Some COVID perspective. A reminder - I am an expert in one area (human genetics/genomics); I know many experts in other areas (infections epi, viral genomics, wastewater, clinical trials) worldwide and I am magpie like in picking up information from them and twitter.

I have one large COI in these discussions in that I am a longstanding consultant to Oxford Nanopore, which makes one of the new COVID tests, LamPORE. I am actually pretty tech agnostic (or catholic) in how to scale testing, but people should be aware of my COI

We know so much more than March. We know the virus that causes this disease; its incubation pattern and bursty-transmission. We know the age range, comorbidities and now the main genetics that lead to the disease being severe. We know many people are entirely asymptomatic

We are pretty sure the disease is not lethal or seemingly concern in young (say, under 15) except in rare cases, but there is nasty disease ("LongCOVID") that still needs characterisation present in at least middle age, perhaps younger adult individuals

We have pretty quickly repositioned some drugs to improve clinical outcomes of the disease (notably dexamethasome); developed new treatments (in trials now) and remarkably have numerous trials of a variety of vaccines, where preliminary data is pretty good.

However, the human contact patterns, testing and tracing in many countries, notably parts of Spain, France and UK have not managed to contain the infection to low levels. This is different from March in that hospitalisations are slower, but they still are steadily rising.

Before one goes onto what to do next, it is important to also note the consistent low transmission rates in Japan, South Korea, Germany and most recently Italy. This is not by any means perfect and may change, but it is notable.

(Other countries have successfully eliminated the virus and have a quarantine approach, eg, New Zealand, and all credit to them, but this is a different solution to JP, DE, SK and IT which does have endemic virus)

The combination of hygiene, contact patterns, testing and tracing in these countries have consistently lead to lower transmission in this wave. It probably is not a single thing, but a combination of things working in each case well.

Many people can use this is skewer or get exasperated by their government/health systems - perhaps fair enough - but far more important in my view is understanding why and understanding then how to map this to the local situation.

(This goes to my "golf" analogy - golf is a game with metrics, leaderboards etc, but each player is playing themselves and the course, with the clubs they have and in some sense, they are playing no one else).

There's a long shopping list of things here to think about. Good mask wearing and pretty obsessive hygiene. High levels of testing (but not in Japan at the start). Trace system with a focus on backtracing (finding sites of infection, thus finding +ves who are asymptomatic)

Backtracing with action is particularly important, and it is subtle I believe in its delivery.

These need to be prosecuted and changed into tailored actions inside countries. This is so easy to tweet and so hard to operationalise (probably one of the constants in the pandemic) but one should never assume that because something hasn't happened in a location it can't.

Stepping back from this, we also need a plan B, plan C and probably plan D until we get to the vaccine. Here I am taken both by @JeremyFarrar's urge to have debates *before* decisions (however messy and complex they are) and >>

@mendel_random's plea to think about lives vs lives framework - ie, the weighted life quality of each decision for how to rank and choose the more crude NPIs to achieve control. These are not easy decisions, but ultimately these decisions *have to be* made inside healthcare

(A friendly health economist fixed my gaze once when I recoiled a bit from this thinking over a decade ago and said 'you are either going to make a decision rationally or irrationally here, which would you prefer?').

I am focusing on getting more operational efficiency and guidance, and above all help share what I can about what works and what is *important* about what works (ie, causal factors for success) from different places.

And before my UK audience use this thread to vent about the UK (again, I get why, I just don't think it is useful), I'd remind them that one of the key reasons this wave is better worldwide is dexamethasome, a repositioned drug for COVID discovered by RECOVERY, the large UK trial

(other good things from the UK here: anchor cohorts for understanding the genetics from GenomiCC and UK BioBank; ISARIC ICU stats and epidemology. Many good things from DE- test+trace exemplar, clear delivery, structural studies of the virus. Spanish+Italian human genetics contr)