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

Chapter 1: Outbreak

Canada's index case

    Warren landed in Calgary on the evening of October 14 and immediately went to his hotel, still showing no symptoms of Avian Flu. He had a drink in the hotel bar and went to his room for a long sleep. The next day, however, he complained of a headache and had a nagging cough during a breakfast with colleagues. He bought aspirin and cough drops in the hotel. Then he went to the tourism industry conference.
    It is believed Warren infected a large number of people there. While influenza is most easily communicated by people breathing air contaminated by virus resulting from an infected person coughing or sneezing, it is likely that Warren infected many of his contacts by shaking hands and touching objects that other people subsequently touched, such as business cards and doorknobs; these people then touched their mouths or eyes before they washed their hands, infecting themselves.
    The conference buzzed with news of the WHO travel advisories against Vietnam, Singapore, Thailand and Japan, speculations of an imminent advisory against China, and predictions of devastation for their industry. Canada had earned about $16.7 billion from international travel in 2011 after a long, difficult recovery from the SARS epidemic. The tourism industry wondered: How much would they lose this time, especially if this new Chinese flu showed up in Canada, like SARS did? How much could they afford to lose?
    A rumor began to spread at the conference that the government had decided to close the border to air travel entirely, which would spell financial ruin for all of them. This rumor, like many later associated with the Pandemic, turned out to be untrue.
    The government knew that if it closed the border, it would create an economic catastrophe and still probably not keep Avian Flu out of the country. Confronting a pandemic presented a game of risk management with high-stakes tradeoffs affecting entire populations and economies. Governments implemented their response policies in phases to mitigate risk. As the risk increased in scale and severity, so did the policies.
    On the last day of the conference, Warren collapsed during a social event. Colleagues helped him to his feet, noting that he had begun suffering a spectacular nosebleed. They thought he had drunk too much, as his face had turned shiny and scarlet, and that he had fallen and hit his nose on the floor. Tensions over their financial future had made everybody irritable, and alcohol flowed freely at the open bar.
    Warren stayed on his feet for a few moments, began yelling his wife’s name, then collapsed again and lay on the floor trembling, his back oddly arched as if its contact with the floor caused him extreme pain. Blood poured from his nose.
    His colleagues called 911.
    Paramedics brought Warren to a hospital. The doctors did not ask if he had recently traveled to Asia. They eventually diagnosed him with influenza, gave him a bed and notified his family in Edmonton. The conference attendees returned to their homes throughout Alberta. Some had come from as far away as Toronto, Montreal, Vancouver and the States, including New York City, Chicago and Los Angeles.
    Some took the virus back with them. It would take nearly two weeks before public health authorities began to suspect that the Avian Flu had begun spreading exponentially across North America.
    John Warren became the index case for the Canadian outbreak that unleashed the long nightmare of Avian Flu in North America. Because of the large number of people he infected, he was considered a “super spreader.”
    Meanwhile, over the next several weeks, additional flu carriers landed in San Francisco and Los Angeles, and then traveled on to other destinations in North America.
    The genie had left the bottle.