The Jakarta Pandemic

by Steven Konkoly

  “My colleague, Dr. Relstein, will explain what we now know about the H16 subtype.”

  “First, we now know that the strain of the H16 subtype causing the outbreak throughout Asia is N1. So the influenza strain is classified at H16N1. We have confirmed through observation and genetic matching that H16N1 is highly pathogenic. Four to five times more pathogenic than the avian flu of 2008. H16N1 is even projected to surpass the Spanish flu of 1918 in terms of pathogenicity, or its ability to produce an infectious disease in another organism, though it is way too early to establish an accurate predictive model. H16N1 is trending in that direction, however, and this greatly concerns our organization.

  “H16N1 is highly efficient at human-to-human transfer. Once again, more so than the avian flu. We will catch no break here. It can survive for 24 to 48 hours on non-porous surfaces and up from 16 hours on porous surfaces, which is slightly longer than most influenza strains. It can be transmitted by any bodily secretions, aerosol or liquid of any consistency. Personal protection measures will be critical to blunting the spread of this virus, combined with effective social distancing measures.

  “As for a behavioral timeline, we have some rough calculations. These are based on the CDC’s observations in China and ongoing observations by ISPAC teams throughout the Pacific rim. From initial exposure and infection to H16N1, a patient can remain asymptomatic for 3-5 days. This data is rough, but trending toward 4-5 days. These are the hardest data points to establish. Either way, this is much longer than the avian flu or the Spanish flu and presents a number of challenges. The biggest challenge being that a sick patient will interact with the public longer before it becomes obvious that they are sick. Asymptomatic patients will have more time to spread the disease. Asymptomatic patients start shedding the disease after just one day of initial infection, leaving a possible period of 2-4 days where the patient is contagious with no symptoms. Shedding means that the disease is now leaving the infected body by any of a several routes, where it can now infect another body.

  “Once symptoms start, the patient will continue shedding at a high level for another 5-7 days, even when initial flu symptoms have subsided. Patients will likely remain contagious for 11 days from first infection. This is our best estimate for now.

  “Symptoms for H16N1 are typical of a pandemic influenza virus, or even a rough seasonal virus strain. Sudden onset of high fever, headaches, body aches, severe congestion, cough, extreme fatigue, and in the case of children, possible severe vomiting and diarrhea. Symptom severity varies by patient. Frequent instances of severe respiratory illness, such as pneumonia, acute respiratory distress, and viral pneumonia have developed following several days of the original flu symptoms. Respiratory illnesses have developed as early as 2 days after symptoms and as late as 8 days. We don’t have many cases spanning back further than 8-10 days. Most of these patients were observed in China.

  “I know you are all very concerned about the potential lethality of the H16N1 virus. Right now, we do not have enough data to project a case fatality rate. With that being said, a low number of patients inside and outside of China have died from H16N1, mostly from severe respiratory complications. Some have died from sudden and massive respiratory failure, within 1-3 days of symptom onset. These deaths resemble scientific reports described during the Spanish flu of 1918, when apparently healthy, young adults would show sudden respiratory symptoms and die within the same day. Today we call this a cytokine storm or more formally, ARDS, acute respiratory distress syndrome. A massive immune reaction to the invading virus, which triggers a deadly and often irreversible, inflammatory response within the lung tissue.

  “This is where we stand today. Our scientists are continuing an aggressive research program aimed at learning as much about the virus’s behavior and characteristics as possible. At this point, we would like to open the floor to any questions you may have. Yes.”

  He pointed to a young black man dressed in a pair of dark brown chino pants, white dress shirt without a tie, and blue blazer.

  “Thank you, Jeff Saunders, Associated Press. Do either of you have an estimated number of total cases worldwide?”

  “I spent some time this morning with CDC epidemiologists, who closely monitor all of the data pouring out of Asia from all sources, the ISPAC, GeoSentinel, GOARN, the WHO and more. I thought our own organization was doing the best job evaluating this data, however, even our own Dr. Ocampo approached me this morning to say that he was, I quote, ‘blown away.’ So, after merging our numbers with the CDC, we can safely estimate that there are roughly 1,700 confirmed cases spread throughout the Pacific rim, outside of China. Unconfirmed but probable cases, based on CI reporting, GeoSentinel, and GOARN likely exceed 25,000. The numbers are still a bit sketchy from China, but the CDC estimates the total number of cases to be more than 60,000 and growing rapidly. So we are looking at roughly 85,000 cases of confirmed or soon to be confirmed H16N1. Next question. Go ahead.”

  She nodded toward a tall, middle-aged woman, with dark brown hair and blue eyes, wearing a navy blue business suit, with a light blue blouse. She displayed an overly-serious face as she asked her question.

  “Has the ISPAC received any information about the missing team in Jakarta?”

  “Not yet. We have petitioned the UN, once again, to apply pressure to the Indonesian government, however, it appears that the Indonesian representatives to the UN assembly have been absent from all sessions for the past three days. At this point, we just want to retrieve our team safely and redeploy them where they will be permitted to execute their duties.”

  She nodded toward another woman in the back of the auditorium.

  “Hi, Sandra O’Donnell from the Wall Street Journal. Do you have a more specific number for current the death toll?”

  She glanced uncomfortably at Dr. Relstein, who pulled the microphone closer to his face.

  “I used the word ‘low’ to describe the number of H16N1-related deaths, and I apologize for not being more specific. I hesitate to mention fatality numbers this early because, statistically, they don’t tell us a lot right now. This may sound morbid, but in the complicated projection models used for pandemic predictions, we need lots of fatalities before the data becomes useful to us. Right now, without revisiting the numbers, I am willing to estimate somewhere around 450 deaths.”

  The auditorium suddenly buzzed with the excitement of dozens of reporters trying to ask questions at the same time.

  Alex heard the number “450” yelled several times.

  “Ladies and gentlemen, please calm down,” Dr. Devreaux said.

  “Where have most of the deaths occurred?” someone yelled loud enough to be heard over the crowd.

  “Mostly in China, but within the last day we’ve seen an increasing number of deaths outside of China,” Dr. Relstein answered.

  Several reporters tried to ask questions at the same time. Dr. Relstein pointed to a hispanic man, wearing a tweed jacket, pink shirt with yellow tie, and khaki pants.

  “Fred Alvarez, FBC news affiliate. How many of the deaths have been from ARDS?”

  Dr. Relstein paused noticeably and lowered his head slightly.

  “More than half, at this point. However, before anyone jumps to any conclusions about this number…”

  The entire room was again buzzing with conversation.

  “Please, before you draw your own conclusions, let me share my own with you. Please keep in mind, our goal is in no way to sugarcoat this information, or withhold information, for any reason. The ISPAC and CDC are committed to preparing the public for whatever might be coming their way, and a complete free flow of information is the first step toward accomplishing this. With that being said, I don’t want to release information that can be misinterpreted and lead to erroneous decisions. As for the ARDS deaths, the number is indeed high compared to all deaths. However, if you recall, ARDS typically claims its victims early, within a few days, sometimes faster. It follows that at this early stage in observation, mo
st of the deaths seen would be from ARDS. As the days stretch onward, the ratio of ARDS deaths to all other H16N1 linked deaths will decrease significantly.”

  “Have I explained this well enough to quiet the room a bit?”

  Nervous laughter erupted from the room.

  The conference room returned to a moderately quiet level.

  “We still have time for a few more questions,” Dr. Devreaux said.

  “Dr. Harrison Leblanc, Emory University’s Immunology and Virology Department.”

  “Haven’t we hired you yet, Harry?” Dr. Relstein interjected.

  “The day is still young, Joshua. Any projections regarding clinical attack rates, or is it still too early?”

  “Still too early, I’m afraid. We would need to survey data from large population groups in order to narrow those projections to a meaningful level. Large outbreaks in China may soon provide enough data to achieve a statistically significant prediction, but right now, we simply don’t have enough data.”

  “Not even a statistically insignificant guess. I’m willing to work with outside of the margins for now,” Dr. Leblanc said.

  “We really should have made you a better offer at the CDC. You’re not planning to let me off the hook, are you?”

  Open laughter erupted from the room. Even Dr. Devreaux was muffling a laugh.

  “I can be bought, but probably not before you answer the question.”

  More laughter. The mood was definitely lighter, but Alex guessed that his answer was going to silence the room.

  “Very, very roughly a 30-50% clinical attack rate.”

  “What does clinical attack rate mean? Sorry, Matt Gershon, Atlanta Tribune.”

  “No problem, very good question. Clinical attack rate means the percentage of a given population that gets ill from a specific virus.”

  “How rough is this number?” Dr. Leblanc asked gravely, the light banter gone from his voice.

  Given the difference in his tone, the entire room silenced, waiting for Dr. Relstein’s response.

  “Very rough. Like I said, not enough data exists to narrow the margin of error.”

  The camera shifted back to Dr. Leblanc, and Alex saw that he was uncomfortable with the answer. Dr. Leblanc nodded his head and sat down. Dr. Leblanc’s face looked ashen gray. The doctor doesn’t like the answer either. As Dr. Leblanc sat back in his seat, several other reporters jumped out of their seats to ask questions. Dr. Devreaux pointed directly at a hefty gentleman, wearing gray slacks and a white oxford shirt.

  Alex leaned forward and grabbed the laptop sitting on the coffee table in front of the couch. He flipped open the screen and wirelessly connected to his home internet signal.

  “Thanks, John Volkman with the Indianapolis Star. Have any cases been reported in the U.S.?”

  “None so far,” she replied.

  “Given the basic virus behavior you just described, isn’t it possible that the H16N1 could already be in the U.S.? Plenty of flights out of Hong Kong and China make their way to U.S. cities. Flights from all over Asia.”

  “You’re correct to connect the dots like that, John. This is of grave concern to us as well. Yes, it is quite possible for the virus to already be here in the United States. There is no reason to assume that it is not. Currently, the Department of Health and Human Services has implemented health watch protocols at all points of entry into the United States, with special emphasis on flights originating from cities near confirmed H16N1 outbreak areas or suspected areas. The hope is that, like in the U.K., any travelers sick with the flu will be detected and quarantined. DHHS is also working with several other domestic agencies to track down travelers from these areas that arrived within the last 8-10 days. In this way, DHHS can get eyes on travelers that may have arrived infected, but still asymptomatic. Just keep in mind, that this is a huge task, given the sheer volume of foreign passengers entering the U.S. on any given day. The CDC’s role, and now our role as well, is to provide DHHS the best projections for either widening or narrowing their screening criteria. Unfortunately, given the rapid spread of the virus, I don’t see us recommending any narrowing of the screening criteria.”

  “Thank you,” John said, as he sat down.

  “One more question. Jeffrey Peterson,” she said.

  “Thank you, Jeff Peterson, New York Times.”

  “What is the current status of the WHO’s efforts, and what is your new joint venture’s relationship with the WHO.”

  “I’ll take the first part of that, Allison,” Dr. Relstein said.

  “The WHO is currently heavily engaged in pandemic response and containment efforts in China. A vast majority of the world’s cases are located in China, and the WHO responded by deploying a majority of its resources in an attempt to mitigate the spread of the virus throughout and beyond China. Now, I’m sure you asked that question for a reason. I think I know what it is.

  “It is our opinion that the WHO is bogged down in China, no doubt executing their mission with the same professionalism and effectiveness demonstrated in 2008. Unfortunately, the WHO may have committed nearly 75% of its rapid response resources to China, which only leaves one quarter to help contain the growing pandemic threat outside of China. If the WHO cannot execute an immediate, large-scale redeployment, there is little hope of containing or slowing the current pandemic threat.”

  “What is being done to speed up this process?” Jeff asked.

  “I’ll answer that one,” Dr. Devreaux said. “This is obviously a complicated and sensitive issue. We have presented our case directly to WHO and UN leadership, and will continue to press the issue. We have also presented our recommendations to DHHS and the White House. The issue is a top priority for us.”

  She nodded to Dr. Relstein.

  “The WHO and CDC have always enjoyed an amiable and professional relationship. At this point, we will do everything on our end to maintain this relationship, however, the WHO rapid response capability is like an army. Their pandemic response package runs the entire spectrum of capability, from early detection and surveillance teams, civil health education teams, all the way to full containment teams. The CDC and ISPAC can only provide on the ground surveillance and detection capability, which frankly will not be necessary once the field detection kits are fully distributed. Beyond this, as a combined entity, we can provide first rate, real-time epidemiological projection to help actively shape WHO efforts. Nonetheless, this information is near useless in the hands of a diminished WHO response. As Dr. Relstein indicated, this is a top priority. Getting the bulk of the WHO’s assets out of China is critical to executing an effective international pandemic response strategy.”

  “Sorry to drag this question out, but what if the WHO can’t effectively disengage from China?” Jeff stated.

  “Then the WHO will likely prioritize their deployments to nations with highly vulnerable populations and weak domestic pandemic response plans. The remaining nations will have to stand on the own and rely upon the rapid, efficient execution of their own domestic plans. Ladies and gentlemen, thank you for your time and questions. We plan to announce another session, likely for the same time tomorrow.”

  The room exploded into a cacophony of simultaneously blurted questions and spirited discussion.

  Alex heard one reporter ask about military options and China. That’s exactly what I was thinking. How are they planning to get the WHO out of China. The world is never going to see those assets. 75%. What a fucking arrogant gamble.

  Alex looked at his laptop screen, which was on the Google homepage. He typed “previous pandemic clinical attack rates.” Several seemingly good links appeared on the first page. He clicked on the third link down, which indicated it may contain a table. The page appeared, and Alex read through the text and the table. No wonder that Dr. looked like he just shit his pants. Projected 30-50% is much higher than any previously seen pandemic. Both the Hong Kong flu of 1968 and the Asian flu of 1957 demonstrated clinical attack rates hovering at 30%. The
avian flu of 2008 remained lower than either of those, steadying at 15%. Epidemiologists declared that no clinical attack rate could be established for the Spanish flu of 1918, due to a lack of reliable record keeping. This made sense to Alex, given the fact that many experts still argue about the final number of deaths attributed to the 1918 flu. 50-100 million remains the disputed range. Alex guessed that the clinical attack rate must have been much higher than 2008, possibly higher than 1968 or 1957, given the high number of deaths compared to what must have been a lower world population in 1918. All of this gave Alex a very uneasy feeling.

  Joint CDC and ISPAC Press Conference Number Two

  Early November 2013

  The recording started, and the scene was the same as yesterday, with two podiums separated by a white screen. Dr. Devreaux and Dr. Relstein took their respective podiums. Dr. Relstein began the conference. Dr. Relstein looked exhausted, dark circles were beginning to take shape under his eyes.

  “Good morning, everyone. Just as a note, this morning’s update will run shorter than yesterday’s. Both Dr. Devreaux and I are scheduled for a 10:30 videoconference with the White House, which obviously takes priority. I just wanted to give you all fair warning. We will both be as brief and informative as possible, leaving time for questions. Thank you in advance for your understanding. Dr. Devreaux?”

  “Thank you, Josh. First and foremost, all of us here extend a heartfelt thank you to the sailors and marines involved in the rescue of our survey team. The team’s families and friends are relieved beyond words, as are we at the ISPAC. Few details of the rescue operation have been made available, but from what we can ascertain from our debrief of the team, the rescue was conducted at considerable personal risk to those involved. Thank you so very much, your professionalism and service will never be forgotten.