the media presents opposing viewpoints as equal when, in fact, the majority of researchers and bulk of evidence point in one direction. Oil and tobacco companies used this tactic effectively to seed doubt about the science linking their industries to harm.

Kathleen Hall Jamieson, director of the Annenberg Public Policy Center at the University of Pennsylvania, said the scientific community must improve its communication. Expertise, alone, is insufficient when people mistrust the experts’ motives. Indeed, nearly 40% of Republicans report little to no confidence in scientists to act in the public’s best interest.

In a study published last year, Jamieson and colleagues identified attributes the public values beyond expertise, including transparency about unknowns and self-correction. Researchers might have better managed expectations around covid vaccines, for example, by emphasizing that the protection conferred by most vaccines is less than 100% and wanes over time, requiring additional shots, Jamieson said. And when the initial covid vaccine trials demonstrated that the shots drastically curbed hospitalization and death but revealed little about infections, public health officials might have been more open about their uncertainty.

As a result, many people felt betrayed when covid vaccines only moderately reduced the risk of infection. “We were promised that the vaccine would stop transmission, only to find out that wasn’t completely true, and America noticed,” said Rep. Brad Wenstrup (R-Ohio), chair of the Republican-led coronavirus subcommittee, at a July hearing.

Jamieson also advises repetition. It’s a technique expertly deployed by those who promote misinformation, which perhaps explains why the number of people who believe the anti-parasitic drug ivermectin treats covid more than doubled over the past two years — despite persistent evidence to the contrary. In November, the drug got another shoutout at a hearing where congressional Republicans alleged that the Biden administration and science agencies had censored public health information.

Hotez, author of a new book on the rise of the anti-science movement, fears the worst. “Mistrust in science is going to accelerate,” he said.

And traditional efforts to combat misinformation, such as debunking, may prove ineffective.

“It’s very problematic,” Jamieson said, “when the sources we turn to for corrective knowledge have been discredited.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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