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

Chapter 1: Outbreak

The world responds

    On October 9, after Margaret Redstone’s report of the data collected from Branch’s mission to Hong Kong circulated throughout the WHO, the organization instructed its Beijing office to request information about the situation from the Chinese government. China, however, again denied that any outbreaks had occurred. Provincial health officials had reported high activity of A/Hong Kong, the government said, but no emergence of a novel pathogen. The WHO’s request to send investigators was again denied.
    Under the International Health Regulations, the WHO has the authority to enter member nations and study suspected outbreaks based on information from credible non-official as well as official sources, and can alert the rest of the world if a public health threat is perceived in a particular country.
    The regulations, however, happen to be difficult to meaningfully enforce. And the WHO still lacked the hard evidence it needed to initiate a pandemic alert.
    On October 10, the WHO’s Hanoi office reported a cluster of cases of severe respiratory disease in Vietnam, brought into the country by a Chinese-American businessman passing through Guangzhou, Guangdong’s capital, on the way to visiting a computer chip assembly and testing factory in Hanoi. Hanoi reported 30 cases, in all age groups, from the factory and hotel where the businessman had been staying. Twenty-five had been hospitalized and six had died due to sudden and severe pneumonia and acute respiratory failure. Another four were on mechanical ventilation at Bach Mai Hospital.
    Now the WHO’s Hanoi office requested information from Beijing about a possible outbreak in Guangzhou.
This time, China’s health minister acknowledged the existence of an epidemic of “atypical pneumonia,” but declared it effectively contained. Provincial health ministers in Guangdong and Shanghai echoed these announcements to the public through local media.
    China’s Center for Diseases Control (CDC) announced that there had been an outbreak of Chlamydia pneumoniae, a bacterium treatable with antibiotics.
    The epidemic has been contained, they said. It’s over.(9)
    The disease had begun spreading internationally. Public heath experts debated the next step in the WHO’s Operations Center, or the “War Room,” a sophisticated decision-making and information gathering and processing operation.
    On October 12, the WHO distributed a travel advisory recommending postponement of all but essential travel to Vietnam. They also distributed a detailed case definition, based on what they’d learned about the disease in Vietnam, to other countries.
    But they still hadn’t addressed China, which they believed was the origin of the virus, and China wasn’t budging.
    On October 13, GPHIN began collecting stories from the Japanese media about several cases of a severe respiratory disease, apparently centered around a tourist who had recently visited Shanghai to take in the sights and do some shopping. Immediately, emails, faxes and phone calls blitzed back and forth between the WHO in Geneva and its Japan office. The WHO’s Japan office contacted Beijing and demanded information.
    This time, the Chinese didn’t answer.
    On October 15, laboratory testing confirmed that the Hanoi virus was H5N1. A strain of Avian Flu easily communicable between humans. The WHO exploded into frantic activity.
   The War Room reached an agreement to draft a global pandemic influenza alert that raised the alert level to Level 6, indicating that a novel virulent strain had been discovered and conclusively proven to be easily communicable between humans. Elizabeth Huang, the WHO’s director-general and a native of Hong Kong, agreed to issue it. Governments around the world were advised to begin implementing their pandemic influenza response plans. The WHO further distributed a travel advisory recommending postponement of all but essential travel to Guangdong and Shanghai. Media all over the world picked up the story and began covering these actions.
    Normally, the WHO would consult the governments of its 192 member states before attempting any direct communication with their citizens. But they had lost too much time. Every hour lost gave Avian Flu another opportunity to spread to other countries, triggering a pandemic.
    The reaction was swift and predictable.
    On the floor of the UN, the Chinese ambassador delivered a terse speech reminding the organization of the dangers of overstepping its authority by interfering with the sovereignty of member nations. He said there is no novel virus causing an epidemic in the People’s Republic of China.
    China was not the only nation to be angered by the WHO’s actions. A number of countries, including Canada and the United States, argued that the WHO should have consulted them first. The WHO’s pandemic warning had already begun to disrupt the world economy.
    Around the world, in fact, billions of dollars were already evaporating in lost tourism, market reactions and canceled contracts.
    The global alert produced fast results outside of China, however, and vindicated Huang. Now that they knew what to look for, health officials in Vietnam, Singapore, Thailand and Japan began reporting clusters of infection in their countries.
    These reports electrified the global health community. They no longer feared a future pandemic. They were already looking at one.