Nancy Cox, a renowned figure in influenza research for many years, has passed away. She led the influenza team at the Centers for Disease Control and Prevention (CDC) for 22 years, expanding it from a small branch of 14 to a robust division of over 100 members. Cox also served as the director of the World Health Organization’s Collaborating Center for the Surveillance, Epidemiology, and Control of Influenza at the CDC.
Cox passed away on Thursday due to glioblastoma, a type of brain cancer. She was 77.
As a virologist, Cox was instrumental in guiding the CDC’s response to seasonal flu and in preparing for potential influenza pandemics. She was well-regarded for her efforts in promoting global initiatives to monitor the evolution of seasonal flu viruses and to identify new viruses that could lead to pandemics.
“She was a critical component of connecting countries all around the globe,” said Daniel Jernigan, who worked under Cox as deputy director of the flu division and succeeded her upon her retirement in 2014. “Because of her vision, we are better prepared for pandemics and providing better prevention of influenza illness and death.”
Under Cox’s leadership, her team made significant contributions to the surveillance system that supports the annual updates of flu vaccines.
“She was central to the integration of modern technologies into vaccine strain selection and pandemic preparedness activities and was always the first to remind everyone what was at stake, the health of millions,” said Richard Webby, head of the WHO Collaborating Centre for Studies on the Ecology of Influenza in Animals and Birds at St. Jude Children’s Research Hospital in Memphis.
Colleagues and collaborators of Cox quickly lauded her dedication, diplomatic skills, and commitment to expanding global flu surveillance.
“There are a lot of really great scientists involved in influenza. … But nobody had the kind of respect and breadth and reverence that Nancy had. And it was really clear why,” stated Keiji Fukuda, who served as chief of influenza epidemiology under Cox before joining the WHO’s influenza program in 2005.
“Part of it is that she just knew so much about influenza — the science, the history, the contemporary milieu. Part of it was because she was kind of at the nexus of science and public health. But I think a lot of it was just because of how she was.”
Cox was known not only for her profound knowledge of influenza but also for her strong and supportive leadership. Arnold Monto, a veteran flu researcher and professor emeritus at the University of Michigan, highlighted Cox’s efforts to help junior colleagues develop their skills, enabling them to grow and thrive.
Fukuda, now retired, described her as a terrific boss. “She could be goofy. She could be funny. She could be girlish. And she could be very stern when she was upset,” he noted. “But what you knew is that she was always attentive, and she was fair, she didn’t micromanage, and she expected you to work hard. And when you looked at her as an example, you just were working for somebody that you wanted to work hard for.”
Born and raised in rural Iowa, Cox earned a bachelor’s degree in bacteriology from Iowa State University. She went on to study at the University of Cambridge in the United Kingdom on a Marshall fellowship, where she obtained a doctorate in virology.
She began her career at the CDC in 1975 and was appointed head of the influenza branch in 1992.
The field of influenza research gained significant attention in the late 1990s and mid-2000s when the H5N1 bird flu virus began causing widespread poultry deaths in China and other parts of Southeast Asia, and infected some humans as well. Concerns grew that a flu pandemic, the first in over three decades, could be imminent and potentially severe, given that about half of the confirmed human cases were fatal in the early stages.
Cox and her colleagues were vigorous advocates for pandemic preparedness.
“She was the focal point of influenza response, surveillance, and research in this country,” remarked Anthony Fauci, the former head of the National Institute for Allergy and Infectious Diseases at the National Institutes of Health.
“She was very, very, very well respected by colleagues at NIH, including me.”
In 2006, Cox was recognized as the Federal Employee of the Year by the Partnership for Public Service, a nonprofit organization promoting excellence in government employees. That same year, she was included in the Time Top 100 list alongside figures like Oprah, Bill and Melinda Gates, Hillary Clinton, and then-President George W. Bush.
Despite the ongoing challenges posed by H5N1, which continues to affect poultry and a variety of mammals, including some humans, a pandemic has not yet occurred. In a 2019 STAT article, Cox cautioned against becoming complacent about the virus.
“We don’t know how the story’s going to end,” she warned.
In 2024, when H5N1 was unexpectedly found in dairy cows in the United States, Cox expressed amazement at the virus’s ability to defy expectations. “It seems that these viruses must have some kind of ‘special sauce’ that has allowed them to find ways to persistently spread, evolve, and cause what appear to be increasingly serious problems in both wildlife and domesticated animals,” she commented in an email to STAT.
Influenza is notoriously unpredictable. Cox frequently remarked, “If you’ve seen one flu season, you’ve seen one flu season.” The influenza research community was caught off guard in 2009 when an anticipated bird flu pandemic was instead caused by an H1N1 virus that had developed in pigs. Although the virus was believed to have originated in Mexico, the first two confirmed cases were children in California with no contact with pigs or each other. The CDC was central in unraveling the situation.
Richard Besser, CEO of the Robert Wood Johnson Foundation and acting CDC director at the time, recalled his numerous interactions with Cox during that tense period. “In briefings to the public, she gave the country confidence that we were doing all that we could to protect the health of people here and around the world. She modeled what it was to be a true public servant,” he stated.
During the intense effort to trace the virus’s origins and spread, Cox experienced a personal tragedy when her house was struck by lightning and burned down. Fortunately, no one was injured.
She was reported to have returned to work the following day in smoke-scented clothes. “It was devastating,” she admitted. “But I flipped a switch in my mind to concentrate on what we thought might turn into a pandemic.”
Throughout her tenure leading the CDC’s flu operations, Cox consistently addressed the challenge of global influenza virus sharing, tackling it with determination. Kanta Subbarao, who worked under Cox as section head for molecular genetics and later led a WHO flu collaborating center in Australia, noted her efforts to forge relationships with influenza researchers in various countries, including China, and to help boost their scientific capabilities.
“We had Chinese scientists [training at CDC] and we had collaborations and co-authorships and so on. So I think she worked very hard to try to bring them into the global umbrella of influenza surveillance,” said Subbarao, now part of the department of microbiology and immunology at Laval University in Quebec City.
Jernigan highlighted Cox’s diplomatic skills, stating, “She recognized that you don’t compel sharing, you really invite it. And you do that through opening up and providing something and bringing something to the table.”
Cox is survived by her husband, Evan, a daughter, a stepson, and four grandchildren.
