by Daniel Kalla
“Yes, hello, this is Dr. Haarde from Icelandic Health speaking,” he says, his accent giving his words a lovely lilt. “How can I be of assistance?”
“Sorry to disturb you so late, Dr. Haarde, but we have a bit of a situation here in Seattle. A new outbreak.”
“Related to our meningitis, yes?” he suggests, astutely making the connection.
“Exactly.” Lisa glances over to Angela, who taps her temple, impressed. “We have a local outbreak of what appears to be the same strain of meningococcus as the one that hit Reykjavík last winter.”
After Lisa summarizes the cases, Haarde says, “It does indeed sound very similar to our epidemic, yes.”
His use of the term epidemic heightens Lisa’s unease. “When was your last reported case?” she asks.
“Late February,” he says. “To be accurate, the poor girl died in early March.”
“Can you remind us how many victims in total you saw in Reykjavík?”
“There were seventy-six infected patients that we know of.” He pauses. “And thirty-five deaths.”
“So the mortality rate was almost fifty percent.”
“Forty-six percent, yes.”
“And the outbreak began at one of the high schools?”
“It did.”
“But spread beyond the school? Into the community?”
“Yes. At its worst, we had three distinct geographical clusters of infection around the city. All of them traceable to the index cases from the high school. Most of the victims were teenagers.”
“So how did you contain it, Dr. Haarde?” Angela pipes up.
“We implemented very comprehensive contact prophylaxis,” he says. “We started anyone who might have had exposure—even the most casual of interactions—on antibiotics. We even closed our schools for six weeks.”
“Quarantines?”
“It wasn’t necessary, really. People were frightened enough. Very few people gathered in public.”
“And you had no luck with vaccines?”
“None at all. We tried both commercially available products. Neither was effective.” He exhales so heavily that the speaker whistles. “One boy died of meningitis only a few days after receiving his immunization.”
“So antibiotics were your only real weapon?” Lisa asks.
“The truth is, we do not know how much of a difference any of our measures made. We are still unsure why the outbreak halted as abruptly as it began. Or if it has truly left us.” His voice lowers, as if letting them in on a secret. “Many people here are concerned that it might be lying dormant and will return again this winter.”
“Thank you, Dr. Haarde, that’s very enlightening,” Lisa says. “We’ll probably have more questions for you once we have a more complete picture of our situation. I hope it’s all right if we contact you again.”
“At a more reasonable time, of course,” Angela adds, as if she played no part in the late hour of the call.
“I would be pleased to share what I can from our experience,” he says. “I hope Seattle is not as… affected as we were.”
His grim tone, more than his description of the Icelandic outbreak and its frightening death toll, gnaws at Lisa. As she is just about to hang up, Haarde adds, “Incidentally, even though we have not seen a new case in over five months, we are still proceeding with our vaccination campaign.”
“Vaccination?” Lisa glances at Angela. “I thought you said none of the vaccines were effective against this strain of type B meningococcus.”
“That is true of the existing products on the market, yes. However, there is a new vaccine. Neissovax, produced by Delaware Pharmaceuticals.”
“Neissovax…” Lisa vaguely remembers reading a journal article a year or so earlier about the experimental vaccine.
“The early-phase-three trial results have only recently been published, but they are promising,” Haarde says, meaning that the drug has already undergone extensive testing and has been proven safe and effective among a trial group that must have included more than a thousand people to be classified as phase three. “Because of our history, we have volunteered to be the pilot site for a citywide immunization program.”
“When’s that supposed to begin?”
“Next month.”
As soon as Lisa disconnects, she looks over to Angela again. “So Delaware has already produced enough to vaccinate a whole city?”
CHAPTER 5
Happy memories from grad school flood back to Nathan Hull as he strolls past the columns of sleek stainless-steel machinery that sprout from the polished concrete floor and spiral to the ceiling forty feet above. Visually, the state-of-the-art development facility bears no resemblance to Nathan’s college lab, which was a tiny space crammed with racks of beakers, centrifuges, and other obsolete equipment. Missing, too, are the stenches of solvents, ammonia, and other chemicals. But the plant here in Littleton, Massachusetts, shares the same buzz of science, innovation, and promise that filled his lab at MIT.
Progress. Delaware Pharmaceutical’s forty-five-year-old vice president and chief development officer feels it all around him. Just as the mortar and pestle gave way a hundred years before to volume-controlled recipe processes that became the backbone of pharmaceutical manufacturing, robotics and automation are now supplanting that once-core technique. Delaware has invested hundreds of millions in this new facility, borrowing expertise from the aeronautical and automobile industries to create modular continuous processing in an end-to-end integrated and totally automated system. A plant that could be picked up, shipped, and reassembled anywhere in the world in weeks, if not days. A single site where R&D of new products could seamlessly morph overnight into 24/7 manufacturing and distribution.
Still admiring the machinery, Nathan ambles over to join Dr. Fiona Swanson where she stands inspecting a stack of bins. He can tell at a glance that his team’s director of product safety doesn’t share his sense of awe.
“So does this mean you’ll come to Reykjavík, too?” Fiona asks, in a mild Minnesotan accent that still occasionally reminds Nathan of a character in Fargo, one of his favorite movies among the Coen brothers’ oeuvre, even of all time.
“Wish I could,” Nathan says. “I can’t remember a bigger trial at this stage of development than this one.”
Fiona reaches into the nearest bin and extracts an individual yellow-capped vial. “Fifty thousand doses isn’t a trial, Nathan. It’s a full product launch.”
He holds up a palm. “Agreed, Fee. Not my idea.”
“But you’re going to do it, anyway?”
“We didn’t approach the Icelandic government. They came to us.”
When Nathan first met with the country’s minister of health, he told her it was premature to enroll an entire city in what effectively amounted to another phase-three trial of an unproven vaccine. And as it became clearer over the next few months of negotiations that the meningitis outbreak in Reykjavík had gone dormant or died out altogether, Nathan’s reticence to release Neissovax only intensified, as he saw no upside in vaccinating for a threat that was no longer active. He stalled as long as he could. But when the internal results from Delaware’s first large-scale clinical trial proved even more impressive than forecast, Nathan’s colleagues grew impatient. Eventually, Peter Moore, Delaware’s CEO, intervened. Nathan’s boss sat him down over herbal teas—Peter had forsaken caffeine, including his six-coffee-a-day habit, ever since suffering a mild stroke—and told him: “You know as well as I do that we could wait a thousand years and never stumble onto a better opportunity to market a new product.” So Nathan relented.
Fiona rolls the vial between a thumb and a finger. “And if something goes wrong in Reykjavík?”
“You saw the pooled data,” Nathan says, feeling compelled to defend a decision he still doesn’t fully support. “Over fourteen hundred subjects. No major reactions. And an effectiveness of well over ninety-eight percent. Better than we could have hoped for.”
“All under
carefully controlled trial conditions. Could be very different in the real world.”
Nathan slips the vial from her hand. “You’ll be there to manage things.”
“Can’t manage what we can’t foresee.”
Nathan studies the vial. He finds the block-letter font that reads NEISSOVAX across the top of the label appealing, but the yellow cap still grates. He would’ve gone with the green, but the marketing gurus insisted otherwise. “We got our marching orders, Fee. Neither of us likes them particularly. But our job is to ensure the rollout goes as smoothly as possible.”
“Yeah, that same argument worked wonders at the Nuremberg Trials.”
He can’t help but laugh. “Let’s get hammered on the flight home and forget it all for a few hours.”
“It’s a forty-minute flight to New York.” Fiona shows her first real smile of the afternoon. It’s slightly lopsided and brings out the luminescence in her gray eyes. As always, she wears minimal makeup, and her face is a bit long and narrow for his taste, but he still finds her attractive in a nineteenth-century, Russian-literary-heroine sort of way. He wonders if it’s her lingering sadness that’s so appealing.
“We’ll drink triples,” he says. “Then grab dinner in the city and finish the job.”
“Sure. Why not? I could use a good bender.”
There’s no ulterior motive behind his offer. Their friendship is comfortably platonic. Nathan has hardly dated since his divorce was finalized, six months earlier. The official end of his eighteen-year marriage hit him harder than he expected and slowed his post-separation tear of casual dating, and sex, to a trickle. Besides, he would never get physically involved with a colleague or coworker. He has always considered that to be the quickest form of career suicide. And aside from his two teenage sons, career means everything to him. The last woman he dated, albeit casually and briefly, once asked Nathan if he ever got lonely, and his candid answer surprised even him: “I’m way too busy to be lonely. Or at least to notice it.”
Regardless, Fiona isn’t accessible in the romantic sense. She hasn’t dated since she buried her husband over five years ago. It’s possible she has stayed celibate the whole time. Or maybe not. Fiona is as private a person as Nathan has ever met. Despite their closeness at work, he sometimes feels he doesn’t know her at all.
“Have you seen enough?” Nathan asks, handing the vial back to her.
Fiona carefully replaces it in the bin. “Here, yes. But I want at least a week of advanced reconnaissance in Reykjavík to ensure the storage and distribution facilities meet our standards.”
“Of course. But you should also take a few days to drive the Ring highway. My sons and I loved it when we visited a couple summers back. Spectacular cliffs and waterfalls. And you’ve got to check out the hot springs at Geysir. It’s where the word geyser literally comes from. To quote Ethan: ‘Geysir blows Old Faithful out of the water!’ ”
“Oh, Ethan.” She chuckles. “Good thing he got his mom’s sense of humor.”
“Thanks.”
Nathan’s phone rings, and he digs it out of his jacket pocket.
“Mr. Hull?” the woman calling says. “I’m Dr. Lisa Dyer with Seattle Public Health.”
“Dr. Dyer, you just caught me on a site tour. I’ll be back in the office tomorrow—”
“Your assistant told me. And I’m sorry to disturb you this way, but we’re dealing with a time-sensitive matter here.”
“In Seattle?”
“Yes,” she says. “There’s been an outbreak of meningitis. Four kids have died.”
Nathan taps the phone’s speaker icon so Fiona can listen in as Dr. Dyer fills them in on the meningococcal outbreak in the Pacific Northwest. The creases around Fiona’s eyes deepen with each sentence. And her head begins to shake as soon as the woman mentions Delaware’s upcoming Reykjavík vaccine trial.
“I empathize with your urgency,” Nathan says. “But this isn’t anything we can sort out over the phone.”
“Of course not. Maybe if I email you some of our preliminary findings, we could set up a videoconference with your team—”
“It’ll be easier if I just come see you, Dr. Dyer.”
“In Seattle? Aren’t you on the East Coast?”
Fiona taps her chest, indicating that she intends to accompany him.
“Yes,” he says. “Meet at your office tomorrow morning? Say nine?”
CHAPTER 6
“Do you want me to get out and push?” Lisa teases as the Jeep Cherokee crawls along the gravel driveway.
Tyra Osborne chuckles. “We should be all right. This puppy has four-wheel drive.”
It’s a running joke between them how much Lisa’s coworker obsesses over her new SUV. On the way south from downtown, Tyra drove the I-5 as aggressively as usual, weaving in and out of the carpool lane as if there were a race to get here. But once they turned off onto the gravel road leading to the main lodge at Camp Green, she slowed to the current snail’s pace to prevent any pebbles from dinging her car’s precious wheels or undercarriage.
“How did your HPV vaccine forum go?” Tyra asks.
“Feisty crowd,” Lisa says with a small shrug.
“Anti-vaxxers?”
“Mainly.” Lisa punches Tyra’s shoulder playfully. “Wish you could’ve been there with me.”
“Uh-uh. Oh, hell no. I would’ve absolutely lost it.”
Lisa knows that’s not true. Tyra is unflappable, and both Lisa and Seattle Public Health are lucky to have her as the program director, the nursing counterpart to Lisa’s medical role. The fortyish, stocky African American is motivated and efficient, but perhaps most vitally from Lisa’s perspective, Tyra is the consistent voice of reason and calm in the department. And she has helped Lisa avoid several missteps. But Tyra’s disdain for the anti-vax movement rivals or even surpasses Angela’s.
“There’s going to be a ton of pushback to the new mandatory HPV vaccination policy,” Lisa says.
“Even if those fools choose to ignore centuries of science, why can’t they use just a pinch of common sense?”
“The place anti-vaxxers come from… I’m not sure we’re even capable of seeing it the way they do.”
“The wrong way?” Tyra says as she parks her car a careful distance from an old pickup in front of the lodge.
“It’s like a faith for many of them.”
“I got nothing against anyone’s religion, just as long as their beliefs don’t hurt others,” Tyra says as she opens her door. “But in the case of anti-vaxxers, theirs really do.”
Stippled sunlight peeks through the dense tree towering above, and the fresh scent of cedar hangs thick in the air as Lisa and Tyra head up the wooden steps and into the main office. The woman standing behind the registration counter appears as if she might have just checked in a ghost. Her gaunt face is drawn tighter than the bun on the back of her head.
Lisa introduces Tyra and herself to the woman, who responds with a blank nod. “I’m Maisy Campbell. The camp’s director.”
“Thanks for taking time to meet us, Maisy,” Tyra says, sliding her and Lisa’s business cards across the counter.
“I still can’t believe it,” Maisy says without touching them. “I’m in shock. We’ve never seen anything like this before.”
It would be beyond bizarre if you had, Lisa thinks. But all she says is, “These outbreaks are incredibly sporadic, Ms. Campbell. Totally unpredictable.”
“I just can’t believe those children are gone.” Maisy motions to the fireplace. “They were right here. Joseph, Emma, Grace, and Connor. Only two days ago. Laughing and singing with the rest of us. Connor played the guitar.” Her voice cracks. “And Emma was so funny. She’d keep the kids in stitches with her impersonations.”
“A meningitis outbreak will do that,” Tyra says. “Which is why we wanted to follow up on the call you got from our office about reaching out to every single camper and staff member as soon as we can.”
Maisy’s eyes go wide. “Will
there be others?”
“That’s what we’re aiming to avoid,” Tyra says. “But we need to reach them right away. Start them on antibiotics. All of them. Do you have the contact information we asked for?”
“Yes, of course,” Maisy says as she taps the top of the computer screen.
“And have you gotten in touch with anyone so far?” Lisa asks.
“We canceled next week’s camp. And we sent a mass email this morning about the illness. I can’t even keep up with all the replies…”
“How many people were at the camp this past week?”
“Hundred and seven campers, twelve counselors, four support staff, and me,” Maisy replies without having to consider it.
A hundred twenty-four people exposed to this deadly pathogen? Christ! Lisa motions to the computer. “We’ll need the whole list.”
“I can email it to you.” Maisy types away at the keyboard, before she stops and looks up at them. “There aren’t any… you know… confidentiality issues with me sharing this?”
“You’re totally protected.” Tyra smiles. “Under the public-health statutes, we’re legally entitled to access this information.”
Maisy accepts the explanation with a nod and then copies their email addresses from the business cards. Lisa feels her phone vibrate in her pocket and assumes it must be a notification of the email Maisy just sent. Moments later, the phone buzzes again repeatedly, signaling an incoming phone call, but she ignores it. “Do you happen to know if any of the campers returned from Iceland recently?” she asks.
“Iceland?”
Lisa didn’t think Maisy’s eyes could go any wider, but they do. “We believe the source of the bacteria traces back there. And we wanted to know if any of the campers or staff might’ve visited this summer.”
Maisy shakes her head. “I never heard anyone mention it. For most of the kids, our camp is as far away from home as they’ll get in the summertime. If one of them had gone all the way to Iceland, you can bet he or she would have been bragging about it.”
Lisa nods, feeling a bit deflated. “Do you mind giving us a quick tour of the facilities?”
