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

Chapter 2: State of Emergency

"I woke up in a hospital bed"

    Survivors would later describe the horrors of infection. Kim Albright, formerly a pharmaceutical sales representative in Toronto, recalls calling on hospitals where her customers all wore face masks. “Since I dealt with doctors all the time, I was one of the first to find out how bad this bug was,” she recalls. “My customers told me it was the most lethal form of flu they’d ever seen, one that caused hemorrhagic pneumonia——you bled into your lungs and coughed it up until the lungs just gave up and you died.”
    Doctors warned her to stay away from the hospitals, but Albright says demand for her company’s products had skyrocketed, and the commissions were too good to pass up.
    “Then one night I arrived home feeling like crap, my face warm to the touch, and went straight to bed,” she adds. “The next morning, I felt a little better and started to make my sales calls. In the back of my head, I knew I was coming down with something, but I kept bargaining with myself: You can’t get sick now, just make one more sales call and you can sit it out for a bit. It’s the drive you have when you’re in pharmaceutical sales——it’s like an addiction, you don’t know when to give up. I was coming out of Queen Mary Hospital when I collapsed, unable to speak or move. The doctor I had just been talking to came out and arranged for me to be carried back inside.”
    Sean Parker, an electrician in Ottawa, says he was walking from his home to a nearby job site when he blacked out. “I woke up in a hospital bed surrounded by walls of plastic sheeting,” he says. “People hurried past the sheets——like dark ghosts, calling to each other. At first, I thought I’d been mugged; my body felt like every inch of it had been beaten with a tire iron. My eyes and head hurt like somebody had punched my naked eyeballs and fractured them. I was in some sort of ward, burning up with fever and lying in a bath of my own sweat, and people all around me were moaning. I had a tube jammed into my mouth feeding me oxygen, an IV bag feeding fluids into my veins.”
    Parker says he spent the next two weeks unconscious, and couldn’t believe the state of the world when he woke up.
    “It was hard enough for me to accept that the bad flu going around turned out to be bird flu, that I’d gotten it, and that I actually survived,” he says. “It was even harder to accept how bad things had gotten around the world while I’d been unconscious. I felt like Rip Van Winkle, sleeping through history and waking up in a strange world I barely knew anymore. It didn’t take long for things to get bad and start to fall apart.”
    Lisa Dunn, a registered nurse working for a hospital in Vancouver, had been following quarantine procedures and checking her body temperature once a night when she realized she was getting sick. “One night I felt warm and my temperature was fluctuating, then spiked,” she recalls. “I was working long hours; I could have gotten anything. I stayed up late that night bargaining with God. By the morning, I was burning up and I knew I’d gotten the flu. I sat down and wrote a goodbye letter to my friends and family, then drove myself to the hospital.”
    Ken Leahy, an advertising executive in Toronto, remembers how helpless he felt lying in a hospital bed unable to speak or move. “Most of the time I didn’t know who I was and felt so much pain I didn’t care if I lived or died,” he says. “Then these moments would come where I was lucid again and I’d start thinking about Cindy and the kids. If I died, who would look out for them? And worse, had I infected them? Would I live only to find out I’d killed my own family? Would I want to live if this happened?” These moments, he adds, were actually more painful than the symptoms of the flu.
    Jean White, a housewife living in Thunder Bay, Ontario, says the fever dreams were the worst part: “In one dream, my kids were babies again, but I couldn’t find them no matter how hard I looked. There were hornets nests in the cribs, and the hornets flew out and into my lungs. These dreams would quickly become vivid nightmares, as real to me as the house I’m sitting in. I watched my husband get torn apart by a machine, get blown up in a freak gas explosion; I saw my kids fall down an elevator shaft, die in a car rolling off a cliff. Everything important to me got taken away over and over. Time lost all meaning. This torture went on for what felt like years. It’s what Hell must be like.”
    Kim Albright is no longer a pharmaceutical sales rep. As a result of her infection and the virus attacking her brain, she became partially blind in her left eye. She’s still on disability, and considering a career change. “For now, I’m just smelling the flowers,” she says. “Staring death in the face really makes you appreciate life, the people you love, and all the little things that make life interesting——if only you pay attention.”

    Pathogens are given R0 ratings, which indicate their reproductive value. If a given disease has an R0 value of 2, for example, then one infected person will transmit infection to an average of two other people.
The reproductive value of a disease is based on three factors. First, how contagious is it——how easy to transmit? Second, how long after a person becomes infected is he or she able to infect other people? And third, how many people who are susceptible to the disease live in the outbreak area?
    The lower the R0 number, the easier an outbreak is to contain. If R0 is <1, for example, one person will pass it on to another person in an arithmetical rather than exponential infection rate.
    SARS exhibited an R0 value of 2.2-3.7, measles an R0 value of about 12 and mumps an R0 value of about 8. Common influenza’s R0 value is anywhere from 1.5 to nearly 4. The Hong Kong pandemic strain of 1968 had an R0 value of <2. The Spanish Flu of 1918-19 had an R0 value estimated at 1.8-3.(27)
    Epidemiologists have estimated Avian Flu’s R0 value in Canada to be >2 prior to government intervention strategies such as school and public venue closings. That means in the first days of the epidemic, an infected person might pass it on to as many as two or more other people. School closings and other interventions gradually reduced this number, but it remained high enough to ensure exponential spread of the virus.
    The Avian Flu presented several problems. Humans and this variant of the H5N1 virus had never encountered each other before. There was no vaccine, no natural immunity in the population. In short, everybody proved susceptible to it. Infected individuals easily communicated the virus, which was as contagious as common flu. And the virus incubated in the human body in just 1-4 days; an infected person could unwittingly pass on the virus before developing symptoms, with peak infectivity occurring soon after.
    Assuming an R0 value of 2-2.4 for Avian Flu and a generation interval of 2-3 days, with no interventions and ignoring super spreaders such as John Warren, one person infected with H5N1 could theoretically produce a chain of infection involving more than 450 people in two weeks and more than 500,000 people in a month.
    Avian Flu was spreading fast among Canada’s population.
    Based on the initial reports about mortality and number of cases, health officials in Alberta began to accept the possibility of a severe pandemic strain. By the end of October, flu patients in the Calgary Health Region, the worst hit at the time, had already created a demand for about 65 percent of acute care hospital beds (a “bed” being the equipment and personnel needed to care for an individual, requiring critical care, who would be occupying it), more than 70 percent of all ventilators, and about 475 percent of available ICU beds. Already, just one week into the epidemic, the health system lacked enough life-saving equipment, forcing doctors to make painful choices.
    In just another week, so many people would seek hospitalization in cities like Calgary that their critical capacity would be exceeded, and the hospitals would begin to shut down, virtually closing their doors to the public.