It's been a while since I've been back to this thread and a lot of changes have happened. We now seem to be in a situation where several countries have established community spread so the nature of prevention/mitigation processes is evolving and I think we are gradually seeing some more awareness of the gravity of COVID-19 both by policy makers and the general public which is a good thing but there is still much more to be done.

I just wanted to highlight a few issues to consider regarding mortality rates as unfortunately we are heading in the direction where this is going to become increasingly important over the coming weeks/months. The most important point to highlight is that mortality rates can and will change. There is a wide degree of uncertainty in mortality rates because they depend on a number of factors. These can be broadly categorised into factors related to the virus itself (i.e. pathogenicity, genetic shifts which may/may not occur during this pandemic), host related factors (e.g. older individuals/multiple medical comorbidities/immunological status) and healthcare infrastructure related factors (i.e. availability of acute/high dependency/ITU hospital beds).

Of all of these factors it is the last one (i.e. healthcare infrastructure) which will could have the greatest degree of impact and where we have the greatest degree of control with respect to mitigation factors. For the sake of argument (i.e. these figures are not necessarily accurate), let's say the current mortality rate of the virus is 1% but that 10% of people develop serious symptoms which require intensive care in hospital. Once hospital beds are full/overwhelmed, a proportion of those in the serious symptoms category who would have survived had they had access to intensive medical care will die. This will result in a rise in mortality rates.

The other issue related to the above is non-COVID-19 related mortality. All medical interventions have an opportunity cost. For every person with COVID-19 in ITU, there is one less bed available to treat someone with cardiac failure following a heart attack, or cardiorespiratory support following major trauma. This means that we will have to consider not only the mortality attributed to the virus but also the mortality attributed to lack of access to care for people with other medical conditions.

The task at hand is to manage the flow of patients into and out of high dependency medical care as best as we can. The best way to do this is to slow down the rate of new infections through personal/societal infection control approaches. Just in terms of casual observation I feel like we are very far behind in the US and UK (the two countries I have been in since the pandemic started). People are still touching their faces, coughing/sneezing everywhere, not practising social distancing measures effectively. I've seen people wearing masks doing bizarre things like taking them off to touch rub their nose/touch their face etc. I can't tell if people have changed their hand washing habits but I suspect not. All those alcohol gel bottles everyone have been buying must be sitting under the kitchen sink because I have yet to see anyone in public using alcohol gel (which is where you should be using it if you don't have access to a sink to wash your hands).

We need to do a lot better to educate people on basic hygiene measures and social distancing because this is what will have the greatest impact. I really don't know how we can do this better but people need to have constant reminders not to touch their faces, not to cough/sneeze everywhere, to wash their hands. Maybe we should blast these messages out every couple of minutes on the radio/TV/public transport? I don't know but some of the behaviours I am observing just make me cringe and make me despair!