Outbreak

by Robin Cook

  “I have been involved in two recent outbreaks,” said Marissa, “and I have not been infected, though I’ve come into contact with patients who had.” She didn’t mention her own continuing fear. “We have determined that close personal contact is necessary to spread Ebola. Airborne spread is apparently not a factor.” Marissa noticed that a few of the people in the audience removed their masks. She glanced around at Dr. Weaver, who gave her an encouraging thumbs-up sign.

  “Is it really necessary for us to remain within the hospital?” demanded a man in the third row. He was wearing a physician’s long white coat.

  “For the time being,” said Marissa diplomatically. “The quarantine procedure that we followed in the previous outbreaks involved separating the contacts into primary and secondary groups.” Marissa went on to describe in detail what they had done in L.A. and St. Louis. She concluded by saying that no one who’d been quarantined had come down with the illness unless they had previously had direct, hands-on contact with someone already ill.

  Marissa then fielded a series of questions about the initial symptoms and the clinical course of Ebola Hemorrhagic Fever. The latter either terrified the audience into silence or satisfied their curiosity—Marissa couldn’t decide which—but there were no further questions.

  While Mr. Davis got up to talk to his staff, Dr. Weaver led Marissa out of the auditorium. As soon as they were in the narrow hallway, she told him that she wanted to see one of the initial cases before she called the CDC. Dr. Weaver said he’d assumed as much and offered to take her himself. En route he explained that they had placed all the cases on two floors of the hospital, moving out the other patients and isolating the ventilation system. He had every reason to believe they’d made it a self-contained area. He also explained that the staff employed to man the floors were all specifically trained by his people, that laboratory work had been restricted to what could be done in a hastily set up unit on one of the isolated floors and that everything used by the patients was being washed with sodium hypochlorite before being directly incinerated.

  As for the quarantine situation, he told Marissa that mattresses had been brought in from the outside and the outpatient department had been turned into a huge dormitory, separating primary and secondary contacts. All food and water was also being brought in. It was at that point that Marissa learned that Dr. Weaver had been an EIS officer at the CDC six years previously.

  “Why did you introduce me as the expert?” asked Marissa, remembering his embarrassing exaggerations. Obviously he knew as much as or more than she did about quarantine procedures.

  “For effect,” admitted Dr. Weaver. “The hospital personnel needed something to believe in.”

  Marissa grunted, upset at being misrepresented, but impressed with Dr. Weaver’s efficiency. Before entering the floor, they gowned. Then, before entering one of the rooms, they double gowned, adding hoods, goggles, masks, gloves and booties.

  The patient Dr. Weaver brought Marissa to see was one of the clinic’s general surgeons. He was an Indian, originally from Bombay. All Marissa’s fears of exposure came back in a rush as she looked down at the patient. The man appeared moribund, even though he’d been sick for only twenty-four hours. The clinical picture mirrored the terminal phase of the cases in L.A. and St. Louis. There was high fever along with low blood pressure, and the typical skin rash with signs of hemorrhage from mucous membranes. Marissa knew the man would not last another twenty-four hours.

  To save time, she drew her viral samples immediately, and Dr. Weaver arranged to have them properly packed and shipped overnight to Tad Schockley.

  A glance at the man’s chart showed the history to be fairly sketchy, but with eighty-four admissions in less than six hours she could hardly have hoped for a textbook writeup. She saw no mention of foreign travel, monkeys, or contact with the L.A. or St. Louis outbreaks.

  Leaving the floor, Marissa first requested access to a telephone, then said she wanted to have as many physician volunteers as she could get to help her interview the patients. If many patients were as sick as the Indian doctor, they would have to work quickly if they were going to get any information at all.

  Marissa was given the phone in Mr. Davis’s office. It was already after eleven in Atlanta, and Marissa reached Dubchek immediately. The trouble was, he was irritated.

  “Why didn’t you call me as soon as the aid request came in? I didn’t know you had gone until I got into my office.”

  Marissa held her tongue. The truth was that she’d told the CDC operators that she should be called directly if a call came in suggestive of an Ebola outbreak. She assumed Dubchek could have done the same if he’d wanted to be called immediately, but she certainly wasn’t going to antagonize him further by pointing out the fact.

  “Does it look like Ebola?”

  “It does,” said Marissa, anticipating Dubchek’s reaction to her next bomb. “The chief difference is in number of those infected. This outbreak involves one hundred cases at this point.”

  “I hope that you have instituted the proper isolation,” was Dubchek’s only reply.

  Marissa felt cheated. She’d expected Dubchek to be overwhelmed. “Aren’t you surprised by the number of cases?” she asked.

  “Ebola is a relatively unknown entity,” said Dubchek. “At this point, nothing would surprise me. I’m more concerned about containment; what about the isolation?”

  “The isolation is fine,” said Marissa.

  “Good,” said Dubchek. “The Vickers Lab is ready and we will be leaving within the hour. Make sure you have viral samples for Tad as soon as possible.”

  Marissa found herself giving assurances to a dead phone. The bastard had hung up. She hadn’t even had a chance to warn him that the entire hospital was under quarantine—that if he entered, he’d not be allowed to leave. “It’ll serve him right,” she said aloud as she got up from the desk.

  When she left the office, she discovered that Dr. Weaver had assembled eleven doctors to help take histories: five women and six men. All of them voiced the same motivation: as long as they had to be cooped up in the hospital, they might as well work.

  Marissa sat down and explained what she needed: good histories on as many of the initial eighty-four cases as possible. She explained that in both the L.A. and the St. Louis incidents there had been an index case to which all other patients could be traced. Obviously, there in Phoenix it was different. With so many simultaneous cases there was the suggestion of a food- or waterborne disease.

  “If it were waterborne, wouldn’t more people have been infected?” asked one of the women.

  “If the entire hospital supply was involved,” said Marissa. “But perhaps a certain water fountain . . .” Her voice trailed off. “Ebola had never been a water- or food-borne infection,” she admitted. “It is all very mysterious, and it just underlines the need for complete histories to try to find some area of commonality. Were all the patients on the same shifts? Were they all in the same areas of the hospital? Did they all drink coffee from the same pot, eat the same food, come in contact with the same animal?”

  Pushing back her chair, Marissa went to a blackboard and began outlining a sequence of questions that each patient should be asked. The other doctors rose to the challenge and began giving suggestions. When they were done, Marissa added as an afterthought that they might ask if any of the patients had attended the eyelid surgery conference in San Diego that had been held about three months before.

  Before the group disbanded, Marissa reminded everyone to adhere carefully to all the isolation techniques. Then she thanked them again and went to review the material that was already available.

  As she had done in L.A., Marissa commandeered the chart room behind the nurses’ station on one of the isolation floors as her command post. As the other doctors finished their history taking, they brought their notes to Marissa, who had begun the burdensome task of collating them. Nothing jumped out of the data except the fact that all the patients
worked at the Medica Hospital, something that was already well known.

  By midday, fourteen more cases had been admitted, which made Marissa extremely fearful that they had a full-blown epidemic on their hands. All the new patients, save one, were Medica subscribers who had been treated by one of the original forty-two sick physicians before the physicians developed symptoms. The other new case was a lab tech who had done studies on the first few cases before Ebola was suspected.

  Just as the evening shift was coming on duty, Marissa learned that the other CDC physicians had arrived. Relieved, she went to meet them. She found Dubchek helping to set up the Vickers Lab.

  “You might have told me the damn hospital was quarantined,” he snapped when he caught sight of her.

  “You didn’t give me a chance,” she said, skirting the fact that he had hung up on her. She wished there was something she could do to improve their relationship, which seemed to be getting worse instead of better.

  “Well, Paul and Mark are not very happy,” said Dubchek. “When they learned all three of us would be trapped for the length of the outbreak, they turned around and went back to Atlanta.”

  “What about Dr. Layne?” asked Marissa guiltily.

  “He’s already meeting with Weaver and the hospital administration. Then he will see if the State Health Commissioner can modify the quarantine for the CDC.”

  “I suppose I can’t talk to you until you get the lab going,” said Marissa.

  “At least you have a good memory,” said Dubchek, bending over to lift a centrifuge from its wooden container. “After I finish here and I’ve seen Layne about the isolation procedures, I’ll go over your findings.”

  As Marissa headed back to her room, she mulled over a number of nasty retorts, all of which only would have made things worse. That was why she had said nothing.

  After a meal of catered airplane food eaten in an area of the outpatient clinic reserved for staff in direct contact with the presumed Ebola patients, Marissa returned to her chart work. She now had histories on most of the initial eighty-four cases.

  She found Dubchek leafing through her notes. He straightened up on seeing her. “I’m not sure it was a good idea to use the regular hospital staff to take these histories.”

  Marissa was caught off guard. “There were so many cases,” she said defensively. “I couldn’t possibly interview all of them quickly enough. As it is, seven people were too sick to speak and three have subsequently died.”

  “That’s still not reason enough to expose doctors who aren’t trained epidemiologists. The Arizona State Health Department has trained staff that should have been utilized. If any of these physicians you’ve drafted become ill, the CDC might be held responsible.”

  “But they—” protested Marissa.

  “Enough!” interrupted Dubchek. “I’m not here to argue. What have you learned?”

  Marissa tried to organize her thoughts and control her emotions. It was true that she’d not considered the legal implications, but she was not convinced there was a problem. The quarantined physicians were already considered contacts. She sat down at the desk and searched for the summary page of her findings. When she found it, she began reading in a flat monotone, without glancing up at Dubchek: “One of the initial patients is an ophthalmologist who attended the same San Diego conference as Drs. Richter and Zabriski. Another of the initial cases, an orthopedic surgeon, went on safari to East Africa two months ago. Two of the initial cases have used monkeys in their research but have not suffered recent bites.

  “As a group, all eighty-four cases developed symptoms within a six-hour period, suggesting that they all were exposed at the same time. The severity of the initial symptoms suggests that they all received an overwhelming dose of the infective agent. Everyone worked at the Medica Hospital but not in the same area, which suggests the air-conditioning system was probably not the source. It seems to me we are dealing with a food- or waterborne infection, and in that regard, the only commonality that has appeared in the data is that all eighty-four people used the hospital cafeteria. In fact, as nearly as can be determined, all eighty-four people had lunch there three days ago.”

  Marissa finally looked up at Dubchek, who was staring at the ceiling. When he realized that she had finished speaking, he said, “What about contact with any of the patients in the L.A. or St. Louis episodes?”

  “None,” said Marissa. “At least none that we can discover.”

  “Have you sent blood samples to Tad?”

  “Yes,” said Marissa.

  Cyrill headed for the door. “I think you should redouble your efforts to associate this outbreak with one of the other two. There has to be a connection.”

  “What about the cafeteria?” asked Marissa.

  “You’re on your own there,” said Dubchek. “Ebola has never been spread by food, so I can’t see how the cafeteria could be associated . . .” He pulled open the door. “Still, the coincidence is curious, and I suppose you’ll follow your own instincts no matter what I recommend. Just be sure you exhaust the possibilities of a connection with L.A. or St. Louis.”

  For a moment Marissa stared at the closed door. Then she looked back at her summary sheet and the huge pile of histories. It was depressing.

  Almost as if Cyrill’s last words had been a challenge, Marissa decided to visit the cafeteria, which had been built as a separate wing over a garden courtyard. The double doors leading to the large room were closed, and on the right one a notice had been tacked up stating: CLOSED BY ORDER OF STATE HEALTH COMMISSIONER. Marissa tried the door. It was unlocked.

  Inside, the room was spotlessly clean and furnished in stainless steel and molded plastic. Directly ahead of Marissa was the steam table, with stacks of trays at one end and a cash register at the other.

  A second set of double doors, with little round windows, was located behind the steam table and led to the kitchen. Just as Marissa was deciding whether to go through or not, they opened, and a stout but attractive middle-aged woman appeared and called out to Marissa that the cafeteria was closed. Marissa introduced herself and asked if she could ask the woman a few questions.

  “Certainly,” replied the woman, who explained with a faint Scandinavian accent that her name was Jana Beronson and that she was the cafeteria manager. Marissa followed her into her office, a windowless cubicle whose walls were filled with schedules and menus.

  After some polite conversation, Marissa asked to see the lunch menu for three days ago. Miss Beronson got it out of the file, and Marissa scanned the page. It was a usual cafeteria menu, with three entrées, two soups and a selection of desserts.

  “Is this all the food offered?”

  “Those are all the specials,” answered Miss Beronson. “Of course we always offer a selection of sandwiches and salads and beverages.”

  Marissa asked if she could have a copy of the menu, and Miss Beronson took the paper and left the office to Xerox it. Marissa decided that she would go back to each of the initial cases and ask what they had eaten for lunch three days ago. She would also question a control group made up of people who ate from the same menu but who did not become ill.

  Miss Beronson returned with the copy. As she folded the paper, Marissa said, “One of your employees was stricken, wasn’t she?”

  “Maria Gonzales,” said Miss Beronson.

  “What was her job here?”

  “She worked either the steam table or the salad bar,” answered Miss Beronson.

  “Could you tell me what she did on the day in question?” asked Marissa.

  Getting up, Miss Beronson went over to one of the large scheduling boards on her wall. “Desserts and salads,” she told Marissa.

  Marissa wondered if they should test the whole cafeteria staff for Ebola antibodies. Although Ralph had been joking when he’d suggested an “Ebola Mary,” perhaps it was possible, although it had not been the case in Africa.

  “Would you like to see our facility?” asked Miss Beronson, trying to b
e helpful.

  For the next thirty minutes Marissa was given a grand tour of the cafeteria, including both the kitchen and the dining area. In the kitchen, she saw the walk-in cooler, the food preparation area and the huge gas ranges. In the dining area, she walked along the steam table, peering into silverware bins and lifting the covers of the salad-dressing cannisters.

  “Would you like to see the stock rooms?” Miss Beronson asked, when they were done.

  Marissa declined, deciding it was time to start checking to see what the initial Ebola patients had chosen from the menu in her purse.

  Marissa rocked back in the swivel chair and rubbed her eyes. It was 11:00 A.M. of her second day in Phoenix, and she’d only managed four hours of sleep the previous night. She’d been assigned one of the examination alcoves in the OB-GYN clinic, and every time someone went by, she’d been awakened.

  Behind her, Marissa heard the door open. She turned and saw Dubchek holding up the front page of a local newspaper. The headline read: CDC BELIEVES HIDDEN SOURCE OF EBOLA IN U.S.A. Looking at his expression, Marissa guessed that he was, as usual, angry.

  “I told you not to talk to the press.”

  “I haven’t.”

  Dubchek smacked the paper. “It says right here that Dr. Blumenthal of the CDC said that there is a reservoir of Ebola in the U.S.A., and that the outbreak in Phoenix was spread by either contaminated food or water. Marissa, I don’t mind telling you that you are in a lot of trouble!”

  Marissa took the paper and read the article quickly. It was true that her name was mentioned, but only at second hand. The source of the information was a Bill Freeman, one of the doctors who’d helped take patient histories. She pointed this fact out to Dubchek.

  “Whether you talk directly to the press, or to an intermediary who talks to the press, is immaterial. The effect is the same. It suggests that the CDC supports your opinions, which is not the case. We have no evidence of a food-related problem, and the last thing we want to do is cause mass hysteria.”