THE THIN WHITE LINE: the history of a future avian influenza pandemic

Chapter 1: Outbreak

China's terrible secret

    After September 17, hospitals and clinics throughout the west Pearl River Delta region saw a sudden upsurge in severe influenza cases. Several of them died within 48 to 60 hours after developing symptoms. In most cases, doctors identified pneumonia as the cause of death, although in some cases the virus by itself was strong enough to kill its host. The fact that most of these people were young and healthy, and died so quickly, sent a shock wave through Guangdong’s health system.
    As the cases mounted, other symptoms revealed themselves. For most, the disease started with a cough followed by a frontal headache——a strong pain behind the eyes, even within the eyelids, as well as in the ears and lower back. Next: exhaustion and a high-grade fever, and aching in what felt like every atom of the body.
    Some patients exhibited a thickly coated tongue with a bright red tip. About half suffered epistaxis, or nasal hemorrhage, serous fluid pouring from the nose up to half a liter at a time. Ailing patients coughed up bloody sputum. Some, their lungs ravaged and unable to breathe on their own, became oxygen-starved and cyanotic, requiring mechanical ventilation until they either recovered or their lungs failed completely. The disease often attacked the lower lungs, causing acute respiratory distress.
    One woman died in such pain en route to the hospital, her face so contorted in its death mask that her friends no longer recognized her.
    Few diseases struck people down so suddenly. A person could be out walking and suddenly collapse from pain, fatigue and disorientation, and die within hours.(4)
    Meanwhile, the first lab tests came back, with no match to anything known. Health officials knew little more than they were up against a Type A influenza virus. They did not even know what to call it, falling back on the term “atypical pneumonia,” which they had used to describe SARS when humans first discovered it in 2003——or rather, when it first discovered humans as a vast ecological niche.
    Health officials became increasingly alarmed. They had no idea what they were facing——how to treat it and how to stop it. Worse, they recorded a 30 percent mortality rate among the first 36 known cases, most of whom had either direct contact with Zeng at his restaurant or secondary contact with one of the primary cases. In short, three out of 10 of the first people who caught the flu died from it. The enormous implications confronted government officials: If half of China’s population caught it, and 30 percent of them died, 15 percent of the total population would die——180 million people.
    The initial mortality figures ignited a debate among Chinese epidemiologists. Some suspected they had discovered a new, highly lethal disease——an airborne, even more virulent SARS——while others argued that the mortality rate was probably misleading, that they were seeing the worst of it in the hospitals and that many other people probably caught the virus but were either asymptomatic or suffered milder symptoms and recovered under home care. For all they knew, many suspected cases of A/Hong Kong could actually have been infections from this new disease. In any case, the high mortality rate influenced the response of health officials.
    In short, China entered a state of denial.

The Avian Flu virus attacks the lungs. This anteroposterior chest X-ray shows left lower lobe pneumonia in a patient with Avian Flu. Most deaths attributable to the flu were caused by hemorrhagic pneumonia. (5)

    In Guangdong province, health officials struggled with an outbreak of a deadly new disease but made no announcements to the public through the media. In fact, the Propaganda Department distributed a directive to all media outlets in the province instructing them not to cover any “alleged” disease outbreaks at all.
    More than 100 million Chinese have Internet access, and there are hundreds of commercial newspapers, magazines and television stations. Nonetheless, information is strictly controlled by the government; China’s State Secrets Law requires the media to gain prior authorization to report on “sudden events” such as disease outbreaks, riots and accidents that the government wants to keep secret. Media outlets could be fined for any reporting that violates this law. The Propaganda Department used this law to suppress information about the spread of HIV/AIDS in China, SARS in Guangdong, and Hepatitis A in Shanghai, for example. They considered such reporting to be “fake news.”
    The Chinese government placed an ultimate value on public order and political stability; they feared koan——a return to the terrible chaos preceding Communist rule——more than the potential consequences of the epidemic. Additionally, provincial officials feared the severe impact on economic growth and resulting social disruption that would likely result from telling the global health community about the epidemic.

Figure 1-1. Estimated clinically ill avian influenza cases in the People’s Republic of China over the course of the epidemic.

    As a result of censorship, not only did the public remain uninformed about the outbreak of Avian Flu in Guangdong, but provincial health authorities also concealed it from neighboring provinces and districts such as Hong Kong; only the Ministry of Health in Beijing could tell them, and it had already decided not to do so.(6)
    The government, however, could not control word of mouth. Peasants looking for work in the cities described farmers dropping like flies in the interior. Factory workers told of a wasting disease that raged through packed, poorly ventilated worker dormitories in the industrial zones. Teachers complained about emptying classrooms. Doctors and nurses described patients being treated in the corridors of overcrowded hospitals. The spread of rumors outpaced the epidemic. In their wake, a panic-stricken public cleared out grocery stores of staples such as rice and salt, and bought up Western and traditional medicines such as Banlangen (isatis root, widely used to treat common colds). Prices skyrocketed in shops and stores. A/Hong Kong and other strains continued to circulate, presenting similarly to the disease and spreading further panic.
    Meanwhile, people in the affected region fled to neighboring provinces, while tourists and businesspeople from other provinces and countries continued to visit Guangdong’s industrial cities. The virus followed these migrations like seeds blown on random winds. For example, Zeng Yunshan’s daughter had missed her father’s death; a flight attendant for China Southern Airlines, she’d had to fly her regular route to Shanghai, a city of more than nine million people, the morning of September 17. She brought the Avian Flu with her and facilitated its spread into one of China’s biggest cities.

    The epidemic, China’s horrible secret, continued to grow until, in early October, the first signs of its existence leaked into the world.
     While the rapid expansion of commercial air travel in previous decades had created highways for novel viruses to circle the globe within months, information technology developed during the same time gave humanity a critical weapon in the fight against infectious diseases. Information could be communicated and shared across the planet instantly. Knowing that a virus has emerged, and defining its characteristics very soon after an outbreak, gives the global health community time to respond——either to defend itself from spread, or to go on the offensive and stop it, including destroying its source.
    The World Health Organization (WHO), the United Nations specialized agency for health established in 1948, therefore considered surveillance to be the first line of defense against novel strains of influenza. If a new strain is detected early, it can be studied, even stamped out before it spreads. If it begins spreading, the whole world can be warned to take measures and get a jump start on developing a vaccine.
    The WHO established the Global Influenza Surveillance Network to accomplish two objectives. The first was to monitor seasonal influenza, determine what flu strains were circulating, and then make twice-annual recommendations to WHO member countries about the content of vaccine.
    The second objective included using the Network as an alarm system for emerging flu strains that could cause a pandemic.
    Because of the clampdown on information in China, the Network did not detect the outbreak and this system failed. The world continued to believe China simply suffered a bad flu season. Instead, another surveillance system, developed by Canada, raised suspicions at the WHO that a new, deadly human pathogen had been born.
    The Internet-based Global Public Health Intelligence Network (GPHIN) acts as an Internet monitor, tracking and sharing news of public health significance. GPHIN, developed by the Public Health Agency of Canada, had been used as an early warning system by the global health community since 1997.
    Several courageous journalists in the Chinese media had begun reporting about the outbreak in Guangdong, and subsequent outbreak in Shanghai, as if deriding ridiculous rumors. Although the government forbade reporters to talk to doctors and nurses, some did so anyway and wrote up stories describing the outbreak as if it were a rumor that should not be believed. This allowed newspapers to share information with the public in a way that avoided censorship. The stories continued to be published until the government got wise, fined the newspapers and imprisoned several reporters.(7)
    GPHIN, however, caught the stories and attracted the interest of officials at the Centers for Disease Control (CDC) headquartered in Atlanta, which in turn notified the WHO. The first alarms rang in the global flu surveillance system.