Opinion
A National Strategy for COVID-19
VIEWPOINT
Testing, Surveillance, and Mitigation Strategies
David Michaels, PhD, At the beginning of the COVID-19 pandemic, the
MPH response of the US federal government was seriously
Milken Institute School flawed. For example, the Centers for Disease Control
of Public Health,
and Prevention (CDC) erred when it came to policy
George Washington
University, development and messaging for testing, surveillance,
Washington, DC. masking, and ventilation, and CDC-developed test kits
were also defective. Some policies from the Depart-
Ezekiel J. Emanuel, ment of Health and Human Services restricted private
MD, PhD
sector progress, further delaying availability of tests.
Perelman School of
Medicine and The Early guidance on testing was mistargeted, getting
Wharton School, tested was a logistical nightmare, and too few tests
University of were performed. Once an acceptable, yet suboptimal,
Pennsylvania,
Philadelphia. testing infrastructure was established, it was marginal-
ized, thought to be superfluous because of the vac-
Rick A. Bright, PhD cines. Even now, testing results are not reliably linked
The Rockefeller with sociodemographic data, vaccination status, or
Foundation, New York,
clinical outcomes; the availability of reliable rapid tests
New York.
remains limited; and prices are too high.1
Similarly, there has never been comprehensive,
geographically and population representative genomic
Viewpoint 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 impor-
tance 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 improv-
ing ventilation.
It appears that SARS-CoV-2 will persist, and the
COVID-19 pandemic will continue for some time. Con-
sequently, to achieve a sustainable “new normal” with
substantially lower virus transmission and mortality from
COVID-19, testing, surveillance, masking, and ventila-
tion all need significant improvement.
Testing
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.
Corresponding
The country needs a comprehensive testing and report-
Author: David
Michaels, PhD, MPH, ing system for all viral respiratory illnesses. Data from
Milken Institute School all medical and testing facilities, all emergency depart-
of Public Health, ment cases, and all hospitalizations, ICU admissions, and
Environmental and
Occupational Health,
deaths need to be reported to the CDC and linked to
George Washington anonymized sociodemographic, vaccination, and clini-
University, cal outcomes data. The reporting system should accom-
950 New Hampshire
modate the ability to incorporate data from at-home tests,
Ave NW, Washington,
DC 20052 (dmm@ ensuring a simple mechanism to self-report results, and
gwu.edu). should provide real-time reporting on a public website.
jama.com
© 2022 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 01/12/2022
Every person in the US should have access to low-
cost testing to determine if they are infected and infec-
tious. 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 infec-
tious avoid transmitting the virus to others in their
homes, workplaces, schools, and other settings and to
get prompt medical care if needed. Several states cur-
rently 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 re-
ceives notification of a positive test result from a health
care facility or at home, the system should automati-
cally provide clear guidance on self-isolation and treat-
ment options that may include anti–COVID-19 medica-
tions 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 mul-
tiplexed molecular and rapid antigen tests for respira-
tory viruses that detect multiple respiratory pathogens
will distinguish SARS-CoV-2, influenza, respiratory syn-
cytial virus, other viruses, and bacterial pathogens. In ad-
dition, the US should accelerate development of new
technologies, including wearables and other platforms
(such as graphene-based) that can rapidly test for mul-
tiple pathogens with a single test.
Surveillance
The recent emergence of the Omicron variant has high-
lighted the need for a comprehensive, nationwide en-
vironmental surveillance system that includes waste-
water and air sampling to monitor for potential outbreaks
of viral and bacterial illnesses. Traditional surveillance sys-
tems 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 prog-
ress has been made toward establishing environmen-
tal surveillance programs for SARS-CoV-2, but there is a
need to rapidly expand to other pathogens and reach ru-
ral and other communities that lack wastewater sys-
tems. A comprehensive national system is needed to
reach the full potential of this surveillance approach,
(Reprinted) JAMA Published online January 6, 2022 E1
 Opinion Viewpoint

which should empower local jurisdictions with rapid, actionable data
and transform pandemic prevention into a more equitable and pro-
active 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 se-
quence 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 posi-
tive COVID-19 tests than is currently being sequenced, with the re-
sults uploaded into global databases in real-time. Rapid sharing of
this genomic data could facilitate a broader analysis of the emer-
gence 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 surveil-
lance system to monitor all vaccinated individuals for the fre-
quency 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 ef-
fectiveness 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 vac-
cine, the US lacks a reliable way of identifying who has received only
the first 2 doses and who has received a third dose.
Mitigation Strategies
Like influenza, SARS-CoV-2 is spread by aerosols.4 Well-established
public health mitigation strategies can reduce risks and complica-
tions from viral respiratory infections including SARS-CoV-2. Mitiga-
tion strategies should be implemented, including new enforceable
Occupational Safety and Health Administration standards, espe-
cially 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 poten-
tially 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 increas-
ing the intake of outside air, using efficient filters (rated at mini-
mum 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 face-
piece respirators (FFRs), such as N95s or KN95s, rather than cloth
or surgical masks, to reduce transmission of respiratory viruses in-
cluding 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 na-
tional 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 recommenda-
tions from trusted public health authorities, advising local govern-
ments 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 vari-
ables 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 pro-
tect themselves.
Conclusions
To reduce COVID-19 transmission, achieve and sustain a “new nor-
mal,” 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, surveil-
lance, and mitigation measures that does not currently exist.

ARTICLE INFORMATION
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.
REFERENCES
1. DePillis L, Umansky E. Here’s why rapid COVID
tests are so expensive and hard to find. Accessed
November 8, 2021. https://bit.ly/3FHQKt7
2. Rabin RC, Anthes E. The virus is an airborne
threat, the CDC acknowledges. New York Times.
Accessed November 15, 2021. https://nyti.ms/
3eBkHPo
3. White House. President Biden announces new
actions to protect Americans against the Delta and
Omicron variants as we battle COVID-19 this winter.
Accessed December 15, 2021. https://bit.ly/
3JwUxvo
4. Wang CC, Prather KA, Sznitman J, et al. Airborne
transmission of respiratory viruses. Science. 2021;
373(6558):eabd9149. doi:10.1126/science.abd9149
5. Michaels D, Wagner GR. Occupational Safety and
Health Administration (OSHA) and worker safety
during the COVID-19 pandemic. JAMA. 2020;324
(14):1389-1390. doi:10.1001/jama.2020.16343
6. Allen J, Gounder CR. We have a
once-in-a-generation opportunity to fix our
crumbling schools. The Hill. Accessed November 8,
2021. https://bit.ly/3pGNdFP
7. Brosseau LM, Ulrich A, Escandon K, Anderson C,
Osterholm MT. Commentary: what can masks do?
Center for Infectious Disease Research and Policy.
Accessed November 12, 2021. https://bit.ly/
3mGnOKs

E2 JAMA Published online January 6, 2022 (Reprinted) jama.com

© 2022 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ on 01/12/2022