Questions swirl over who's running the CDC

Why it matters: Almost six months into the Trump administration, the vaunted health agency is staring down threats like respiratory viruses, avian flu and foodborne diseases without a bona fide public health official or designated point person at the helm.

• That's left some decisions flowing straight up to Health Secretary Robert F. Kennedy Jr.

What they're saying: "You want to make sure the agency is ready should there be a public health emergency," said Richard Besser, a former acting CDC director and now head of the Robert Wood Johnson Foundation.

• "That's something you can't plan for, and given it can take time to get a permanent director in place, you want to make sure that the agency is able to do its work appropriately."

State of play: Kennedy faced questions about the direction of the agency during a Senate hearing last month, telling Sen. Lisa Blunt Rochester (D-Del.) that Matthew Buzzelli, who's listed on the CDC website as chief of staff, is the acting director.

• Kennedy called Buzzelli, a former Justice Department trial lawyer and private sector executive, a public health expert, Stat reported. His biography on the CDC website lists no public health experience.
• President Trump in March nominated then-acting CDC director Susan Monarez, a career government scientist, to be permanent head of the agency after he withdrew the nomination of his first choice, former Rep. Dave Weldon.
• But under the rules governing federal vacancies, Monarez couldn't continue serving as acting director. The Senate has yet to schedule a confirmation hearing.

Health and Human Services spokesperson Andrew Nixon said on Wednesday that Buzzelli is performing some director duties in the meantime.

• "The CDC Chief of Staff has been carrying out some of the duties of the CDC Director as the Senior Official, as necessary, and is surrounded by highly qualified medical professionals and advisors to help fulfill these duties as appropriate," Nixon told Axios in an email.
• Nixon didn't respond to questions about who is carrying out the rest of the responsibilities.
• Blunt Rochester's office told Axios that the agency hasn't furnished any more answers about who's leading CDC since the May 14 hearing.

CDC employees also aren't sure who's in charge. Most external communications updates have to be approved by the office of the HHS assistant secretary for public affairs, which reports directly to Kennedy, according to one agency employee who spoke on the condition of anonymity out of fear of repercussions.

• The assistant secretary role was filled in May, per the HHS website.
• "We're being so inefficient, so grossly inefficient, because we cannot make decisions," they said. "We're spending a lot of time planning for all these contingencies that we wouldn't normally have to plan for if we actually had some leadership."
• The departure of midlevel leaders, like the reported resignation this week of a career CDC physician who led the COVID vaccine recommendation work group, adds an extra layer of concern.
• Lakshmi Panagiotakopoulos sent a letter to work group members saying that she felt she could no longer continue to help the most vulnerable in her role, per a Reuters report.
• Her resignation comes after Kennedy announced that the CDC would no longer recommend COVID vaccines for healthy kids and pregnant women. The CDC later updated its guidelines to recommend that healthy kids discuss whether to get the vaccine with their doctor.

• "Losing that type of guidance is really hard and really demoralizing, because you know you're losing somebody that does care about the science," the CDC employee said. "The fear is the more people like that that leave, the more of a power vacuum that is, the more it leaves open for mis- and dis-information."

Between the lines: In the absence of a named acting director, some official duties are being handled by Kennedy himself.

• Last month, Kennedy approved an expert panel recommendation for chikungunya vaccinations for travelers and lab workers, according to the agency website and first reported by Inside Medicine.
• Kennedy did not act on advisers' recommendations for RSV and meningitis vaccines.
• A federal statute known as the Vacancies Act says the that when a top agency position is vacant, the "first assistant" in the office automatically becomes acting director if no one else is named. But the statute doesn't define who the first assistant is.

What we're watching: The uncertainty could continue for a while.

• Monarez would be the first CDC director to be confirmed by the Senate after Congress changed requirements amid post-pandemic scrutiny of the agency in 2023.
• The Senate health committee told Axios on Wednesday that it has not yet received all the paperwork necessary to schedule a hearing on the nomination. Another Senate staff member told Axios that Monarez has recently been making the rounds and meeting with senators.

The bottom line: "CDC folks are really well equipped for dealing with uncertainty, because we work on emergency responses," the agency employee told Axios. Still, "it's hard when the internal is chaotic."

- Tina Reed contributed reporting

Editor's note: The story has been updated to show the assistant secretary for public affairs position is filled, per an update posted June 5 on the HHS website.