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

Chapter 2: State of Emergency

Mother, mother, I feel sick,
Send for the doctor quick, quick, quick.
Doctor, doctor, shall I die?
Yes, my dear, and so shall I.
How many carriages shall I have?
One! Two! Three! Four!

——skipping rhyme circa 1864

"Ebola of the lungs"

    On October 26, Dr. George Wells, chief of medicine, and Dr. Kristin Chambers, medical director of infection control, donned standard isolation gowns, gloves, face shields and N95 respirator masks, then entered the Intensive Care Unit of Mountain View General Hospital.(12) This modern urban hospital, located in Calgary, housed more than 500 beds and 2,000 staff, and treated more than 20,000 patients per year.
    Recently, their jobs had become consumed with identifying and isolating cases of a new superflu that resulted in a wave of hospitalizations and panic among the staff.
    Over the past week, the number of flu cases entering Mountain View suddenly surged. In Canada, five to 20 percent of the population comes down with seasonal flu each year, resulting in up to 8,000 deaths, and a bad flu circulated, so the hospital had expected and planned for a surge. But every day brought in new patients, and young, healthy people started to die from flu right in the middle of a modern hospital. Two staff members caught it. Now the staff felt exhausted and terrified.
    The hospital placed the most severe cases in Airborne Infection Isolation Rooms in the IC ward, the idea being to isolate people who could transmit highly infectious disease via aerosol droplets. The two doctors entered one of these rooms.

    Inside, a woman lay on a bed, connected by wires and plastic tubes to a monitor, oxygen supply and intravenous bottles. EKG tracing flashed across the screen of a cathode ray tube. Her pulse was thready and unstable.
    Her medical chart identified her as HOLDEN, ELIZABETH.
    The day before, the ER staff admitted her into the ICU with signs and symptoms indicating community-acquired hemorrhagic viral pneumonia resulting from the acute onset of respiratory illness. She presented a high-grade fever of 40°C, a heavy cough and sore throat, and, strangely, a heavily coated tongue with a bright red tip. Her white blood cell count read 10 times above normal, her body a war zone between its immune system and a rapidly replicating invader. Other complaints included frontal headache, arthralgia, myalgias, pharyngitis, coryza, prostration and epistaxis.
    In other words, she was burning up, coughing so hard she could break a rib, nasal passages inflamed, every atom in her body crying out in pain, difficulty breathing, bleeding into her lungs, and so confused and exhausted she could do nothing except lie there.
    As for epistaxis, they saw evidence of that firsthand. The woman moaned softly and shifted her head on his pillow, triggering a brief flow of bloody fluid from her nose and spread in a dark stain on the linen. The virus interfered with the flow of blood from the heart’s right ventricle to the lungs, producing a damming effect of blood and its release through the nasal passages at the slightest movement.
    The worst patients showed up with skin a deep shade of blue. Blood gushed from their noses and mouths, sometimes bled out of their ears and eye sockets as they coughed up pints of bloody yellow-green pus. An astonished Dr. Wells would later describe the virus as “Ebola of the lungs.”
    They had treated Holden with broad-spectrum anti-microbial drugs and put her on humidified high-flow oxygen to keep her breathing. The fever and cough persisted, but the drugs appeared to be keeping the disease at bay. She was 25 years old and before this, in perfect health.
    Whatever infected Liz Holden was gradually destroying her lungs’ ability to function. Her X-ray chart, which should have revealed clean black lungs on the negative, exhibited large white blotches on the upper and lower lobes.
    The lungs are needed to oxygenate the blood and sustain life. The X-ray showed the chest cavity around the lungs congested with fluid, how the lung tissue had become heavy. It therefore took Holden more effort to breathe.
    If her illness worsened, she would literally drown in her own fluids.
    The doctors did not realize this at the time, but the infections in many Avian Flu patients resulted in cytokine storms. During a cytokine storm, the immune system turns on itself. When the body’s immune system fights off an invader, its cytokines call immune cells to concentrate at the site of infection and fight it. Normally, the cytokines stop at a certain point, but in some cases, such as when a novel pathogen is encountered, they continually call up new immune cells, resulting in a cytokine storm, which can damage body tissues and organs. In the lungs, a cytokine storm can cause immune cells and fluids to block off airways, starving the blood of oxygen and resulting in death. This is why the disease proved so pathogenic against young people; their robust immune systems were turned against the bodies they were designed to protect.
    The hospital had admitted more than 100 patients now believed to have the disease, not counting potential new cases in the crowded waiting room. Infection control officers at Calgary’s other three hospitals told Chambers they had their own cases; she estimated the total number of cases at Calgary hospitals to be at least 600 on October 26. The hospitals had begun filling up and exhausting their surge capacity. For every case that ended up in the hospital, however, there could be several being cared for at home, and of course, there could be many more infected in the community who had not yet begun showing symptoms. For all they knew, they could have been seeing the tip of an iceberg.
    As it turned out later, they were.

    The disease initially presented like common flu, then turned deadly, with some atypical symptoms consistent with what they now knew about the new influenza virus that had emerged in China. However, lab testing had not yet confirmed this diagnosis. For now, the doctors at Calgary’s hospitals considered the disease as a highly virulent influenza-like illness that could be communicated through direct contact and droplets, and that responded to a narrow range of antivirals.
    Avian Flu or not, a novel virus——airborne, highly contagious and lethal——had compromised Mountain View Hospital. A nurse and paramedic had come down with it, and the rest of the staff had begun to panic. Two of them had lived in eastern Canada and had gone through SARS in Toronto. They knew how bad things could get in a serious epidemic.
    Health professionals like Wells and Chambers had defeated polio and tuberculosis. They’d grown accustomed to being on the winning side of the war against germs, they commanded expertise and machines and technology and worldwide surveillance with instantaneous communication, but this new bug scared them. They knew that people swam through life in an ocean of invisible bugs, that viruses constantly evolved and traded genes to potentially create new pathogens against which humans had little protection. They knew they were looking at a force of nature in action, something new unleashed into the world, and hated this new disease even as they perversely respected it.
    The virus, primordial and relentless, seemed to be communicating to them through Holden’s symptoms, and what it said terrified them.