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We fitted a model of SARS-CoV-2 transmission in care homes and the community to regional surveillance data for England. Compared with other approaches, our model provides a synthesis of multiple surveillance data streams into a single coherent modelling framework allowing transmission and severity to be disentangled from features of the surveillance system. Of the control measures implemented, only national lockdown brought the reproduction number (Rteff) below 1 consistently; if introduced one week earlier it could have reduced deaths in the first wave from an estimated 48,600 to 25,600 (95% credible interval [95%CrI]: 15,900–38,400). The infection fatality ratio decreased from 1.00% (95%CrI: 0.85%–1.21%) to 0.79% (95%CrI: 0.63%–0.99%), suggesting improved clinical care. The infection fatality ratio was higher in the elderly residing in care homes (23.3%, 95%CrI: 14.7%–35.2%) than those residing in the community (7.9%, 95%CrI: 5.9%–10.3%). On 2nd December 2020 England was still far from herd immunity, with regional cumulative infection incidence between 7.6% (95%CrI: 5.4%–10.2%) and 22.3% (95%CrI: 19.4%–25.4%) of the population. Therefore, any vaccination campaign will need to achieve high coverage and a high degree of protection in vaccinated individuals to allow non-pharmaceutical interventions to be lifted without a resurgence of transmission.

Estimating mortality attributable to different diseases, risk factors, or events is pivotal to inform resource allocation and evaluate public health interventions. Information on death rates and burden also supports wider aims of societal governance, public accountability, and memorialisation. Recent examples of mortality estimation include the true toll of hurricane Maria in Puerto Rico, 1 mortality during famine in Somalia, 2 and the war in South Sudan. 3 Mortality data have also been essential in understanding the spread of covid-19. However, under-reporting in official death records has greatly obscured this understanding. We explore why under-reporting of deaths should have been expected, examine how use of alternative mortality sources can help advocate for a more equitable pandemic response, and highlight the crucial need for increased investment into civil registration and vital statistics systems before the next pandemic.