A National Strategy for COVID-19: Testing, Surveillance, and Mitigation Strategies

At the beginning of the COVID-19 pandemic, the response of the US federal government was seriously flawed. For example, the Centers for Disease Control and Prevention (CDC) erred when it came to policy development and messaging for testing, surveillance, masking, and ventilation, and CDC-developed test kits were also defective. Some policies from the Department of Health and Human Services restricted private sector progress, further delaying availability of tests. Early guidance on testing was mistargeted, getting tested was a logistical nightmare, and too few tests were performed. Once an acceptable, yet suboptimal, testing infrastructure was established, it was marginalized, thought to be superfluous because of the vaccines. Even now, testing results are not reliably linked with sociodemographic data, vaccination status, or clinical outcomes; the availability of reliable rapid tests remains limited; and prices are too high.¹

Similarly, there has never been comprehensive, geographically and population representative genomic surveillance to effectively detect and track variants of SARS-CoV-2, leaving the US with limited and delayed information about the emergence of new variants until other countries identify them. In addition, from the beginning of the pandemic until May 2021, the importance of aerosol transmission of SARS-CoV-2 was not fully recognized and appreciated,² leading to incorrect, delayed, and highly confusing recommendations on masking, wearing high-quality respirators, and improving ventilation.

It appears that SARS-CoV-2 will persist, and the COVID-19 pandemic will continue for some time. Consequently, to achieve a sustainable “new normal” with substantially lower virus transmission and mortality from COVID-19, testing, surveillance, masking, and ventilation all need significant improvement.

First, the CDC needs to collect and disseminate accurate real-time, population-based incidence data on COVID-19 and all viral respiratory illnesses. The US should not be reliant on extrapolating cases and outcomes from data collected from a few, underrepresentative sites. The country needs a comprehensive testing and reporting system for all viral respiratory illnesses. Data from all medical and testing facilities, all emergency department cases, and all hospitalizations, ICU admissions, and deaths need to be reported to the CDC and linked to anonymized sociodemographic, vaccination, and clinical outcomes data. The reporting system should accommodate the ability to incorporate data from at-home tests, ensuring a simple mechanism to self-report results, and should provide real-time reporting on a public website.

Every person in the US should have access to low-cost testing to determine if they are infected and infectious. The Biden administration’s plan to distribute 500 million at-home rapid tests and ramp up production using the Defense Production Act is an important step in the right direction but many more are needed.³ The federal and state governments need to ensure these tests are in plentiful supply, free to individuals with Medicaid coverage, and free or low cost to the rest of the population to help individuals who might be infectious avoid transmitting the virus to others in their homes, workplaces, schools, and other settings and to get prompt medical care if needed. Several states currently send their residents free, rapid COVID-19 test kits. All states and the federal government should also make tests readily available.

Importantly, when the CDC tracking system receives notification of a positive test result from a health care facility or at home, the system should automatically provide clear guidance on self-isolation and treatment options that may include anti–COVID-19 medications or an opportunity to participate in research studies to assess therapeutic interventions. Additional effort will be needed to ensure that testing and therapeutics are made affordable and equally accessible to members of underserved communities, including individuals with low income and those in rural or other hard-to-reach areas.

More knowledge about disease epidemiology could be obtained from each clinical specimen. Deploying multiplexed molecular and rapid antigen tests for respiratory viruses that detect multiple respiratory pathogens will distinguish SARS-CoV-2, influenza, respiratory syncytial virus, other viruses, and bacterial pathogens. In addition, the US should accelerate development of new technologies, including wearables and other platforms (such as graphene-based) that can rapidly test for multiple pathogens with a single test.

The recent emergence of the Omicron variant has highlighted the need for a comprehensive, nationwide environmental surveillance system that includes wastewater and air sampling to monitor for potential outbreaks of viral and bacterial illnesses. Traditional surveillance systems are highly reactive. By the time a health system or laboratory detects and reports a concerning pathogen or variant, it is too late to contain its spread. Great progress has been made toward establishing environmental surveillance programs for SARS-CoV-2, but there is a need to rapidly expand to other pathogens and reach rural and other communities that lack wastewater systems. A comprehensive national system is needed to reach the full potential of this surveillance approach, which should empower local jurisdictions with rapid, actionable data and transform pandemic prevention into a more equitable and proactive practice.

In addition, a comprehensive genomic surveillance system for variants is needed to provide early indications of immunity escape and emergence of new variants. This includes the critical need to sequence vaccine breakthrough cases, even from mild infections. The country needs a system organized by the CDC to sequence a far greater and more geographically representative proportion of positive COVID-19 tests than is currently being sequenced, with the results uploaded into global databases in real-time. Rapid sharing of this genomic data could facilitate a broader analysis of the emergence and spread of novel variants, enabling targeted distribution of resources to slow the spread of a new variant.

The US needs to establish a real-time, opt-out digital surveillance system to monitor all vaccinated individuals for the frequency and severity of adverse effects, postvaccination infections, and waning immunity. Two years into the pandemic, the US is still heavily reliant on data from Israel and the UK for assessing the effectiveness and durability of COVID-19 vaccines and rate of vaccine breakthrough infections. In addition, when the definition of “fully vaccinated” shifts to 3 doses (or perhaps more doses) of mRNA vaccine, the US lacks a reliable way of identifying who has received only the first 2 doses and who has received a third dose.

Like influenza, SARS-CoV-2 is spread by aerosols.⁴ Well-established public health mitigation strategies can reduce risks and complications from viral respiratory infections including SARS-CoV-2. Mitigation strategies should be implemented, including new enforceable Occupational Safety and Health Administration standards, especially requiring workplace masking, distancing, and ventilation.⁵

The most effective way to prevent transmission of respiratory diseases, including COVID-19, is to eliminate exposure to potentially infectious individuals, encouraging individuals who may have illness to stay home. This requires systematic access to testing and paid sick and family medical leave for all US workers, especially low-wage, temporary, freelance, contractor, and gig economy workers.

The next most effective mitigation approach focuses on upgrades to ventilation and air filtration systems, including increasing the intake of outside air, using efficient filters (rated at minimum efficiency reporting value of 13 or higher) and adding high-efficiency particulate air filtering devices. These systems will need to be implemented in offices, schools, public transportation, and other congregate workplace and social settings, such as restaurants and bars. Congress has allocated tens of billions to schools for such upgrades,⁶ and should provide additional funding or tax incentives for targeted high-impact upgrades. New infrastructure funds for public transit and airport improvements should also be linked to implementing these permanent improvements. Localities should be incentivized to modify their building codes to require that all new buildings integrate these upgrades.

The country needs to encourage use of high-quality filtering facepiece respirators (FFRs), such as N95s or KN95s, rather than cloth or surgical masks, to reduce transmission of respiratory viruses including SARS-CoV-2 in crowded indoor settings where community exposure risk is elevated.⁷ To meet demand and prevent reliance on imported products of questionable quality, there needs to be a national initiative to sustainably produce domestic FFRs and ensure they are readily available to all US residents for free or very low cost. The government could mail vouchers to US households to pick up FFRs at pharmacies, grocery stores, schools, and other locations.

In addition, there needs to be a system for clear recommendations from trusted public health authorities, advising local governments and the public about the appropriate use of facial coverings, depending on the setting; an individual’s vaccination, immune, and risk status; and the level of community transmission. An easily interpretable risk assessment map that encompasses these variables to provide immediate risk determination at the zip code level for individuals could be developed and updated daily. Such a system would help reduce confusion and guesswork that many individuals face today as they make daily decisions on how to protect themselves.

To reduce COVID-19 transmission, achieve and sustain a “new normal,” and preempt future emergencies, the nation needs to build and sustain a greatly improved public health infrastructure, including a comprehensive, permanently funded system for testing, surveillance, and mitigation measures that does not currently exist.

Corresponding Author: David Michaels, PhD, MPH, Milken Institute School of Public Health, Environmental and Occupational Health, George Washington University, 950 New Hampshire Ave NW, Washington, DC 20052 (dmm@gwu.edu).

Published Online: January 6, 2022. doi:10.1001/jama.2021.24168

Conflict of Interest Disclosures: Dr Michaels reported receiving grants from the McElhattan Foundation and Institute for New Economic Thinking and personal fees from the Actors’ Equity Association, Health Action Alliance, Estée Lauder Companies, and Verily Life Sciences. Dr Emanuel reported personal fees, nonfinancial support, or both from companies, organizations, and professional health care meetings and being a venture partner at Oak HC/FT; a partner at Embedded Healthcare LLC, ReCovery Partners LLC, and COVID-19 Recovery Consulting; and an unpaid board member of Village MD and Oncology Analytics. Dr Emanuel owns no stock in pharmaceutical, medical device companies, or health insurers. No other disclosures were reported.

Additional Information: Drs Michaels, Emanuel, and Bright were members of the Biden-Harris Transition COVID-19 Advisory Board from November 2020 to January 2021.