Covid has been raging for 2 years. Multiple variants have emerged. Worldwide, hundreds of millions of people have been infected, millions have died, and untold numbers have developed long Covid. Covid has disproportionately affected communities of color, those living in poverty, and those in less developed countries. Covid has disrupted education and led to significant learning loss. And, there has been tremendous economic dislocation, millions of people thrust into poverty, and the loss of tens of trillions of dollars from the world economy. Importantly, effective vaccines and therapeutics have helped make progress combatting the virus, but cases and deaths still remain high.

As the pandemic enters its third year, two factors have become critical. One is fatigue. People are tired of restrictions used to fight Covid. Simultaneously, the virus continues to surprise experts and make it challenging to anticipate what lies ahead. In all cases, the world must be better prepared.

In 2022, it is possible for a new variant of concern to emerge. But greater population immunity increases the probability of a lower disease burden, lower strain on the health system, and fewer deaths, if waning immunity or immune evasion do not become significant factors.

The United States’ pandemic phase—with restrictive public health measures—can end when average daily deaths due to Covid and other major respiratory illnesses decline below 0.5 per 1 million Americans, or 165 deaths a day at a national level. At that point, the United States can transition into the next normal, although individual regions may be able to make earlier transitions, depending on local Covid metrics.

But on March 1, 2022, the nation is not yet at the next normal. The shift to the next normal should not induce complacency, inaction, or premature triumphalism. To rapidly reach and sustain the next normal, the country must implement a comprehensive and coordinated roadmap to both address this pandemic and develop the capacity to confront future biosecurity threats.

The following 12 elements constitute the fundamental core of this Roadmap and are elaborated in this report.

1. Major Respiratory Viral Illnesses
Shift the focus from Covid to major respiratory viral illnesses like flu and RSV infection, with the interim goal of reducing annual deaths below the worst influenza season in the last decade. Even in a pessimistic scenario, the next 12 months are likely to see about half the deaths from Covid compared to 2020 or 2021. But this should not lead to complacency, as unexpected viral changes may occur. There are concrete steps the U.S. can take to increase the chances of this outcome.(Chapter 2: Possible Scenarios)

2. Dashboard
Create, maintain, and disseminate a transparent infectious diseases dashboard to guide both the public and policymakers at the national, state, and local levels on the introduction, modification, and lifting of public health measures. The dashboard should also provide guidance on the distribution of therapeutics and other special protections for the immunocompromised, elderly, and other vulnerable populations. (Chapter 1: Next Normal)

3. Testing, Surveillance, and Data Infrastructure Increase
Increase surge production capacity for at-home rapid tests to 1 billion per month. Establish a test-to-treat infrastructure that links all testing with high sensitivity and specificity to immediate medical consults and appropriate treatment, clinical trial enrollment, and public health guidance. Invest in a substantial upgrade of the data collection and analysis infrastructure

for pathogen surveillance at the local, state, and national levels. Implement standardization and timely collection, analysis, and public sharing of data from expanded and enhanced environmental, genetic, and zoonotic monitoring systems, including those involving wastewater and deer. In addition, establish and sustain infrastructure to rapidly collect and analyze population immunity data. (Chapter 3: Testing and Surveillance; Chapter 9: Health Data Infrastructure).

4. Indoor Air Quality
Direct the Environmental Protection Agency (EPA) and Occupational Safety and Health Administration (OSHA) to develop standards to improve indoor air quality and protect workers from inhalation exposure. Direct states and localities to use American Rescue Plan and other appropriated funds to upgrade ventilation and air filtration in schools, childcare facilities, and public buildings. (Chapter 4: Cleaner, Safer Indoor Air)

5. Vaccines and Therapeutics
Support the development of new, more effective therapeutics, especially multi-drug oral antivirals, and next generation vaccines, especially mucosal and pancoronavirus designs. Develop a test-to-treat platform to ensure rapid and equitable access to treatments for the most vulnerable populations and reduce disparities.(Chapter 6: Vaccines; Chapter 7: Therapeutics)

6. Global Investment
Shift the goal of U.S. contributions to the global vaccination effort from stopping infections through population vaccination coverage alone to improving the distribution and administration infrastructure necessary to fully vaccinate the most vulnerable people in low- and middle-income countries. (Chapter 6: Vaccines)

7. Long Covid
Rapidly coordinate and expand research on long Covid, to produce data and biospecimens available through open science, with specific emphases on the INSPIRE and RECOVER studies. Aim to generate definitive answers to fundamental questions on frequency, risk factors, prognosis, and the benefits of vaccines and therapies for long Covid, within the next year. Augment social, financial, and health supports for individuals affected by long Covid. (Chapter 8: Long Covid)

8. Equity
Better address health disparities by creating a permanent cadre of community health workers to support vulnerable populations highly susceptible to adverse outcomes from viral respiratory illnesses and leveraging trusted community groups such as faith-based organizations. (Chapter 10: Public Health Infrastructure)

9. Workforce
Expand and support the public health and health care workforces through improved wages, health benefits (including mental health), tuition assistance, loan forgiveness, and safe working conditions. Incentivize the accelerated adoption of automation for routine chores and paperwork. To institutionalize both virtual care and various forms of home care, extend and expand regulatory policies and reimbursement flexibilities. Ensure that a flexible pool of workers is available in emergencies. (Chapter 10: Public Health Infrastructure; Chapter 11: Healthcare Workforce; Chapter 14: Worker Safety)

10. Biosecurity and Pandemic Leadership
Create the post of Deputy Assistant to the President for Biosecurity (within the National Security Council), responsible for preparing for, monitoring, addressing, and coordinating responses to and communications about any biosecurity and pandemic threats. This post should coordinate efforts to counter foreign and domestic sources of anti-science misinformation on vaccines and drugs. (Chapter 12: Communications and Education)

11. Communication
Implement a comprehensive, scientifically-tested communication and behavioral intervention infrastructure to increase vaccination, testing, and treatment, especially among vulnerable groups (Chapter 12: Communication and Education)

12. Schools and Childcare
Governments should not close schools and childcare facilities unless all other community mitigation measures fail. Implement policies and programs, such as improved air filtration and expanded school nurse programs, that enable schools and childcare facilities to remain open and safe for in-person instruction and care without the need for special public health mitigation measures. Target program implementation assistance to schools in communities with the greatest need. (Chapter 13: Schools and Childcare)