The most recent official update on the novel coronavirus raises the possibility that most of the recent cluster — 13 cases out of 30 — may be due to the novel disease spreading within one hospital. (Yesterday there were reports of the spread having to do with dialysis. I’m skeptical of that.) Infectious disease experts find the idea of hospital spread very worrisome, because when the related disease SARS arose 10 years ago, hospitals unknowingly caused its first rapid spread. International health authorities are taking this threat seriously: On Monday, the World Health Organization published a multi-page infection-prevention guide for any hospitals that might take in victims.
When SARS broke out of southern China in early 2003, I was in the midst of a year-long project shadowing members of the disease-detective corps of the Centers for Disease Control and Prevention, known as the Epidemic Intelligence Service. Some of the most explosive SARS outbreaks they were sent to investigate were in hospitals, and front-line health care workers were some of the earliest victims.
This is the second of two excerpts from a book I wrote in 2004 about the EIS, Beating Back the Devil, describing what the early days of SARS were like. In the previous one, a hospital swamped by SARS locks its doors, with its sick staff inside. In this one, a doctor who worked in that hospital — and alerted the world to the threat — loses his life to the disease.
While the CDC and the WHO focused on Hanoi, the still-unexplained disease had seeded itself around the world. And in almost every expansion, a hospital played a role.
On the afternoon that Dr. Liu checked into the Metropole Hotel from Guangzhuo, a Chinese-Canadian family were checking out. They lived outside Toronto, but they had been visiting their son in Hong Kong to celebrate Lunar New Year. They arrived home February 23. A few days later, Kwan Sui Chu, the 78-year-old mother, began to feel feverish. On March 5, she died at home of a heart attack. Two days later, her son Tse Chi Kwai, felt feverish too. He sought help in the crowded emergency department of Scarborough Grace Hospital in a Toronto suburb.
Tse died March 13. His visit to the hospital started a chain of infection that would produce 251 cases of illness in Canada, and 43 deaths.
Staying on the same floor as Dr. Liu were three young women from Singapore who had come to Hong Kong on a shopping trip. When they returned home, they sparked an outbreak that sickened 34 others. A Singaporean doctor who treated some of the first patients infected by those women visited New York City for a medical meeting, and then flew home through Europe. He was taken off the plane in Frankfurt, along with his pregnant wife and mother-in-law, and hospitalized there, becoming Europe’s first cases of the new disease.
On the night that Dr. Liu stayed in the hotel, he attended his nephew’s wedding banquet. He infected one of the other relatives there, as well as a local resident who was visiting the hotel. Both men were treated at separate Hong Kong hospitals. A visitor to one of the hospitals later took a plane to Beijing, carrying the infection into China’s interior and passing it to travelers who brought it to Inner Mongolia and Taiwan.
Dr. Liu checked himself into a Hong Kong hospital on February 22. He warned the staff to put him in isolation, and he told some of them about the epidemic he had helped to treat in Guangdong. He died March 4. Thanks to Liu’s visit, and other patients flooding across the border, there would eventually be 1,755 cases of the disease and 299 deaths in Hong Kong. One of those was Johnny Chen. He died in Hong Kong on March 13, one week after being medevac’d from Hanoi.
It would take weeks for those connections to emerge. But in Hanoi, behind the locked doors of the French Hospital, one of Chen’s nurses died on March 15. The doctor who intubated him died on March 19. Fifty-six of the French Hospital’s health care workers and their families were sick, so many that they spilled over into Bach Mai Hospital next door. The CDC and WHO were just beginning to understand the scope of what they faced.
Scott Dowell, a CDC physician, rushed to the airport through Bangkok’s 24-hour traffic to meet Urbani’s flight from Hanoi. Dowell had no idea what the parasitologist looked like, but he spotted him as soon as the bus from the airplane disgorged its passengers. Urbani was taller than most of the others, but it was his expression that caught Dowell’s eye: He was pale and had a grim look on his face.
Dowell and a local quarantine officer greeted Urbani gingerly — they were careful not to shake hands — and then led him through an unused part of the airport to an out-of-the-way driveway. They were expecting an ambulance, but its frightened crew had stopped to get protective gear. Then they had gotten lost in the airport. It would take them ninety minutes to find the right door.
Dowell and Urbani arranged two plastic chairs about six feet apart — close enough to hear each other over the traffic noise, but far enough, Dowell thought, to keep the risk of infection low. They talked.
“Carlo was quiet,” Dowell said. “He wasn’t particularly sick; he wasn’t short of breath, he wasn’t coughing. Mostly he had a bit of fever, and he was scared he would get a lot worse.”
The ambulance, when it arrived, took them to Bamrasnadura Hospital, a state-run facility that the ministry of health had designated as the main quarantine hospital in case an ugly disease ever came to Thailand. It was after 2:00 a.m. They found Urbani a room that was off by itself on the third floor, away from areas where patients were being cared for. Bamras, as it is called, is a typical tropical hospital. The wards are open to the air at both ends, and there is no air-conditioning — so there was no such thing as a negative-pressure room with one-way airflow that could keep disease organisms from floating out into the hospital. Dowell and the staff hastily improvised one, propping fans in the windows to suck air in from the hallway and blow it outside.
They moved Urbani in, and checked his vital signs. He had a fever of about 100 degrees. His chest sounded clear when they listened to it. His chest X-ray was clear as well, and the level of oxygen in his blood was acceptable.
“For the most part he was not a patient who needed to be in a hospital,” Dowell said. “But he was scared, and depressed. In Hanoi he had seen patients who were well in the morning and very sick in the afternoon, and he feared it would be quick.”
Dowell was being shipped to Taiwan; the country had held SARS at its borders for weeks, but cases were finally appearing. He asked Mike Martin, another CDC physician, to take over Urbani’s case.
“Nothing seemed bad,” Martin remembered. “We had heard about mild cases of the disease, and I figured he was one of them. I thought, Maybe this is going to be OK.”
Urbani, though, was still scared, and he felt isolated in the room they had stashed him in. They decided to move him into the center of the floor, directly opposite the nurses. In three days, the hospital cleared the ward of every other patient; they made the entire floor into an isolation suite, putting up double walls of glass that enclosed Urbani’s new room and the nursing station, with a sealed one-way corridor in between. From their desk, the nurses had a clear view of Urbani in bed about eight feet away. It was a little too far to see the pulse monitor and oximeter, so to read them in a hurry they kept a set of binoculars on top of the desk. To talk to him face-to-face required additional steps. Everyone entering the floor was required to wear basic protective gear: gowns, gloves, and a fitted N-95 mask with mesh small enough to catch viruses before they could be inhaled. Between leaving the nursing station and entering the corridor to Urbani’s room, the doctors and nurses doubled up on protection: a second gown and gloves, shoe covers, and goggles.
For more than a week, the arrangements felt like overkill. Urbani still had a low fever, and a cough that came and went. He complained of shortness of breath, and the staff put him on some supplemental oxygen, from a cannula that hung just underneath his nose. Dowell called every night to keep Urbani’s spirits up. Martin went to Bamras every day.
“At the time, I thought I was going almost more for social reasons, to show him that we were paying attention and that we cared about him,” he said. “Medically, he wasn’t at risk.”
Martin had written orders for chest X-rays to be shot every few days, to be sure Urbani’s lungs were staying clear. The first few were fine. Then one, midway in the second week, was not. Martin began listening to the daily phone calls among WHO and CDC teams working on SARS around the world, hoping for a treatment that might make a difference. He tried antibiotics to protect against the start of a secondary bacterial infection, newly developed antivirals, steroids because Hong Kong thought they were useful. Nothing helped. Urbani’s oxygen levels were steadily declining. In the second week, they put him on a mask that forced air into his lungs.
“He would go for a day and be great, and then have a few bad days, and then a good day,” Martin said. “He was strong, so strong. And mentally, he was always there.”
Until, briefly, he wasn’t. Pressurized oxygen is difficult to tolerate for long. The compressor noise is loud and assaultive, and the whooshing air dries out the mouth and throat. For whatever reason, on a day when he had been in the hospital for more than two weeks, Urbani lifted off his oxygen mask, and his lungs collapsed.
Martin arrived to find the Italian physician sedated and on a ventilator. The intubation had been smooth and quick, and his blood-oxygen levels were back to acceptable levels. But it was the beginning of an irreversible slide.
“He went two or three good days,” Martin said. “And, you know, you’re always grasping at straws. I remember thinking, in just a couple of days, he’s going to turn the corner. We’ll keep him comfortable, we’ll do good medical care, and we’ll just wait for him to come around.”
He never did.
Dowell returned to Bangkok. He and Martin were both experienced clinicians, but neither was a critical-care specialist. They asked the WHO for extra help, and the agency sent an Australian doctor whose specialty was intensive care. On the morning of March 29, she met with Martin to go over Urbani’s condition. He had had a bad night, and she had had trouble keeping him oxygenated; she wanted Martin to know the details before she left for a few hours’ break.
From the nursing station, Martin looked through the double set of windows. Urbani was lying peacefully, and there were nurses in the room with him. He picked up the phone to report to Dowell — and out of the corner of his eye, he saw one of the nurses spring toward Urbani’s bed. Martin dropped the phone and ran, out of the nursing station, through the robing room for the second set of layers, and in with Urbani. The Italian’s heart had stopped. They pounced on him with defibrillator paddles, and within a minute brought him back.
A cardiac arrest is never good, but a minute is a short amount of time to be without oxygen; brain tissue is not seriously damaged until four minutes have passed. But Martin had no idea why Urbani had coded. He went back out to the nursing station, called Dowell, and began searching for the morning lab results, hoping to find some clue in the blood chemistry. With his head in the chart, he heard one of the nurses bang on the window. He looked up. Urbani had coded again.
This time, getting him back took twenty minutes, an impossible length of time to be without a reliable heart rhythm. Still, Urbani rebounded: his pulse rate surged and stabilized, and his blood-oxygen began to creep back up. The team were uneasy, though, and they stayed by his bedside. There was a moment’s normalcy, and then his heart failed a third time.
Dowell had arrived at the hospital, but there was no time to gown and glove. He grabbed a mask and slid into the walled nurses’ station. Through the double windows, he could see Martin and a Bamras doctor and a succession of nurses, leaning stiff-armed over Urbani to give him chest compressions, backing away while one of them tried the defibrillator, waiting to see if the rhythm took hold, and then rushing in with compressions again.
The Thai doctor climbed on the bed for extra leverage. She was soaked with sweat, and her mask slipped. The sight jarred Martin out of his trance of urgency. He realized the risks the staff were running. He pulled her off the bed. She fought him. He pushed her out the door, and vaulted on the bed to take her place.
“Nobody wanted to lose Carlo,” Martin said. “Nobody wanted to see him die.”
After more than an hour, Martin and the nurses stepped back from the bed. There was no hint of a pulse. Urbani lay gray and unmoving. At 11:45 in the morning, they pronounced him dead.