I want to step back and give some thoughts about the Coronavirus developments this week and some sense of the 3 months ahead from my perspective.

Context: I am an expert on a small number of these topics; I am a one-step-away-from-experts who understands data and statistics enough on many of these; some areas I am just an interested amateur. I have one huge conflict of interest in testing which I will flag in-stream.

Reminder: This is a highly infectious virus which causes a severe disease which is often fatal in the subset of population. Frustratingly the infectious individuals are often completely asymptomatic as well as very often low risk.

Something approaching normality will not return until we have effective treatments (removing the "often fatal" in the summary above, and mitigating "severe") or vaccines (removing the "highly infectious" in the summary above).

Remarkable progress has been made on both fronts: for treatments, large, straightforward randomised trials (mainly in the UK, also worldwide) have produced strong evidence that two drugs work, and two possible drugs do not work.

There are many potential other drugs (in particular a recent low powered safety trial of one drug gave a positive result even given the low numbers - needs to go into a large randomised clinical trial).

We need *more* straightforward, large, randomised clinical trials around COVID treatments. When you see the clear cut results from well powered trials you realise how much wasted energy we put into small scale trials or just no trials at all.

(I know this is hard to do logistically, and like many things in this pandemic it is all to easy to say on twitter or on a zoom call "do this" - far hard to execute and operationalise. All credit to all the clinical trialists who are doing this right now)

Far further from my expertise are the smaller improvements in clinical care pathways (airflow improvements, anti-coagulants, proning etc). These too need to happen and be shared worldwide.

Vaccine progress has also been remarkable; there are over 100 candidate vaccines; a far smaller number have got to Phase 3 trials (I am one such person on a Phase 2/3 trial!). Noone would have predicted this progress in march.

Vaccines do not have to have perfect to be useful; reducing transmission by 50% would be great; reducing severity of disease by 50% would be great; anything higher or combinations of these - wow!

Despite though this progress on treatments and vaccines - and we need to do this all as fast as can be done safely - we are looking at least navigating autumn, probably winter without a massive change to the profile of the disease on these two fronts.

The autumn involves changes in contact patterns. Firstly schools, in particular older students and universities would naturally come back and this implies far more contacts inside these groups.

Secondly in the northern hemisphere it will be harder to easily be outside. We know high transmission risk is indoor places with poor ventilation; shouting and singing are not good.

So, we need to push to the next level of reducing transmission by isolation. As a backstop we have to still have on the table large "lockdown" like measures. These though are massively disruptive and we should aim to avoid them if at all possible.

How to do this? We need to test deeper, and do our upmost to test moderate to high risk individuals.

Here my conflict of interest comes into play: I am a long established consultant to Oxford Nanopore, one company that has developed a scale-out, portable testing scheme broadly of the same performance as RT-PCR, but less (but not zero) lab kit and very "truck" portable.

An important point about testing is even today the problem is not testing *capacity* it is testing *logistics/operations*. With the new technologies coming on-stream it is the logistics/operations side that needs as much effort as the technical capacity side.

One positive is that many of these new testing schemes (including LamPORE from nanopore to be clear) offer far higher portability - in trucks. One can think more about bringing high capacity to a location and people management.

We can go further. research evidence is that infectious people often shed into saliva; this can again simplify issues.

Finally we can think about pooling - 5 way or 10 way pooling which automatically increases capacity but then one needs to agonise about sensitivity follow up protocols.

The other big card to play is early, passive detection via Sewage. There is increasing evidence worldwide that the viral RNA is detectable in Sewage (thankfully it looks mainly deactivated by stomach acid presumably!). Sewage is a passive, at scale, pooling scheme

Here sewage needs to be considered as part of a surveillance / situational awareness scheme (along with cases across a country). The passive nature of sewage (people really don't have to change their habits at all) and large scale pooling means this is just excellent

It is not perfect; there is a host of issues on extraction and points of sampling; the sewage network does not reach and/or cannot be easily sampled anywhere near the whole population, though the most at risk broad area (urban) are likely to be biased towards ease of sampling

Situation/surveillance are pointless if you don't have interventions, and the intervention could be bring high capacity testing solutions to a broad location for fine grained case identification.

As much as I am excited about LamPORE being deployed into the NHS I am equally excited about sewage testing in the UK https://www.bbc.co.uk/news/science-environment-53635692

(this is not a UK thing - I know the Dutch are upping their Sewage game and I think we should be doing this worldwide. It is an easy yes).

Furthermore just getting the "shoe leather" infectious epidemiology - test and trace - working at a higher level will be beneficial. This again is organisationally out of my comfort level, but clear that this really really helps (Japan is my exemplar here)

Would all these approaches, deployed well, mean we can navigate autumn and winter? Noone knows - there are too many unknowns here still. But this for me is the best set of cards play until treatments and vaccines come in.

A final, never ending plea - this is not a nation vs nation competition, at any scale. It is a human vs virus contest and a very deadly one to many humans. We need to work together, share results (as many scientists and epidemiologists do) and get on with solutions.