Outbreak

by Robin Cook

  Marissa described the clinical syndrome, referring frequently to her note pad. She sensed that Dubchek was particularly interested in the fact that two of the patients had vomited blood, that another had passed bloody diarrhea and that three had conjunctival hemorrhages in their eyes. When Marissa said that Dr. Richter had been to an ophthalmology meeting in Africa, Dubchek exclaimed, “My God, do you know what you are describing?”

  “Not exactly,” said Marissa. It was an old medical-school ploy: try to stay on neutral ground rather than make a fool of yourself.

  “Viral hemorrhagic fever,” said Dubchek, “ . . . and if it came from Africa, it would be Lassa Fever. Unless it was Marburg or Ebola. Jesus Christ!”

  “But Richter’s visit was over six weeks ago.”

  “Darn,” said Dubchek, almost angrily. “The longest incubation period for that kind of fulminating illness is about two weeks. Even for quarantine purposes, twenty days is considered adequate.”

  “The doctor was also bitten by a monkey two days before he became ill,” offered Marissa.

  “And that’s too short an incubation period. It should be five or six days. Where’s the monkey now?”

  “Quarantined,” said Marissa.

  “Good. Don’t let anything happen to that animal, particularly if it dies. We’ve got to test it for virus. If the animal is involved, we have to consider the Marburg virus. In any case, the illness certainly sounds like a viral hemorrhagic fever, and until proven otherwise, we’d better consider it as such. We’ve worried about something like this happening for some time; the problem is that there’s no vaccine and no treatment.”

  “What about the mortality rate?” asked Marissa.

  “High. Tell me, does Dr. Richter have a skin rash?”

  Marissa couldn’t remember. “I’ll check.”

  “The first thing I want you to do is draw bloods, obtain urine samples, and do throat swabs for viral culture on all seven cases, and have them rushed to the CDC. Use Delta’s small-package service. That will be the fastest way. I want you personally to draw the blood, and for Christ’s sake be careful. From the monkey, too, if you can. Pack the samples in dry ice before shipping them.”

  “I’ve just seen what might be another case,” said Marissa. “One of the clinic’s lab techs.”

  “Include him, too. It sounds increasingly serious. Make sure that all the patients are totally isolated with complete barrier nursing. And tell whoever is in charge not to do any lab work until I get there.”

  “I have,” said Marissa. “You’re coming yourself?”

  “You bet I am,” said Dubchek. “This could be a national emergency. But it is going to take some time to prepare the Vickers Mobile Lab. Meanwhile, start setting up a quarantine for contacts, and try to get in touch with the people who sponsored that eye meeting in Africa and see if any of the other doctors who went are ill. And one other thing: don’t say anything to the press. With all the publicity about AIDS, I don’t think the public could deal with the threat of another fatal viral disease. There could be widespread panic. And Marissa, I want you to wear full protective clothing, including goggles, when you see the patients. The pathology department should have them if no one else does. I’ll be there as soon as possible.”

  Hanging up, Marissa experienced a rush of anxiety. She wondered if she’d already exposed herself to the virus. Then she worried about having already talked to Clarence Herns from the L.A. Times. Well, what was done was done. She was glad that Dubchek was coming. She knew she’d been in over her head from the moment she’d arrived in L.A.

  After putting in a call for Dr. Navarre, Marissa had one of the nurses help her get the materials ready to draw blood from the patients. She needed vacu-containers with anticoagulants, plastic bags, and sodium hypochlorite to decontaminate the outside of the bags. She also needed urine containers and throat swabs. Then she phoned the micro lab and asked to have containers of viral transport media sent up, along with shipment containers and dry ice. When Dr. Navarre called, she related what Dubchek had said about complete barrier nursing and about no lab tests until he’d arrived with a special facility. She also mentioned that they had better get together to talk about systematically quarantining all contacts. Dr. Navarre agreed, shocked to hear that Dubchek thought they might be dealing with viral hemorrhagic fever.

  Following Dubchek’s advice, Marissa got goggles from pathology. She’d never thought about catching an illness through her eyes, but she was aware that their surface was a mucous membrane and was obviously as available to viral assault as her nasal mucosa. When she was fully attired in hood, goggles, mask, gown, gloves and booties, she went to Dr. Richter’s cubicle to begin her sampling.

  Before she started, she examined him for a skin rash. His arms were clear, but he did have a curious red area about the size of a quarter on his right thigh. Lifting up his hospital gown, Marissa noted a fine, but definite, maculopapular eruption covering most of his trunk. She was impressed that Dubchek had anticipated it.

  She drew the blood first, then filled the urine container from the catheter bag. After each was sealed, she washed its exterior with sodium hypochlorite, then put it in a second bag. After the exterior of the second bag was washed in the disinfectant, she allowed it to be removed from the room.

  Disposing of the hood, mask, gown, gloves and booties, and then donning new ones, Marissa went on to the next patient, the medical secretary, whose name was Helen Townsend. Marissa repeated the same procedures she’d done on Dr. Richter, including looking for skin eruptions. Helen also had a faint rash on her trunk, but no red circle on her thigh or elsewhere. She seemed less ill than Richter, but none of the patients appeared well enough to question Marissa much as she went about her sampling. Only Alan Moyers could muster the strength to offer some objections. At first he refused to allow Marissa to draw blood unless she told him what his diagnosis was. He was terrified. When Marissa told him the truth, that she did not know what he had and that that was why she needed the samples, he finally gave in.

  As for the monkey, Marissa didn’t even attempt to get a blood sample. The animal keeper was out for the day, and she had no intention of trying to handle the animal alone. The monkey looked healthy enough, but was not friendly. He threw feces at Marissa through the mesh of his cage.

  Once Marissa completed the packing, making certain that all the screw caps were tightly in place so that carbon dioxide from the dry ice could not penetrate the samples, she personally rode out to the airport and sent the boxes on their way to Atlanta. Luckily she got them on a convenient nonstop.

  Back at the Richter Clinic, Marissa made a detour to the small clinic library. There were a few standard texts there that included sections on viral diseases. She quickly scanned the entries for Lassa Fever, Marburg and Ebola virus. Then she understood Dubchek’s excited reaction on the telephone. These were the most deadly viruses known to man.

  Arriving back on the fifth floor, Marissa found that all eight patients had been isolated in a separate wing. She also found that the clinic outpatient records she’d ordered had arrived. After putting in a call for Dr. Navarre, Marissa sat down and began to study the charts.

  The first belonged to Harold Stevens, the real estate broker. She started from the back and immediately discovered that the last outpatient entry was a visit to Dr. Richter: Harold Stevens had chronic open-angle glaucoma and saw Dr. Richter on a regular basis. His last checkup had been on January 15, four days before he was admitted to the hospital.

  With a sense of growing certainty Marissa looked at the last entry on each chart. There it was. Each patient had seen Dr. Richter on either the fifteenth or the sixteenth of January. All except Helen Townsend, the secretary from medical records, and Alan, the lab tech. The last entry in Ms. Townsend’s outpatient file recorded a visit to an OB-GYN man for cystitis. Alan had seen an orthopod the previous year for a sprained ankle he’d suffered in a hospital basketball league. Except for the medical secretary and the lab tech, th
ere was the strong suggestion that Dr. Richter was the source of the illness. The fact that he’d seen five of the patients just before he developed symptoms had to be significant.

  Marissa could explain the lab tech getting the illness by his sticking himself with a contaminated needle, but she couldn’t immediately explain Helen Townsend. Marissa had to assume that Helen had seen Dr. Richter sometime earlier in the week. She had come down with the illness just forty-eight hours after the doctor. Maybe he had spent a lot of time in medical records earlier that week.

  Marissa’s musings were interrupted by the ward clerk, who said that Dr. Navarre had called to ask if Marissa would kindly come down to the hospital conference room.

  Returning to the room where she’d started the day reminded Marissa of how long she’d been working. She felt bone weary as Dr. Navarre closed the door and introduced the other person who was present. He was William Richter, Dr. Richter’s brother.

  “I wanted to thank you personally for being here,” said William. Although he was impeccably dressed in a pin-striped suit, his haggard face was mute testimony to his lack of sleep. “Dr. Navarre has told me your tentative diagnosis. I want to assure you that we will support your effort to contain this illness to the limits of our resources. But we are also concerned about the negative impact the situation could have on our clinic. I hope that you agree that no publicity would be the best publicity.”

  Marissa felt mildly outraged, when so many lives were at stake, but Dubchek himself had said essentially the same thing.

  “I understand your concern,” she said, uncomfortably aware that she had already spoken to a reporter. “But I think we have to initiate further quarantine measures.” Marissa went on to explain that they would have to separate the possible contacts into primary and secondary contacts. Primary contacts would be those people who had spoken with or touched one of the current eight patients. Secondary contacts would be anyone who had had contact with a primary contact.

  “My God,” said Dr. Navarre. “We’re talking about thousands of people.”

  “I’m afraid so,” said Marissa. “We’re going to need all the manpower the clinic can spare. We’ll also tap the resources of the State Health Department.”

  “We’ll provide the manpower,” said Mr. Richter. “I’d prefer to keep this ‘in-house.’ But shouldn’t we wait until we actually have a diagnosis?”

  “If we wait, it may be too late,” said Marissa. “We can always call off the quarantine if it is unnecessary.”

  “There’s no way we’ll keep this from the press,” moaned Mr. Richter.

  “To be truthful,” said Marissa, “I think the press can play a positive role by helping us reach all the contacts. Primary contacts must be instructed to stay as isolated as possible for a week and to take their temperatures twice a day. If they run a fever of 101° or over, they’ll have to come to the clinic. Secondary contacts can go about their business but should still take their temperatures once a day.

  Marissa stood up and stretched. “When Dr. Dubchek arrives he may have some suggestions. But I believe what I’ve outlined is standard CDC procedure. I’ll leave its implementation up to the Richter Clinic. My job is to try to find out where the virus originated.”

  Leaving two stunned men in her wake, Marissa left the conference room. Passing from the hospital to the clinic building, she approached the clinic information booth, asking directions to Dr. Richter’s office. It was on the second floor, and Marissa went directly up.

  The door was closed but unlocked. Marissa knocked and entered. Dr. Richter’s receptionist was dutifully behind her desk. Apparently she hadn’t expected company, because she quickly stubbed out a cigarette and put the ashtray in one of the desk drawers.

  “Can I help you?” she asked. She was fiftyish with silver-gray, tightly permed hair. Her name tag said Miss Cavanagh. Reading glasses perched on the very end of her nose, their temple pieces connected by a gold chain that went around her neck.

  Marissa explained who she was, adding, “It’s important that I try to determine how Dr. Richter contracted his illness. To do that, I want to reconstruct his schedule for a week or two prior to his getting sick. Could you do that for me? I’m going to ask his wife to do the same.”

  “I suppose I could,” said Miss Cavanagh.

  “Did anything out of the ordinary happen that you can recall?”

  “Like what?” asked Miss Cavanagh, with a blank face.

  “Like his being bitten by a monkey or getting mugged in the parking garage!” Marissa’s voice had a sharp edge to it.

  “Those things did happen,” said Miss Cavanagh.

  “I realize that,” said Marissa. “How about anything else odd or different.”

  “I can’t think of anything at the moment. Wait, he did dent his car.”

  “Okay, that’s the idea,” encouraged Marissa. “Keep thinking. And by the way, did you make the arrangements for his African medical meeting?”

  “Yes.”

  “How about the San Diego meeting?”

  “That too.”

  “I would like to have the phone numbers of the sponsoring organizations. If you could look them up for me, I’d appreciate it. Also I’d like to have a list of all the patients Dr. Richter saw during the two weeks before his illness. And finally: do you know Helen Townsend?”

  Miss Cavanagh took her glasses off her nose and let them hang on their chain. She sighed disapprovingly. “Does Helen Townsend have the same illness as Dr. Richter?”

  “We believe she does,” said Marissa, watching Miss Cavanagh’s face. The receptionist knew something about Helen Townsend, but she seemed reluctant to speak, toying with the keys of her typewriter. “Was Helen Townsend a patient of Dr. Richter’s?” Marissa prodded.

  Miss Cavanagh looked up. “No, she was his mistress. I warned him about her. And there: she gave him some disease. He should have listened to me.”

  “Do you know if he saw her just before he got sick?”

  “Yes, the day before.”

  Marissa stared at the woman. Helen Townsend didn’t give Dr. Richter the disease; it was the other way around. But she didn’t say anything. It all fit into place. She could now relate all the known cases to Dr. Richter. Epidemiologically, that was extremely important. It meant that Dr. Richter was an index case and that he, and only he, had been exposed to the unknown reservoir of the virus. Now it was even more important for her to reconstruct the man’s schedule in minute detail.

  Marissa asked Miss Cavanagh to start working on an outline of Dr. Richter’s schedule for the last two weeks. She told the woman that she’d be back, but if needed, she could be paged through the hospital operator.

  “Can I ask you a question?” said Miss Cavanagh timidly.

  “Of course,” said Marissa, with a hand on the door.

  “Is there a chance I might get ill?”

  Marissa had been suppressing the thought because she didn’t want to frighten the woman, but she could not lie. After all, the secretary would have to be considered a primary contact.

  “It’s possible,” said Marissa. “We will be asking you to restrict some of your activities during the next week or so, and I’d advise you to check your temperature twice a day. Personally, however, I think you will be fine since you haven’t experienced any symptoms so far.”

  Back at the hospital, Marissa fought off her own fears and her developing fatigue. She had too much to do. She had to go over the clinic charts in detail. She hoped to find a reason why some of Dr. Richter’s patients had gotten the disease and others hadn’t. Also Marissa wanted to call Dr. Richter’s wife. Between the wife and the secretary, she hoped she could construct a reasonably complete diary of the man’s activities during the two weeks before he became ill.

  Returning to the fifth floor, Marissa ran into Dr. Navarre. He looked as tired as Marissa felt. “Dr. Richter’s condition is deteriorating,” he said. “He’s bleeding from everywhere: injection sites, gums, GI tract. He’s
on the brink of kidney failure, and his blood pressure is way down. The interferon we gave him had no effect whatsoever, and none of us knows what else to try.”

  “What about Helen Townsend?” asked Marissa.

  “She’s worse, too,” said Dr. Navarre. “She’s also starting to bleed.” He sat down heavily.

  Marissa hesitated for a minute and then reached for the phone. She placed another collect call to Atlanta, hoping Dubchek was already on his way. Unfortunately, he wasn’t. He came on the line.

  “Things are pretty bad here,” reported Marissa. “Two patients are experiencing significant hemorrhagic symptoms. Clinically, it is looking more and more like viral hemorrhagic fever, and no one knows what to do for these people.”

  “There’s little that can be done,” said Dubchek. “They can try heparinization. Otherwise, supportive therapy—that’s about it. When we make a specific diagnosis we may be able to use hyperimmune serum, if it is available. On that track, we’ve already got your samples, and Tad has begun processing them.”

  “When will you be coming?” asked Marissa.

  “Shortly,” said Dubchek. “We’ve got the Vickers Mobile Isolation Lab all packed.”

  Marissa woke up with a start. Thankfully, no one had come into the little room behind the nurses’ station. She looked at her watch. It was ten-fifteen at night. She’d only been asleep for five or ten minutes.

  Getting to her feet, she felt dizzy. Her head ached and she had the beginnings of a sore throat. She prayed that her symptoms were a product of exhaustion and not the beginnings of viral hemorrhagic fever.

  It had been a busy evening. Four more cases had presented themselves in the ER, all complaining of severe headache, high fever and vomiting. One already had hemorrhagic signs. The patients were all family members of the previous victims, underlining the need for strict quarantine. The virus was already into the third generation. Marissa had prepared viral samples and had them shipped to Atlanta by an overnight carrier.