The most recent update on the novel coronavirus that has been spreading in the Mideast since last summer adds three more cases to the outbreak, and raises the possibility that most of the recent cluster — 13 cases out of 30 — may be due to the infection spreading within one hospital. Infectious disease experts find that worrisome, because when the related disease SARS arose 10 years ago, hospitals unknowingly amplified 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 outbreaks they were sent to investigate were in hospitals, and front-line health care workers were some of the earliest victims.
I thought it would be worth remembering what the early days of SARS were like, while we wait to see what this new virus does next. So over the next few days, I’m going to run a couple of excerpts from a book I wrote in 2004 about the EIS, Beating Back the Devil. In this one, a hospital swamped by SARS locks its doors, with its sick personnel inside. In the second excerpt, a doctor who worked in that hospital — and alerted the world to the threat — loses his life to the disease.
Johnny Chen was very sick, and none of the health workers treating him were quite sure why. It was the morning of March 3, a Monday. It was early, but Hanoi is a town that rises early; the neighborhood loudspeakers that play inspirational music and scold residents for littering had crackled to life before 6:00 a.m. Dr. Vu Hoang Thu, a forty-three-year-old internist, had downed a small cup of dark filtered coffee and left the house she shared with her husband and two teenage sons before the sun pierced between the tree trunks in Lenin Park in the center of town. She was at the French Hospital, a rounded, blocky building of pink and white stucco that lay across a wide boulevard from the park, before the nurses on the night shift handed off the care of their patients to the staff coming in for the day.
Vu was one of the physicians assigned to the 56-bed hospital’s general medical ward. Chen was one of her patients. The 47-year old American, a businessman based in China, had been at the hospital for almost a week, choosing the small private institution over the sprawling, scruffy campus of state-run Bach Mai Hospital next door. He had started to feel sick, with a high fever and deep fatigue, immediately after arriving from Hong Kong.
Slowly but steadily, Chen had gotten worse. Despite antipyretics, his fever had stayed stubbornly high. Despite antibiotics, his lungs were slowly filling with fluid; on X-rays, Vu could see the opaque shadow of inflammation moving slowly up his chest. Based on a positive influenza test, the staff had given him an antiviral drug, but there was no sign it had helped. On Saturday he started to cough explosively. On Sunday morning, he slipped into severe respiratory distress. He was lethargic and having trouble breathing. His skin had a greyish tinge, and when he tried to speak, he made no sense.
Clearly he was not getting enough oxygen. Vu ordered Chen put on a ventilator. It was a quick process when it went smoothly, but it was always tense. It was easy to make a mistake, and a doctor had to go nose-to-nose with the patient to sight clearly down the airway. This intubation had gone well. One nurse sedated Chen and gave him an injection that briefly paralyzed him. Another stood by his shoulder, pressing down on his throat cartilage to close his esophagus so the tube would not go the wrong way. A doctor slid the curved laryngoscope into his mouth, squinting down its sights and easing the tube along its guiding stylet, down his throat and between his vocal cords. Within moments, Chen was hooked to the ventilator. Almost immediately, his color began to improve.
That had been the day before. So when she reached the hospital, Vu was surprised to find that Chen was no better: The machine was supplying him with oxygen, but he was still obviously severely ill. There was another surprise awaiting her. One of the nurses who had assisted with his intubation was tired and had a high fever, and she was beginning to cough.
The previous November, a puzzling respiratory disease had cropped up in China’s Guangdong province. Guangdong wraps around Hong Kong on three sides, and its border with the territory is porous because the province, and especially its capital Guangzhou, is the fervent center of China’s new capitalism. Guangzhou holds more than 5 million people. The illness started in Foshan, a fast-growing town of more than 3 million that lies southwest of Guangzhou. Week by week, the unexplained pneumonia spread. Stories appeared in the state-run newspapers — in Zhongshan, south of Guangzhou, and Heyuan, north of the city — denying the outbreak’s existence, but doing it so vociferously that they effectively confirmed it. Rumors that health care workers were sick became so common that the World Health Organization asked the Chinese Ministry of Health to comment. The reply that came back by email said there was only a minor outbreak of influenza B.
On February 3, a 40-year-old man checked himself into the No. 2 Hospital in Guangzhou. His lungs were filling up from pneumonia and he was coughing and feverish. The illness spread rapidly through the hospital. Within two weeks, so many health care workers were sick that they filled an entire ward. The remaining staff were frantic; they worked double shifts, trading off between their sick colleagues and the new patients who were crowding in from the city.
By the second week of February, rumor sof the outbreak reached the Internet. In a chat room on a site called Teachers.net, a California fourth-grade teacher named Catherine Strommen received a note from a Guangzhou teacher she had spoken with a few times before. The note asked: “Have you heard of the terrible sickness in my city?”
She had not, but she thought she knew someone who might. Strommen’s husband had been in the Navy and they had once been assigned to Hawaii, where they made friends with a Navy physician and epidemiologist who lived nearby. The neighbor, Dr. Stephen O. Cunnion, was now an international health consultant in suburban Washington. He relayed her question to ProMED, a listserv for reporting disease outbreaks that is run by the International Society for Infectious Diseases and has more than thirty thousand subscribers worldwide.
Cunnion’s post appeared the next day, February 10. It quoted Strommen’s note: “ ‘Have you heard of an epidemic in Guangzhou? An acquaintance of mine … lives there and reports that the hospitals there have been closed and people are dying.”’
Cunnion got dozens of replies. None were from China — but someone there was listening. Less than a day later, the Guangdong Department of Health made its first official statement about the outbreak. Yes, the agency said, there had been an outbreak of about 300 cases of pneumonia and five deaths, but it was ending.
In fact, it was not ending, though no one outside China would learn that for six more weeks. It had spread to at least eight cities within Guangdong. At the No. 2 Hospital, more than 50 health care workers were sick, and their healthy colleagues were exhausted caring for them. One of the still-healthy ones was Dr. Liu Jian-Lun, a 64-year-old professor of medicine at Zhongshan University in Guangzhou. In late February, he took a break from the epidemic. His nephew was getting married in Hong Kong, and Dr. Liu wanted to be there — even though, in the past few days, he had been starting to feel a little unwell.
On February 21, Dr. Liu and his wife checked into the Metropole Hotel in Kowloon, on the mainland side of Hong Kong. They were given room 911. Staying on the ninth floor with them were a random group of travelers whose names, or fates at least, would soon become known worldwide. One of them was Johnny Chen.
Chen arrived at the French Hospital five days later. He sparked a ferocious outbreak. By March 5, three days after he was intubated, one nurse who had helped grew so sick that she had to be hospitalized. By March 6, nine more of the staff had the same symptoms that she did: sudden high fever, flattening exhaustion, cough.
“From the fifth, we did blood tests every day, for the entire staff,” Vu said. “We didn’t find anything.”
The medical staff had heard of influenza cases in Hong Kong and the claimed pneumonia epidemic on the mainland. They knew Chen had passed through Hong Kong, and they suspected he had acquired his illness there. The hospital’s management called the local WHO office to let them know that something might have crossed the border. WHO has only a small group in Hanoi, headed by an elegant Frenchwoman named Pascale Brudon. She asked a member of her staff, Dr. Carlo Urbani, to take a look.
Urbani was 46, a big, cheerful man with dark hair and a wide forehead who came from Castelplanio, a small town on Italy’s Adriatic coast. He had spent much of his medical life in Africa and Asia, and he had come to Vietnam with his wife and three children to work on programs preventing parasitic diseases in children. He was the former president of the Italian branch of Médecins sans frontieres, known in the United States as Doctors Without Borders, and had helped accept the Nobel Peace Prize given to the group in 1999.
“Health and dignity are indissociable in human beings,” he said at the ceremony. “It is a duty to stay close to victims and guarantee their rights.”
Urbani made his first visit to the French Hospital two days after Chen was admitted. He worried that health care workers were falling ill so quickly. On March 5, he sent a warning email to the WHO’s communicable diseases division in Geneva, and he began coming to the French Hospital every day, sometimes twice a day. He kept checking the sick staff, swabbing their throats for analysis and drawing their blood, looking for a clue that would explain what was making them so ill.
Chen’s family pulled him out of the French Hospital on March 6 and had him medevaced to Hong Kong. His departure came too late for the French Hospital. On the 7th, two more health care workers fell ill, making 12 in all, and Urbani recommended the hospital isolate its sick staff in one ward on its second floor. On the 8th, five of the 12 developed bilateral pneumonia., and Urbani herded the remaining staff into the cafeteria and urged them to wear whatever protective gear they had, especially face masks, at all times. On the 9th, there were 15 cases. In a desperate bid to halt the disease’s advance, the hospital turned off its air-conditioning.
On March 11, the count of sick doctors and nurses rose to 35, plus four of their family members. The hospital did not have enough staff left to operate; it barely had enough to care for its own sick personnel. Its patients were transferred to Bach Mai Hospital next door. The sick staff, most of them now gasping with pneumonia or sedated and on ventilators, stayed. They were accidental victims of a still-unidentified plague, and their workplace had become a plague hospital.
Inexplicably, Vu was not sick. When the hospital sealed its doors, she remained inside. She would not come out for more than three weeks. “I stayed for my colleagues,” she said. “I said to the others who were not sick that we should try to continue. But we were very worried, very scared.”
On the same day, Urbani made a morning visit to the hospital, to check on the sick staff and take another set of samples. Then he hurried back to the WHO office. He was due in Bangkok that evening; he was giving a talk at a scientific meeting, a long-standing commitment, the next day.
From the airport, he called Brudon. “He said he was not feeling very well,” she said. “He said, Pascale, I think I have got this disease.”
Next: Urbani seeks the CDC’s help in Bangkok