It is better to have approximate answers to the right question than to have the exact answer to the wrong one.
Irene Eckstrand, NIH-MIDAS
Here are selections from my notes and some of my thoughts on today. A couple of overview points:
- Today was mainly information gathering and presentation to the participants, who will get into groups tomorrow to work on the issues and come up with recommendations.
- The focus is on non-pharmaceutical community mitigation interventions, and will not cover antivirals and vaccines, even though they were mentioned briefly.
- A summary agenda can be found here
MARTY CETRON, CDC slides
Marty Cetron summarized the 3 main activities of this meeting:
- Release of Institute of Medicine review of the evidence, historical data and mathematical modeling results
- share preliminary results of the many listed activities over the last 6 months
- Solicit input and opinions from participants to guide the development of interim federal guidance on community mitigation strategies
The interim guidance will be written up this month, NPI (non-pharmaceutical interventions) will be one of the chapters, but it will also include other components of community mitigation such as the use of antivirals. This interim guidance will be circulated interagency to be rolled out early January (as I said before). Notice this really is interim as it is very likely to be further revised down the line.
One scary piece – Cetron asked how many people in the room was taking part in meetings on community mitigation using NPI for the first time, ie where data and issues around NPI were presented and discussed, and fully 1/3 of the room raised their hands. Some of the presentations were technically quite challenging, and I wonder how well tomorrow will run, for those for whom this is pretty much the first time they have considered these issues. I think Marty was surprised too. We'll see…
ARNOLD MONTO, U of Michigan slides
Arnold Monto did a review of the pandemic flu problem. Some notable points:
Rajeev Venkayya from the White House Homeland Security Council presented the policy perspective from the administration. The significance of his presentation was not so much in the contents, cos we all know those already, but the fact that it is the view of the Bush administration. I will list a few examples
RAJEEV VENKAYYA, White House slides
- H5N1 CFR is at 60%
- 1918 is not the worst case scenario, we are using the figures for policymaking only
- at 30% attack rate, in a 1918-like scenario, the death rate for those aged 1-19 would be 13 x the annual death rate
- at 40% AR, it would be 20+ times (this is essentially the same as what we discussed previously on the old forum here )
- what prompted the administration to take action was the realization that pandemics can have a broad spectrum of severity, and you need all the tools you can get
- NPI is one prong of multi-prong strategies, including 'Manhattan-like' project on vaccines
- the National Strategies Implementation Plan was just the 'first cut of the planning', now we need a 'roadmap'
- Closing thought: 3 things needed: Leadership, Imagination, & Resilience. There are lots of secondary and tertiary consequences. PH officials may not be the best people to deal with them.
MATTHEW CARTTER, CSTE, Best Slide of the Day! slides
I’m going to skip ahead to the last session of the day, and take one point from Matt Cartter’s presentation. The logic behind the totality of his presentation requires its own discussion to do it justice, and I hope to write that up some time later this week. The point that I’m referring to is on his slides #22 onwards.
What Cartter is saying is that most people have difficulty conceptualizing the severity or implications of a pandemic, let alone the need to prepare. But people understand hurricane warning categories, eg that a Cat 1 is mild, and a Cat 5 is like Katrina, so we can use those as analogies. Essentially he translated the mild, moderate, and severe scenarios into Cat 1, 3, and 5 for that purpose, using total deaths of < 100K for Cat 1, >/= 1M for Cat 5, and Cat 3 would be in between.
These numbers are essentially the result of the combined effects of the attack rate (he uses illness rate for laymen, which I think is great) and CFR (he said we should probably just use mortality). So he plotted those data sets that would result in the 3 different sets of death rates and came up with the charts on slides #22 onwards. I understand Marty Cetron had a hand in that as well, and it was all done by hand.
What is so brilliantly simple (and simply brilliant!) about this is now you have 3 different areas (4 if you count seasonal flu) within which any combination of AR and CFR could fall that would immediately classify the outbreak as Cat 1,3, or 5.
Now is that easy to understand or what?!
The job tomorrow is to fill in the measures for the 3 different scenarios...
___________There are various other topics worth writing about from today, notably the really interesting new data from analysis of historical records from 1918 by Markel and Lipman, plus the discussion arising from the ASTHO consultations with Roger Bernier (not much new info, but good discussion) which I will post at another time. (slides added)