“The importance of this rescue extends well beyond just reuniting the team with loved ones. Information provided by the team confirms beyond a shadow of a doubt in our minds…” she said, nodding to Dr. Relstein, “that Indonesia, and specifically the area around Jakarta, is the epicenter of the H16N1 pandemic outbreak. I will give you a brief synopsis of the survey team’s frightening ordeal.
“Upon debarking their flight at the Jakarta International Airport, they were immediately strong-armed into what they thought was a police van, waiting for them on the runway. Apparently, the individuals involved were a combination of local health officials and law enforcement that had become aware of a government plot to detain the survey team. This small renegade group kidnapped the team in order to prevent their immediate incarceration at the terminal.
“The survey team was shuffled around Java Island for three days, hidden by sympathetic civilians. They operated in constant fear of arrest. The team observed the general state of the pandemic’s progress on the island and conducted close observation of patients when it was possible. The web of locals who hid the team and helped transport them, did so at great risk. The Indonesian government had no intention of letting our team confirm the extent of the disaster unfolding on Java Island. We extend our sincerest thanks and well wishes to these heroes.
“As you may have seen on the website, our rough estimates for the number of flu cases in Indonesia is simply staggering. Our survey team saw entire hospitals filled to capacity with flu victims, soccer stadiums filled, indoor malls filled. Flu patients stacked in every conceivable location for triage and treatment, with scant medical supplies available to local healthcare providers. The scene was described by one of the team members as catastrophic, with no end in sight.
“The team was smuggled aboard a fishing boat and taken out to sea, where they sent an international distress call over the boat’s VHF radio. According to the team leader, it had become common knowledge on the streets that U.S. Navy ships were operating close to Indonesian territorial waters. Fortunately for the team, the call was swiftly answered by the U.S. Navy. The details surrounding the actual rescue operation are classified.
“So, what are we looking at within Indonesian borders? Data given to the team by Indonesian health officials puts the estimated number of cases at easily over a million. Deaths estimated around 45,000. 1 out of 3 deaths are blamed on acute respiratory distress syndrome. Dr. Relstein will handle this topic shortly, so please hold your questions.”
Dr. Devreaux rightly anticipated an outburst from the auditorium, which quieted just as quickly as it started.
“The first outbreak occurred approximately 14 days ago, right outside of Jakarta. The outbreak spread quickly to the rest of Java Island and some parts of Sumatra. Java Island is one of the most densely-populated regions of the world, especially since Indonesia became an Islamic theocracy in 2010 and a safe haven for Muslims worldwide. Without seeking any outside help, and with very little help available internally, the H16N1 virus spread rapidly with devastating effect.
“Cellular phone service was severed by the government 12 days into the crisis, which explains why we could not contact our team. It remains perplexing to me, that an entire nation’s cell phone network was shut down, and the world didn’t notice. Actually, I don’t believe it, but that’s another topic altogether.
“From what Dr. Relstein told me immediately prior to the conference, the UN was imposing a strict travel ban, though from what we learned from our team, no flights were leaving or arriving by the time they fled the country. They said that Java Island was nearly pitch black at night.
“Dr. Relstein will share what we’ve learned about H16N1 and its behavior.”
Dr. Relstein picked up the coffee mug he brought up to the podium, and took a lengthy drink. “Thank you, Allison. So, as you have all noticed, the map, which is now shared by both CDC and ISPAC websites, is very different today than it was 24 hours ago,” he said, pointing to the projection of the map on the screen behind him.
A considerable amount of talking and mumbling erupted from the crowd, as nearly every person seated in the auditorium started to check their cell phone or PDA. Dr. Relstein stopped talking for a moment and responded to the interruption with an annoyed look. He raised his eyebrows and looked at Dr, Devreaux, shaking his head. He stepped forward of the podium and addressed one of the closest journalists.
“What just happened?” he asked a young woman in a gray business suit.
“The WHO just raised the pandemic phase level to six,” she stated, looking stunned.
Dr. Relstein walked back to the podium, took another drink of coffee, and addressed the group.
“All right, everyone. Please, we don’t have much time for this conference, so if I could please have your attention,” he said loudly into the microphone.
The crowd started to quiet, and Dr. Relstein gave them another minute to simmer the excitement.
“Thank you, I have to admit, as a senior spokesperson for the CDC, I didn’t expect to hear that news from all of you first.”
Laughter erupts from the room.
“Well, there is no doubt that the world is right in the middle of a pandemic with devastating potential, so let’s get back to what we now know about H16N1. As data pours in from around the world, it is clear that this flu is spreading, and spreading fast. Further testing and observation confirms that H16N1 is super contagious. Sounds like a very non-scientific term, super, but I don’t know any other way to put it. Upon infecting a host, H16N1 starts shedding more virus in under one day. This is the shortest latent period seen among known flu strains, and I wish the bad news ended there. The shedding is also on a level we have never witnessed with known flu strains. H16N1 appears to be hell-bent on spreading. It can survive on porous and nonporous surfaces longer than we originally calculated and is easily spread by direct and indirect contact. You do not want to sit next to someone on the bus who has this disease. More accurately, you don’t even want to be on the same bus as this person.
“So, let’s take another look at the basic timeline,” he said, shooting a laser pointer at the timeline on the screen.
“The latent period lasts under one day, and this is the only time that the patient is not infectious. Once the disease starts shedding, the patient enters the infectious period. Remember, the patient at this point is still asymptomatic and spreading the disease like wildfire. At some point within 4 to 6 days of first infection, the patient enters the symptomatic period. They are still highly infectious during this period and may remain infectious for another 6-10 days after first symptoms. Like H5N1, children can remain infectious for nearly a week longer than adults. Most of the ARDS deaths occur within a few days of first showing symptoms.
“Yesterday I estimated that ARDS deaths accounted for 1 out of 5 total deaths. Today, we are revising the estimate to 1 out of 3. H16N1, like the Spanish flu and avian flu, seems to trigger an autoimmune cascade in a high percentage of healthy young adults. It’s a cruel irony that this syndrome specifically targets a cross-section of society with the healthiest immune system. We are constantly analyzing this data and revising our projections, but honestly, I thought this number would decrease, not increase. We are still in the very early stages of the pandemic, and ARDS deaths will dominate the death tolls for at least another few weeks. I don’t expect the ratio to go much lower than 1 to 3.
“As for deaths due to pulmonary or secondary complications, like diabetes or heart disease, these are seen starting from 4 days after first symptoms and lasting months. Obviously, these cases will dominate the death tolls, especially as time increases. Generally, the early deaths occur in younger and older patients, or patients with vulnerable secondary complications. Of course, a patient’s prognosis varies significantly based upon the level and duration of care available.
“Before I turn this back over to Dr. Devreaux, I want to emphasize again that H16N1 has several characteristics that make it a unique and deadly
pandemic flu. It is highly contagious and demonstrates a longer than normal asymptomatic period, which presents a challenge to traditional health screening methods. This must be addressed by our government immediately. Strict quarantine and social distancing strategies will be critical to mitigating the spread of this disease.”
He turned to Dr. Devreaux. Dozens of hands shot up from the auditorium.
“Thank you, Dr. Relstein. We are running short on time, so we’ll start questions. We can only take a few. Yes, Dr. Perry? From Johns Hopkins. Is that right?” she asked.
“Thank you, Allison. And for the record, I would be more than willing to join your team here in Atlanta starting immediately.”
Dr Relstein interrupted, “Stephen, consider yourself hired. Sorry it took a pandemic for you to accept our offer.”
“You know very well that I can’t stand the weather down here, and I don’t plan to remain for long, so don’t get excited. So, my question concerns the transmission probability of H16N1. Do you have a rough estimate of secondary attack rate or reproductive probability? Sorry to get technical.”
“Not at all, Dr. Perry. I would be happy to show you those numbers once you sign all of the paperwork,” Dr. Relstein replied.
Dr. Perry laughed out loud and sat down. The joke briefly lifted the somber mood of the room, though Dr. Relstein’s answer quickly sank the auditorium back into the realm of gasps and shaking heads.
“I tried. So transmission probability is the chance of a disease being transmitted from one person to another if they have been in contact, and secondary attack rate is a similar projection. To answer your question, we are still trying to establish a solid estimate for transmission probability. For secondary attack rate, we have been able to isolate data for smaller groups exposed to a single index case. In these cases, we are seeing a 35-44% secondary attack rate, which is high.
“The basic reproductive number is a different beast. It is defined as the expected number of new infectious cases, in a completely susceptible population, produced directly by a single case. This does not count additional cases produced by secondary cases. Consider a sales pyramid scheme. The basic reproductive number is how many people, on average, we expect one person to directly sign up to sell for them. Unlike many of the other predictors used in disease transmission epidemiology, the basic reproductive number can be altered. It has four components: length of infectious period; number of contacts an infectious person makes in a period of time; the transmission probability; and the probability that someone who gets infected is actually infectious. So you can see that it is not actually a characteristic of the virus, but instead a snapshot of the virus at any particular time and place. Most government public health interventional strategies are based on altering this number and thereby mitigating the spread of the flu.
“Right now, the basic reproductive number is hovering around 5, which is very high for influenza. I firmly expect this number to lower as widespread pandemic response measures are implemented. The typical range for pandemic influenza is between 2 and 3. However, H16N1 is unique, so it may retain a unique basic reproductive number. Once again, strict quarantine and social distancing measures can drastically impact the number of contacts exposed to an infected person. At this point, these remain our most viable strategies to containing this virus. Sorry for the long answer. Stephen, when this is finished, please come up here so I can shackle you to my ankle. Dr. Devreaux will hand the last question.”
“We need to wrap this up quick, one more question,” she said and pointed to a tall man standing in the back of the auditorium.
“Thank you. Have either of your agencies consulted with the Department of Health and Human Services to start coordinating more aggressive pandemic response measures. From what you’ve described today, this sounds like a logical next step.”
“I couldn’t agree with you more. The purpose of our videoconference with the White House today is two-fold. First, to provide our most up-to-date data and projections regarding the pandemic. Secondly, to stress the paramount importance of escalating measures taken by DHHS to implement the national pandemic response strategy. We are also currently reaching out to the international community to provide this same information and stress the importance of immediate action. We are working in close coordination with the WHO to this effect. Ladies and gentlemen, I am getting a signal from the sidelines here that we must leave. Thank you.”
Evening News Report
Early November 2013
Alex turned on the television and home theater system. A few days ago, he set the DVR to record the FBC Evening News every night, between 6:30 and 7:00. Instead of staring at the computer all day, or incessantly watching CNF’s looped news feed, he figured they could catch up on everything important, together and at their own leisure. At this point, Alex was mostly concerned about the arrival of the Jakarta flu in the U.S. He could watch and read news reports from the world all day, but he was starting to come to terms with the fact that it didn’t really matter anymore. The flu was coming, regardless of what happened outside of the country. All that really mattered now was what happened inside the country, and how it impacted their neighborhood.
Alex started the news program. Kerrie Connor appeared sitting alongside a large monitor, which showed an image of an American aircraft carrier plowing through rough seas.
“Good evening. Tonight’s top stories. Tensions with China increase as the fate of several hundred World Health Organization health workers remains unknown. At least two more U.S. aircraft carriers and an additional battle group are dispatched to the region.
“In Jakarta, the death toll rises as the killer flu burns unhindered throughout Java Island and spreads to Sumatra. The first reporters on scene describe the sight as devastating.
“And worldwide, the Jakarta flu continues to spread, causing countless thousands of deaths in Asia. Reports of larger flu outbreaks in Europe, the Middle East and Africa have world health officials concerned that the pandemic could become uncontainable.
“We’ll also meet with Dr. David Ocampo, from the ISPAC, and get his assessment of the world pandemic situation.”
“That should be interesting,” Alex grumbled.
“First, a closer look at the crisis developing in China. Department of Defense officials acknowledged today that an additional carrier battle group, comprised of ships from Hawaii and Southern California, would join forces already deployed to Southeast Asia. A battle group centered around the nuclear aircraft carrier George Washington, home ported at U.S. Seventh Fleet headquarters in Japan, is already on station in the area. Rumors of another carrier being recalled from the Arabian gulf for service off the coast of China has not been confirmed.
“Chinese government officials protested the additional deployments to the United Nations. Jennifer Moskowitz reports from United Nations headquarters in Manhattan.”
The screen changed to a picture of a blonde woman with medium-length hair, wearing a rather non-descript black ensemble, standing in front of a spectacularly illuminated United Nations Secretariat building. Several member nation flags waved in a light breeze behind her, bathed in spotlights. The broadcast was live.
“Kerrie, I’m standing in front the United Nations Secretariat building, where the mood today can only be described as tense and desperate. Chinese delegates continued to deflect questions regarding the status of WHO teams within their borders, stating only that these teams are consumed by the task of containing and mitigating the pandemic within Chinese borders and are in no way disposed to abandoning their heroic efforts on behalf of the Chinese people. Tempers flared as delegates from at least a dozen nations accused the Chinese of holding the teams hostage. Delegates from Germany and Australia went so far as to blame China once again for exacerbating the pandemic situation, a reference to China’s mishandling of the 2008 avian flu pandemic.”
“Jennifer, was there any mention of sanctions against China, or the use of force to expedite the release of the WHO teams?
”
“There was no discussion or suggestion of sanctions today by the assembly, however, it is no secret to any of the members that several nations have assembled outside of UN auspice to discuss options in response to China’s actions. Chinese delegates repeatedly lobbied the assembly to formally decry the growing coalition outside of the UN. They are particularly alarmed by the deployment of an additional U.S. carrier battle group to the region, calling this an aggressive and warlike action.”
“Thank you, Jennifer. We’ll all definitely be watching this tense situation closely.”
Jennifer Moskowitz nodded and the screen returned to Kerrie. The screen next to Kerrie showed a Google Earth map of Indonesia, which started to slowly pan closer to the city of Jakarta, on the northwestern tip of Java Island.
“Reporters and a limited number of aid workers landed during daylight hours at Jakarta’s International Airport, to assess the worsening situation on Java Island. Flights are unable to land during nighttime hours, due to a complete blackout on Java Island. Initial reports passed through Indonesian health officials puts the official death toll at nearly 72,000, with over a million cases estimated on Java Island alone. One health official stressed that these figures were only an estimate, since they no longer have any competent way to track the sheer volume of cases and deaths, which grow rapidly by the hour. Health officials told reporters that they were shocked by how quickly the flu spread through the population. The first cases of the Jakarta flu appeared less than three weeks ago. Indonesian diplomats around the world, on behalf of their government, pleaded with the international community for aid, in the form of food, medical supplies and infrastructure support. WHO officials hinted that no pandemic response assets are likely to be deployed to Java Island or Sumatra. An anonymous source at the United Nations stated that WHO resources are stretched thin and are being reserved for locations where containment stands better chances of success. For Java Island and Sumatra, it appears that little hope is on the horizon. Stay with us, we’ll return in a few moments.”
The Jakarta Pandemic Page 58
