March 6, 2003
National Center for Disease Control Headquarters, Beijing, China
571 Infected, 60 Dead
IN FEBRUARY OF THAT YEAR, THE RUMORS OF THE DISEASE IN Guangdong were a minor concern for citizens in Beijing, who had welcomed in the Year of the Goat with a decidedly more conservative palate than Guangdong’s, so enthusiasts of Wild Flavor were reduced to just a few districts in the capital that catered to those seeking Cantonese fare. Snake, pangolin, lizard, civet, and other delicacies were available, but with their city boasting the widest array of regional cuisines in China, Beijingers generally preferred to leave the civet cats to their stereotypically hot-tempered cousins to the south. There was one cultural attribute Beijing shared with Guangdong, however, and that was the atmosphere of breakneck prosperity. After winning the right to host the 2008 Olympic Games, the city had redoubled its decade-long construction spree so that virtually every hutong—traditional neighborhood of wooden houses built around a courtyard—in the city seemed earmarked for destruction. Those near the center of the city, close to the government agencies that comprised much of the area inside the Third Ring Road, had almost all been eliminated and replaced by high-rise buildings, from which sprouted satellite dishes and, from all but the most expensive, clotheslines with garments flapping in the stiff, almost arctic breeze.
As Du Ping’s father was gasping for life, even as he expelled his last breaths during the afternoon of March 6, just two miles away, at the headquarters of the China CDC, Hitoshi Oshitani and Keiji Fukuda, along with several WHO officials, were finally sitting down with several members of the China CDC. No one in that room could imagine that the mysterious disease that was burning through southern China had already reached Beijing. The Chinese officials present included Liu Peilong, from the Ministry of Health; Li Liming, chief of the China CDC; Xi Xiaoching, also from the China CDC; and several officials from Guangdong, including Xu Ruiheng from the Guangdong CDC and Xiao Zhenglun from the Guangzhou Institute of Respiratory Diseases—Xiao had led the team that investigated the Heyuan outbreak. Most notably present was Hong Tao, the venerated microbiologist who had discovered what he thought was Chlamydia in sample tissue from Guangdong.
For Hitoshi Oshitani and Keiji Fukuda, who had waited for over two weeks to meet with counterpart scientists and physicians regarding this outbreak, the presentation they saw was disappointing. The expression in Chinese for this is yuan fa yue, or “a walk in the garden.” In other words, these visiting experts were being shown a few sites but little of actual value or import. Several clinicians and CDC officials made a PowerPoint presentation regarding number of cases, symptoms, and the results of PCR tests and screens, which indicated that whatever the disease had been, it was no longer spreading. However, both Fukuda and Oshitani were perplexed that their counterparts had not contact-traced the cases or bothered to establish a chain of transmission. They seemed satisfied to note that the disease, whatever it was, appeared to be receding.
One PowerPoint slide explained that, as of February 27, there were 745 cases and only 26 fatalities. Yet, shocking to Oshitani and Fukuda was the fact that 212 of those infected were health care workers. The epi-curve put up on the screen—a graph representing the onset of new cases—showed a satisfying turn toward the flat line just a few days earlier, which seemed to make the case that this outbreak was a historical curiosity rather than an impending pandemic. The Chinese side stressed that such a chain of infection was consistent with what appeared to be an outbreak of chlamydial pneumonia.
Fukuda and Oshitani exchanged glances. The incomplete information the Chinese officials found so reassuring raised even more concern for the two epidemiologists. As the lights came up, Hong Tao, the microbiologist, stood and explained that he had found Chlamydia in two lung autopsies and believed the cause of the outbreak to be this bacterial agent.
For Fukuda and Oshitani, this did not look like a Chlamydia-type outbreak. Health care workers would not be succumbing at this rate to a bacterial infection, nor would treatment have proven quite so challenging. It was also highly unlikely that such a disease could prove as fatal as this one was.
“Have you considered that this could be a viral agent?” Fukuda asked.
Hong Tao did not acknowledge the question after it was translated for him. He instead continued to explain that he had found especially high concentrations of Chlamydia in the kidney tissue of deceased patients. As far as the possibility of avian flu was concerned, the Chinese team had so far found just two influenza cases from 162 swab specimens, and PCR tests were also negative. Chest X-rays were also shown to the visiting scientists, and those did not seem consistent with H5N1.
This was convincing data. Despite the lack of follow-up in Fujian, the southern Chinese province from which the avian influenza cases in Hong Kong had emanated, the data indicated that perhaps the first fear of these epidemiologists was unfounded. Also, the high incidence of health care workers infected also indicated that this was probably not influenza. “If this had been influenza,” Oshitani explained to me later, “then it should have been more randomly distributed. This disease was pinpointing health care settings.”
That night, as the two men discussed the day’s meetings over a dinner of Mongolian beef at the Yuyang Hotel, just a few blocks away from the WHO’s Beijing headquarters, Oshitani took a call on his cell phone from Carlo Urbani. Urbani explained that Danny Yang Chin, the index patient in Hanoi, had been evacuated to Princess Margaret Hospital, two and half hours away in Hong Kong. The patient, before he had left, had been in acute respiratory distress and had lapsed into a coma. Meanwhile, there were now thirty-one cases in Hanoi, twenty-five of which were health care workers who had had immediate contact with the index patient. There were already three fatalities and several more patients entering into acute respiratory distress.
“This hospital is now experiencing a major problem due to lack of staff,” explained Urbani. “People are basically panicking.”
Oshitani, Fukuda, and Urbani discussed the possibility that this was the same disease as that which had infected southern China. “Danny Chin traveled through Hong Kong,” Urbani reminded them.
Oshitani and Fukuda told Urbani what they had heard at the China CDC. It certainly sounded consistent: high concentrations of health care workers falling into severe respiratory distress.
“Have they isolated an agent?” Urbani asked.
“Chlamydia,” Oshitani explained.
There was silence on the line.
“I find that highly unlikely,” Urbani said. He had been treating patients with amoxicillin and other antibiotics since the outbreak began and had seen no improvement in those cases. He had received a shipment of amantidine from Hong Kong and was now administering that—to little or no effect on the patients. (Amantadine is an antiviral that tends to be most effective against influenzas; its failure here meant that the agent was unlikely to be an influenza virus.)
“If this is the same disease,” asked Urbani, “then what is it?”
The three men were silent.
“And where is it going?” asked Oshitani.