by Daniel Kalla
“Nope.”
“What does that mean?”
“I don’t buy it. You basically work in the neighborhood. Not once have you ever thought of dropping by my office before today.”
“OK, OK. I’m worried about Olivia.”
“Why? What happened?”
“No. Nothing,” Amber assures Lisa. “She’s fine. But the girl who died this morning. Rebecca Cohen—”
“How do you know her name? We never released it.”
“She was in Liv’s kindergarten class. The posts are flying around the parents’ social media pages.”
Lisa grabs her sister’s arm. “Has Olivia been around Rebecca this summer?”
“No. Not since school ended in June.”
Lisa releases her grip. “Thank God.”
“But it’s too close a connection. And all these sick kids in Bellevue…” Amber looks at her plaintively. “Just how bad is it, Lisa?”
“It’s bad, Amber. Very bad.”
“So what do we do?”
“It hasn’t been announced yet, but we’re about to lower the age of eligibility on the new vaccine.”
“And Olivia would… qualify?”
“Yes.”
Amber slumps down into the chair beside her. “A vaccine? That’s all you can offer? You know how I feel about those.”
“Listen to me. This isn’t tetanus or measles. Some theoretical infectious risk, where Olivia already benefits from all the immunity around her.”
“Nice, sis,” Amber snaps.
“You know what I mean.” Lisa kneels beside the chair. “This outbreak is deadly, Amber. And you live in the heart of the hottest zone. There is no herd immunity. We don’t even know exactly who’s contagious and who’s not. If Olivia were to be exposed…”
“But a vaccine…” Amber drops her chin in silence for a few moments. “Can’t imagine what Allen would say, let alone Dad.”
Fuck Dad! Lisa has to bite her tongue. “Fine. Skip all the others—polio, tetanus, measles, HPV… Who cares? But this meningitis vaccine? Oliva can’t skip this one, Amber. She just can’t.”
CHAPTER 31
Susan Meyer’s hand brushes up against something firm, but she’s not awake enough to recognize it as someone’s back until the person stirs. For a disoriented moment, Susan wonders if there’s a man in her bed. No. No one has slept over since it ended with Owen, that hopeless man-child of a broke guitarist.
Waking more fully, Susan realizes her daughter Mia has crawled into bed with her. Susan is touched. Her fiercely independent fifteen-year-old usually keeps her bedroom door locked at night and hasn’t climbed into her mom’s bed in years.
“My mouth hurts, Mom,” Mia says without rolling over toward her.
It’s not Mia’s words but rather her extreme hoarseness that jolts Susan to full alertness. “You mean your throat?”
“That, too,” Mia croaks. “My mouth feels like I burned it. And my lips are all weird.”
“Weird?”
“I dunno. Swollen.”
Susan switches on the bedside lamp. “Let me see.”
Mia turns over to face her.
It’s all Susan can do not to cry out. She can’t even discern where her daughter lips end and the blisters begin. “Oh my God, sweetheart! Your mouth.”
CHAPTER 32
The usual chaos reigns inside Harborview’s emergency room. Lisa has to flash her ID badge and ask three separate staff members before she’s finally directed to the correct room within the department’s resuscitation zone.
“Never seen one like this,” says the harried ER doctor, Sofia Cortez, as she stands with Lisa outside a door with the curtain drawn across it.
Lisa wonders what possible experience Cortez could already have. To her eyes, she looks barely old enough to have graduated college, let alone work as an attending physician at a major teaching hospital. “How so?”
“The swelling spread in front of my eyes,” Cortez says. “Mia was talking—I mean barely, but she was—when she showed up. Her throat closed over as I had my stethoscope to her chest. We had no choice but to intubate her. There was so much swelling and debris in her airway that I could barely pass the tube through the vocal cords. She got lucky. Five minutes longer at home and she probably would’ve suffocated.”
Lisa has yet to see Mia, but the description is enough to send a chill through her. “And you’re sure it’s Stevens-Johnson syndrome?” she asks, referring to the potentially life-threatening reaction that causes severe swelling and blistering, especially of the skin around the lips and inside the lining of the mouth.
“Yes. The dermatologist already saw her. He agrees. We started her on high-dose steroids, but it’s progressed so rapidly. Even he was shocked.”
“And has she been on any new medications lately? Antibiotics? Anticonvulsants? Or any other drug associated with Stevens-Johnson syndrome?” Lisa asks.
“No medications. Only the meningitis vaccine.”
Lisa’s heart sinks. “When did she get that?”
“Two days ago, apparently.”
“And she didn’t develop the reaction until this morning?”
Cortez makes a gesture toward the curtain in front of the door. “According to the parents.”
“Can I see her?”
“Sure.”
Lisa pushes the curtain aside and steps into the room. Despite the beeping equipment and hive of activity around the bed, her gaze is immediately drawn to the patient, who lies with the head of the bed elevated to almost the sitting position. Mia’s eyes are glassy but open, meaning that, while sedated, she’s still conscious. A ventilator tube passes into her mouth, but Lisa can’t identify her lips through all the blistering and swelling.
“Who are you?” demands the wide-eyed man at the foot of the bed, who looks as if he could be a biker with his cropped hair, bulging shoulders, and sleeves of tattoos.
“I’m Dr. Dyer. With Public Health.”
The woman standing closer to the head of the bed grimaces. “Public Health?”
The man’s eyes narrow. “Does this have something to do with that vaccine Mia got?”
“That’s what we are trying to figure out,” Lisa says. “You’re the father?”
“Yeah, Jim Meyer.” He nods toward the woman. “My ex-wife, Susan. The mom.”
Lisa offers them a sympathetic smile. “When did Mia first complain or show any signs of this reaction?”
“Mia seemed OK at bedtime,” Susan says. “She crawled into my bed early this morning complaining of a sore mouth.” She stares helplessly at Lisa. “She never comes into my room at night.”
Lisa views Mia, whose head is still, but her eyes appear to follow them as they discuss her. She can’t imagine how terrifying it must be for the girl or her parents. “I know Dr. Cortez already asked you, but has Mia taken any medication in the past few days? Even over-the-counter pills.”
“Nothing,” Jim answers for his ex-wife. “Just that vaccine.”
Lisa turns to the patient. “Hi, Mia.”
The girl stares back groggily.
“Is it true, Mia?” Lisa asks. “You’ve taken no other medications? Not even ibuprofen or acetaminophen?”
After a slight delay, Mia shakes her head.
“So it’s got to be that fucking vaccine, doesn’t it?” her father barks.
“Please, Jim,” Susan says, exasperated. “The doctor is here to help.”
“It could be,” Lisa admits. “But we’ve inoculated over two thousand people, and we haven’t seen anyone react this way so far.”
His lips curls into a sneer. “And now you have.”
“We’ll see,” Lisa says. “Meantime, Mia is in good hands. Now that her airway is protected and she’s on the steroids, her doctors expect her to improve.”
“She just about died!”
“Jim!” Susan snaps.
“I understand,” Lisa says.
Susan turns away from her daughter and runs a finger in a ci
rcular motion around her own lips. “Will it scar?” she whispers.
“I don’t think so,” Lisa says, realizing that she’s not entirely certain of what the long-term complications from Stevens-Johnson syndrome are.
Jim spins away with a disgusted snort, but Susan’s eyes remain fixed on hers. “That vaccine was supposed to protect her, wasn’t it, Dr. Dyer?”
Lisa doesn’t try to argue. Instead, she simply nods.
Even after Lisa says her good-byes and drives back to the office, she has trouble shaking the memory of the mother’s betrayed eyes. She’s still thinking about it as she steps into her office. She has barely sat down behind the desk when Tyra walks in.
“Well?” the program director asks as she drops into the chair across from her.
“It’s not good, Tyra.” Lisa summarizes Mia’s condition.
Tyra shakes her head. “But this Stevens-Johnson syndrome can happen spontaneously, right? You don’t need to have been exposed to any medications?”
“The timing seems just too coincidental for that. Even the dermatologist has never seen the syndrome progress this rapidly.”
“But it’s not an allergy, right?”
“No. Technically not. It’s classified as a type-four immune hypersensitivity, because it’s mediated by T-lymphocyte cells. It’s more of a severe idiosyncratic reaction than a true allergy.”
“Exactly.” Tyra holds up her palms. “It could have happened after almost any medication, not just the Neissovax immunization.”
“But it did happen after Neissovax.”
“OK, OK. Let’s say Mia had a bladder infection and was started on a sulfa drug for treatment? And then she broke out in the exact same severe rash.”
Lisa rubs her eyes. “What’s your point, Tyra?”
“My point is: you wouldn’t stop giving out sulfa drugs to everyone else with a bladder infection because one person reacted as badly as Mia did.”
“You’d make a good lawyer, Tyra.” Lisa chuckles. “This is different, though. The amount of scrutiny this vaccine faces. Once word of this gets out…”
Tyra’s face scrunches up. “We can’t let those damn anti-vaxxers and their hysteria dictate how we manage a public-health crisis. Not after a single adverse reaction.”
“Even if it’s a near-fatal drug rash?” a voice asks from her doorway.
Lisa looks over to see Alistair Moyes. “Bad news travels fast,” she says.
“It does.” He steps into the room. “How is the patient doing?”
“Stable. Now.”
Moyes raises an eyebrow. “Stable on a life-support system?”
“Only to protect her airway until the swelling settles down,” Lisa says. “Besides, isn’t it a bit early to say ‘I told you so’?”
“That’s not why I’m here.”
“Why then?”
“I came to discuss the lab results we just received at the CDC.”
“Which results?” Lisa asks warily.
“The post-exposure antibody titers.”
“And?”
“They’re through the roof. Even more impressive than Dr. Klausner suggested.”
“So Neissovax confers full immunity against the Icelandic meningococcus?”
He nods. “In a hundred percent of the samples we’ve tested so far.”
“And what about this girl with Stevens-Johnson syndrome?” Lisa asks, bracing for the worst. “Is that enough to derail our vaccination campaign?”
Moyes studies her for a long moment. “As nasty as it sounds, it’s still only one reaction among thousands of inoculated.”
“It is,” Lisa agrees, surprised.
Moyes turns to Tyra. “And fifteen children have died from this meningitis so far.”
“Sixteen, as of this morning,” Tyra corrects.
“So, in my opinion, no, it’s not,” Moyes says. “It’s enough to raise a red flag. Maybe a bloodred one. But it’s too early to halt the campaign.”
CHAPTER 33
“There’s been a serious reaction.” Lisa’s five-word text pops up in top right corner of the laptop’s screen and stops Nathan cold in midsentence as he’s addressing Delaware’s senior executive committee via videoconference from his hotel room.
“Nathan?” Peter Moore prompts on the screen. “You still with us?”
“Oh yeah,” Nathan mutters as his stomach knots. “Excuse me, everyone. I have to run.”
“We’ve only got two more items on the—”
But Nathan slams his laptop shut before the CEO can even finish his sentence. He grabs for his phone and taps Lisa’s number. “Your text?” he demands as soon as she picks up.
“There’s a girl at Harborview who’s in critical condition,” Lisa says. “She got Neissovax two days ago.”
“A girl?” he blurts.
“Yeah. She has Stevens-Johnson syndrome.”
“What the hell is that?”
“A type of immune reaction that causes a potentially life-threatening rash—terrible blistering like severe burns, especially around the mouth.”
“You’re certain it’s from the Neissovax?”
“There’s no other explanation.”
He listens, numb, as she describes the girl’s condition. He takes little solace in the fact that the victim has stabilized on the ventilator, or that Lisa’s team has decided not to suspend the vaccination campaign.
Lisa’s tone softens. “We’ll figure this out, Nathan.”
“No doubt,” he says, his mind already gearing up into damage-control mode. “Thanks for the heads-up.”
As soon as he hangs up, he dials Fiona, but her phone goes straight to voice mail. “Need to talk!” he texts her.
As he waits for her to call back, Nathan opens his laptop and searches for photos of victims of Stevens-Johnson syndrome. The online images of faces disfigured by blisters, open sores, and puffiness pain him to view. He knows this case can’t be a coincidence, but he refuses to consider the full implications.
Fiona calls about ten minutes later. “I just spoke to Lisa,” are the first words out of her mouth.
Nathan hears a lot of background noise. “Where are you?”
“At the vaccine clinic downtown,” she says.
“Let’s meet.”
Nathan heads down to the lobby and grabs a waiting cab that drops him off at their arranged spot in front of the Seattle Center, one of the city’s busiest cultural and tourist hubs. The iconic, six-hundred-foot-tall Space Needle looms overhead, but Nathan barely notices it as he hurries across the lawn toward the fountain where Fiona is waiting.
Her face is calm, but as he nears, he sees the worry dancing in her eyes. “I tracked down the clinic the girl attended,” Fiona says in a low voice even though no one else is within earshot. “I ran the serial number of the vial she received. That batch was tested back at the plant in Littleton last week. Twice. Zero imperfections.”
“Of course,” Nathan says. “They’ve all been perfect. No one’s doubting the quality control here.”
“But Stevens-Johnson syndrome? We never saw anything like that in our trials.”
“It’s idiosyncratic, right? As I understand it, it can happen with almost any drug.”
Fiona only nods. “Maybe we should pause the campaign until we can investigate further.”
“No one in Lisa’s office is suggesting that.”
“But isn’t it what we should do?”
Only if we want to initiate the single biggest publicity disaster in Delaware’s history. The repercussions of halting the Neissovax campaign would be catastrophic. Even if the reaction was subsequently found to be entirely unrelated, the fallout would likely doom the vaccine’s commercial release. But all Nathan says is, “We should probably follow their lead, Fiona, and not overreact.”
“I’m the one responsible for product safety.”
“And you report to me. Look, this a big setback, Fee. I get it. But this syndrome is a rare reaction. It can happen with multiple medic
ations. It’s probably a one-off.”
“So we do nothing?”
“There’s nothing we can do right now but look into it. Even then, we’re unlikely to find a connection.” He exhales. “This girl didn’t die of her reaction. She’s going to get better. Meantime, there are kids dying of meningitis every day in this city. And Neissovax can help prevent that.”
Fiona stares at him. If possible, her eyes look even sadder than usual. But when she speaks, her tone is calmer. “Maybe you’re right. Maybe it’s not the time to stop. But I’m going to go back and turn over every stone. Run the testing one more time. See if there’s anything at all different about the batch that girl’s vaccine came from.”
Nathan forces a smile. “That’s why we pay you the big bucks, Fee.”
“Big bucks? Yeah, I suppose. Relatively speaking.” She sighs. “But a lower-paying academic career is looking pretty damned attractive right now.”
“As if. I wouldn’t we be able to do this without you.”
Fiona breaks off her eye contact. “I’m not sure I want to be part of this anymore,” she murmurs, and he doesn’t even try to argue.
She sets off down the trail, and he catches up to her. They walk in silence for a few hundred yards down a path that heads toward the Seattle Children’s Museum. The irony of their randomly chosen destination isn’t lost on Nathan in light of the expanding crisis.
The complex is full of museums, green spaces, and playgrounds. He knows the Museum of Pop Culture with its funky architecture and high-tech interactive displays is somewhere nearby. His sons would love it. But the thought of bringing them back to Seattle suddenly holds little appeal. To him, the city is now tainted.
“Have you seen the media coverage around lowering the age of vaccination?” Fiona asks. “It was all over the news this morning.”
“A feeding frenzy, huh?”
“The clinics are going to be even more swamped. We’re probably going to need more supply.”
“Shouldn’t be a problem. I’ll let them know at Littleton,” he says distractedly. The idea of surpassing fifty thousand vaccinations is both alarming and reassuring to him. The higher the denominator, the easier it will be to dilute the impact of any other serious vaccine-related complications.
