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

Chapter 1: Outbreak

Interview with Barbara Ledoux, Quarantine Officer, Vancouver International Airport

VANCOUVER, CANADA

[Barbara Ledoux served as a quarantine officer at Vancouver International Airport during the Pandemic. A registered nurse, she has diplomas in community health and nursing. Before becoming a quarantine officer during SARS, she worked as a nurse at St. Paul’s Hospital in downtown Vancouver. I meet her at the airport, where she still works. Brisk and professional, she greets me in uniform and ushers me into her office, where we share institutional coffee and begin the interview.]

    When I met Woo, he was obviously sick. He looked, even smelled, sick. His face was heavily flushed and shiny with sweat, I remember. Plus he had a bad cough and a runny nose. It could have been a bad cold, but it looked to me like he had a fever. He looked like you could fry an egg on his forehead, in fact. If a passenger has a fever, then we have to treat him as a potential carrier of a novel contagion. So I confronted Woo and asked him to submit to an in-depth screening protocol.
    He refused point blank, saying something like he had important business somewhere. I told him that I wasn’t really asking. He was coming with me.
    My job is to assess ill travelers on international flights. It’s an important job, a vital part of national defense against accidental importation of disease. But it’s thankless just the same. Sometimes you feel more like a cop than a medical professional.
    In any case, I was on solid legal ground in detaining him. The Quarantine Act and the Airport Authority Emergency Protocols empower us to detain any traveler for up to 14 days in isolation if he or she refuses to undergo a medical exam, can’t produce evidence of immunization, and is believed to have been in close proximity to a person who may be the carrier of infectious disease. Woo fit all three conditions for isolation. By refusing my request, he had given me the authority to put him in isolation for the next two weeks. After explaining this to him, not surprisingly, he wanted the exam.
   [Quarantine and isolation are often considered separate concepts. Quarantine, from the Italian quarante, derived from the 40-day segregation of arriving merchant ships during the thirteenth century’s plague outbreaks, is the detention and physical separation of people suspected to be carriers of contagion. More recently, quarantine is defined as compulsory separation of healthy people who have been potentially exposed to disease, while isolation specifically refers to the sequestration of people who are known or suspected to be infected with a contagious disease. ——Author]
    I took him to the exam room, where PPHB [Population and Public Health Branch] officer Darryn Adams gowned up and ran a tympanic temperature check. Woo turned out to have a core body temperature of 40ºC, indicating a high-grade fever. Otherwise, he exhibited other symptoms consistent with influenza——headache, muscular pain, confusion and malaise. Whatever it was, it was slowly flattening him. Adams pricked him to get a small blood sample and ran a rapid influenza test to confirm whether the man had A-type flu. He had it.
    We didn’t know what strain of Type A flu had infected him, however, so Adams collected samples for testing, which involves a throat swab. During this, I thought about my options. I faced a choice, under the Quarantine Act, of either allowing him to continue to his destination and place himself under the surveillance of a medical officer, or holding him in isolation at the quarantine station at the airport. What I really wanted was a simple blood test I could conduct right there, on the spot, to tell me if the man had the Chinese flu, but we didn’t have that.
    I told Woo we were going to have to hold onto him until the lab tests came back.
    If it turned out he had an unrecognizable strain of influenza, we would hold him in isolation until he recovered. If he didn’t, we’d release him. I read him his rights: He had the right to appeal his detention and receive a legal hearing in 48 hours. I told him that if he looked at things a little differently, he would see that all we were doing was delaying him for a while so that we could give him excellent medical care and prevent him from passing on a possibly dangerous infection to his family and the public.
    So we had Woo bottled up, but that only solved part of the problem. He’d been contagious during his flight, so I also wanted to put all of Woo’s fellow passengers into quarantine. My boss nixed my request, though. I had to be satisfied with calling all the passengers on the same flight and instructing them to place themselves under the surveillance of a medical officer at their destinations in Canada.
    This all may sound heavy-handed to you, but the first rule of the job is to overreact: You may not like restricting people’s freedoms, but you must assume the worst—even though the usual result is you’re dealing with a common flu or cold——because the worst could be a pathogen like Avian.
    At that point, we could do nothing but wait four to seven days for the tests to come back and find out if Woo had regular flu or something new. Maybe it would have turned out that he had Avian or SARS or some other superflu and we would have to keep him isolated and chase down the other passengers. Or maybe it would turn out that he didn’t.
    There’s no perfect science when a new superflu can present just like a common flu. You could pick up one guy who has seasonal, run-of-the-mill flu and throw him in quarantine while 10 guys with bird flu walk right by you because they aren’t showing symptoms.
    And that is how it happened.
    We got the lab results sooner than we expected. Woo had contracted the tough variant of H3N2 influenza called A/Hong Kong. He did not have H5N1, Avian Flu.
    But John Warren did.
    That’s how the system failed.(11)