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

Chapter 2: State of Emergency

Definitely a "zebra"

George Wells and other doctors at Mountain View Hospital initially thought their patients suffered from severe but ordinary flu, perhaps A/Hong Kong, which recently invaded North America. Then several young, healthy flu patients died after presenting horrible symptoms characteristically similar to the WHO profile of Avian Flu, and the hospital filed an outbreak report and started new screening procedures for patients.
Then China began dominating the nightly news. The government there experienced a sudden change of heart once the epidemic reached Beijing. Officials now told the truth about the epidemic, closed down schools and non-essential businesses, banned public gatherings, and educated people about social distancing and hygiene, all in a massive effort to break the chain of infection. They also allowed GOARN, CDC and other health organizations, as well as Western news companies, to operate in the country——not quite freely, but enough. It was all too late, of course. Suddenly, sitting at home after a long day at work, Canadians learned about the people dying like flies in the cities, the mass cremations, the looting, the soldiers surrounding the hospitals and firing tear gas into crowds of protestors, and the final, lurching crash of the country’s health system.

Demonstration in Hong Kong against the Chinese government on October 25. The Avian Flu spread rapidly through Guangdong province, but Chinese officials refused to acknowledge the epidemic or allow Chinese media to cover it until it reached Beijing. When the government finally acknowledged the epidemic, it was too late to halt its spread, and many cities, already in turmoil, exploded in violent demonstrations.(14)

    After the SARS epidemic of 2003, Health Canada formed three response teams, one comprised of the country’s top virus detectives. Their mission: Get out into the field within hours of a major outbreak and work with local health authorities on identifying and containing emerging infectious diseases. This team quickly descended on Calgary and began working with Mountain View and the other urban hospitals, following Canada’s Respiratory Illness Outbreak Response Protocol.
    At Mountain View, the epidemiologists confirmed the existence of an event, suggested a diagnosis, established a case definition, began counting cases, and tied the outbreak to a person, place and event through contact tracing. Because of their efforts, John Warren and his trip to Asia would later be identified as one of the original causes of the Canadian epidemic. They also identified those at risk of getting sick, started an epidemiologic investigation, and suggested measures for control and prevention.
    They sought answers to basic questions: Is this something new? Does a problem really exist? How does the pathogen behave? How do different types of people respond to infection? What works best at killing it? Is this a “horse” or a “zebra”?
    Their investigation told them they had something new, and it was highly infectious and deadly. A “zebra.”
    Health Canada epidemiologist Dr. Razik Lodhi recommended that Mountain View immediately enter a state of quarantine and get itself on a pandemic footing. Clinical staff had been caring for patients without adequate protection; the hospital needed to develop appropriate protective measures before more of them became infected. Flu patients continued to mingle with other patients and visitors in the hospital’s admittance area. The hospital still lacked a way to easily separate seasonal flu patients from patients who had contracted this new disease. Not only was the staff in jeopardy, he said, but Mountain View’s ability to continue functioning as a hospital.
    Some uncomfortable laughter at this among the hospital’s administrators at the meeting: Could this bug really shut them down entirely, wipe them off the map?
    We don’t know, Lodhi told them seriously. What we do know is that there is a highly virulent, highly contagious novel pathogen spreading in the community. You’ve got cases of it in 20 percent of your beds. And it looks like this is just beginning.
    The day before, he had seen an autopsy performed on a victim of the pathogen. The examiner had pulled out ravaged lungs heavy with fluid——a pink froth swimming with virus. This bug terrified him.
    After the meeting, the hospital CEO notified the Medical Officer of the Regional Health Authority (RHA) that an outbreak had been identified and requested resources available under a public health emergency. The hospital’s pandemic response plan called for quarantine, stockpiling supplies, separating flu and non-flu cases at the door, preparing for a continuing wave of new patients, and setting up buffers between the outside world, the hospital staff areas, and designated areas inside the hospital for flu patients.
    Meanwhile, Elizabeth Holden labored to breathe.
    Wells and Chambers monitored her life signs in silence. The shouting matches had ended, decisions had been made. The meeting over, they were each drawn here to find a moment of quiet while the hospital went into lockdown; Holden had begun to show signs of recovering, giving them hope.
    All over the building, doors were being locked. Nobody could go in or out.
    This was quarantine.
    In several minutes, Wells and Chambers would have to rejoin the other hospital administrators to tell the clinical staff that Mountain View had initiated Code Orange——code for a major disaster——and had begun a pandemic footing.
    The continuing surge in new flu cases required additional coverage. Because the hospital already had many patients——the staff was treating them in corridors, in fact——they would gradually scale down elective and non-essential services to be able to treat the maximum number of flu patients. In short, the hospital needed a purge to make room. Any existing patient well enough to be discharged would be sent home. The number of patients requiring ICU beds already exceeded available beds; the hospital would supplement by rigging surgical recovery units and anesthetic machines. Within days, the hospital would transition from a full-service working hospital to an influenza treatment center. Meanwhile, to ensure it would be able to continue functioning at all, Mountain View had entered working quarantine and would remain in this condition until the epidemic ended.
    They knew that the next few hours would prove critical; some of the staff would rise to the occasion, while others would panic and possibly abandon their jobs when needed most. Just minutes from now, Mountain View would begin a long, exhausting, dangerous siege that would demand constant physical endurance, emotional strength, clear thinking and perfect judgment around the clock.
    But not yet. The two doctors still had a few moments of peace and quiet to enjoy, even if it was only the calm before the storm.
    Wells took Chambers’ hand in his. He knew it might be a long time before he saw her face again. She returned the gesture by squeezing his hand through isolation gloves.