by Alan Sipress
That week, Yan Li, the Canadian scientist at the center of the storm, sent an e-mail to many of those who had participated in the secret conference call the previous Friday. He said he agreed with their criticisms of his Western blot study and wanted to explain why he had proceeded with this technique.
Li said it would have been difficult to analyze the serum samples using a more reliable test because the Vietnamese didn’t have the proper lab safeguards. “Therefore, it would be better for us to first use the Western blot method for initial testing and provide on-site training to Vietnamese scientists to use this technique in their regular laboratory,” he said. “But the prerequisite was that all, or at least those serum samples initially screened positive by Western blot, be sent back to us so we can further test them.” Li’s own lab in Winnipeg could perform the verifying tests.
After the initial tests came back positive, Li wrote that he had repeatedly told officials from NIHE and WHO that “these were very preliminary results” that could reflect contaminated samples and would have to be retested using a more established method. “It was clear to us,” he said, “that the Western blot method was only for initial screening and training but not for the final decision-making test.”
Dr. Frank Plummer, scientific director general of the National Microbiology Laboratory in Canada where Li worked, later provided me with a similar account of the Canadian collaboration with the Vietnamese, adding that the results of the Western blot tests were supposed to have remained private. “This interim information was neither meant for distribution nor for decision making,” Plummer said. He called it unfortunate that the information was shared with officials, prompting public health concerns.
To some at WHO, Li’s defense rang hollow. They’d heard something similar from the Canadians before, two years earlier, to be precise. That’s when a baffling respiratory outbreak had raced through a nursing home in the suburbs southeast of Vancouver, Canada, and Li’s lab had weighed in with an alarming and ultimately misleading diagnosis.
In the first week of July 2003, scores of elderly residents at the 144-bed Kinsmen Place Lodge in Surrey, British Columbia, started coming down with the sniffles. So did dozens more of the staff. By August about a hundred residents and at least forty-five staff members had developed what looked like a summer cold. Seven residents had died during that period, not an unusually high number for the home. But pneumonia was implicated in three of the deaths, and that was worrisome. Initial tests at several Canadian labs failed to identify the cause of the outbreak. Then, Plummer announced to the media that his scientists had discovered it was SARS.
The revelation rattled Canada. The country was still on edge after the global SARS epidemic earlier in the year. Toronto, Canada’s premier city, had experienced the largest outbreak outside Asia and 250 people had fallen sick. Forty-four had died. Li and his colleagues at the National Microbiology Lab had been deeply involved in researching that epidemic.
The new cases at Kinsmen Place Lodge certainly didn’t look like the same SARS. Most were mild and nearly everyone recovered. But Li’s lab was now reporting that its genetic analysis had revealed an almost perfect match with SARS. Separate tests conducted by the lab on samples from the nursing home had also found antibodies to the SARS Coronavirus. The virus could be returning in a new, unpredictable form. WHO urgently dispatched a SARS expert from Geneva to investigate.
In suburban Surrey, the six-story brick nursing home was placed under quarantine. Ill patients were put into isolation. A sign on the front door greeted visitors: STOP. RESPIRATORY OUTBREAK. STRONGLY RECOMMENDED YOU DO NOT ENTER THE BUILDING. For days, residents could only wave through the windows to relatives on the sidewalk below. At Surrey Memorial Hospital, nineteen health-care workers who had contact with a patient from the nursing home were restricted to home quarantine. Then another nursing home in western Canada reported a similar outbreak.
As time passed, however, tests at other labs, including CDC Atlanta, failed to turn up SARS in the samples. Instead they isolated another Coronavirus called OC43, known to cause common colds. Both WHO and Canadian officials ruled out a new SARS outbreak, and the quarantines were lifted. The misdiagnosis by the National Microbiology Lab was ultimately blamed on a combination of contaminated lab samples and overly sensitive tests that generated false positives. The lab’s reputation took a drubbing.
Li later told the Wall Street Journal that his lab’s results had only been preliminary and were faxed out to the public without his permission.
So as a crack team of investigators secretly set out for Hanoi in June 2005, they suspected that Li’s Western blot results on the samples from northern Vietnam were flawed also. That thought offered a measure of comfort. But there were still those disturbing results from the separate PCR tests conducted by the Vietnamese, and the Vietnamese had a good track record.
Maria Cheng was in China when she took the call asking her to head for Hanoi. Her colleagues in Geneva told her that something was going on in Vietnam but they weren’t sure what. They were more nervous than she’d ever seen them. “They were really scared about what was going on. They thought the pandemic was starting,” she recalled.
Cheng was a bright, young Canadian journalist who had written from Asia for several publications before WHO hired her in the middle of the SARS epidemic to help handle the flood of press calls. She impressed her seniors in Geneva and, after that crisis faded, stayed on, expanding her communications portfolio to include bird flu, polio, and other diseases, splitting her time between headquarters and the field. She was an old hand at flu by the middle of 2005. Yet she didn’t realize how serious the situation might be in Vietnam until Dr. Julie Hall, an influenza expert in WHO’s Beijing office, sat her down.
“If there is a pandemic and you get infected, you’re stuck there,” Hall told her. “Are you really going to do this?”
Cheng said yes.
The Beijing staff showed her how to properly wear a mask fitted to the contours of her face and sent her off.
“It was freaky,” she recounted.
The Vietnamese government had decided, after all, to cooperate with the special mission and provide the required lab samples. By coincidence, Prime Minister Phan Van Khai was due that same week to make the first trip ever to the United States by a top Vietnamese Communist leader, and this was no time to pick a fight. In an interview with the Washington Post on the eve of his trip, Khai signaled his government’s good intentions. “Due to the limited capacity and conditions in scientific research facilities, therefore, we are working closely with the international community,” he said. “A sample has been provided for international experts and foreign countries to carry out joint research.”
In Geneva, Margaret Chan was planning for the worst. Just days earlier, she had been brought in as WHO’s new director of communicable diseases and special representative for pandemic flu. She instructed Stohr to draw up a new list of experts who could advise the director general, Dr. Lee, about whether to sound a pandemic alert once the special team reported back. She recognized this would be as much a political determination as a scientific one.
“They should be from different backgrounds,” she told Stohr. “We need policymakers or advisors to ministries of health, not pure scientists.”
Chan was also concerned that news of the mission would leak. She called Hitoshi Oshitani in the regional office, and they agreed that the agency would say as little as necessary.
In Vietnam, Maria Cheng would have the unenviable task of trying to keep the press in the dark without actually lying to them. It would be hard to miss the foreign scientists that began descending on Hanoi on Monday, June 20. The elite team included Masato Tashiro, the chief virologist from Japan’s NIID; Angus Nicoll, an epidemiologist who was then head of communicable diseases for the British Health Protection Agency; and Oshitani. Also joining the mission was Nancy Cox, the CDC Atlanta’s influenza chief, who would finally get to make sure that the questionable lab findings
were properly verified.
The mood in Hanoi was eerie. The team members were on edge. There was a sense, Cheng recalled, that something really bad could be happening.
They dropped their belongings at the Melia Hotel in downtown Hanoi and headed around the corner to the WHO office for a briefing with Hans Troedsson and Peter Horby. “They were convinced this was the beginning of a pandemic outbreak,” Cheng said. “Peter told me it was definitely happening. We just didn’t know how bad it was.” There was no doubt that the alert level would be raised. The only question, Horby told Cheng, was whether it would be hiked to level four, which signifies increased human transmission of the virus, or five, which means widespread transmission.
Horby said he had a high degree of confidence in the Vietnamese lab technicians. They were careful, and their results had always turned out to be right. That’s why he was so worried.
Wilina Lim and her assistant were the last to arrive. Oshitani had turned to Lim for help in retesting Vietnam’s worrisome samples. As the head of Hong Kong’s public health laboratories, she had been intimately familiar with H5N1 longer than nearly anyone else in her field, having identified some of the earliest cases in 1997. She had been reluctant at first to join the mission, asking instead that Vietnam ship the samples to Hong Kong, where she could do the analysis in her own lab. But the Vietnamese refused.
Lim had never been to NIHE. She had no idea what equipment they had or whether they knew how to use it properly. Even the slightest miscue could contaminate the samples, making gibberish of the results. Lim wasn’t taking any chances. She and her assistant started preparing everything they’d need to run the tests, and that meant everything. In one large cardboard box, they packed their own pipettes and pipette tips, their own primers, and even containers of water for testing. They packed their PCR machine, called a thermocycler, into another box. They also crammed a suitcase full with gloves, sanitary wipes, paper towels, and other assorted supplies. If the samples could not come out to Hong Kong, then Lim would recreate a miniature version of her own Hong Kong lab right inside NIHE.
While Lim was packing, the other team members were already in Hanoi at work, scrutinizing the lab techniques the Vietnamese had used, evaluating the test results in light of information from the field. The days started early, not long after dawn, and went until evening. The team members compared notes over late dinners, night after night, and then went to bed so they could begin anew. Everyone was stressed.
Lim caught an early morning flight to Hanoi on Thursday, June 23, and by midmorning was on the ground. She and Cox consulted on how best to run the new test and check the Vietnamese findings. Lim was anxious to set up her equipment and get started. But there was no room at NIHE. The institute was busy with its routine work. She had to wait. Finally, at 7:00 P.M., the lab staff cleared out, and Lim and her assistant began testing the first of thirty samples. They continued until midnight, then returned early the next morning, using their PCR machine to amplify genetic material in the samples. By that afternoon, they were seeing a clear pattern emerge.
Several colleagues were waiting anxiously in the WHO office when Lim returned with her findings.
Lim reported that her tests were coming back negative, every last one. There was no trace of genetic material from the virus. The patients sampled in Thai Binh had not been infected after all.
The earlier results had been flawed. The positives had all been false positives. The Vietnamese, it turns out, had been using a set of primers they’d been given by the Canadians, and these were detecting rogue bits of genetic material. The new tests using Lim’s primers had all come back clean.
In the office, the relief was tremendous, the swing of mood extreme.
Nicoll had been studying the field results when the pair reported back that there was no evidence the virus was becoming more infectious. He immediately put aside his papers. “What problem?” he suddenly thought. “It all goes away. It’s like water disappearing into sand. You think you have a cluster and you don’t.”
Horby, hugely comforted, packed up his belongings and left. Twenty minutes later he was bound for a previously scheduled vacation in Britain.
“We dodged a bullet there,” Cox said.
And with that, she and Nicoll decided to go shopping. Nicoll loaded up on souvenirs in the markets of Hanoi’s old city near St. Joseph’s, the city’s neo-Gothic cathedral. Cox bought an ao dai, the traditional, form-fitting Vietnamese gown with a high collar and slits up both sides. A day later, the pair headed north to the haunting waters of Halong Bay, one of Vietnam’s most popular tourist destinations, for a cruise amid its sculpted limestone islets.
When officials from Geneva called Hanoi for an update, they were informed that Cox and Nicoll were on a boat and unavailable.
The scare would remain secret. The world would never be told how close WHO had come to putting it on a war footing. Just about the only hint provided by the agency came one day after the team departed Vietnam. Citing WHO, the French press agency reported that an international team of virologists and epidemiologists had left the country after assessing that the threat posed by the bird flu virus was less than they’d suspected. Few other details were offered. “The most important thing,” Troedsson was quoted as saying, “is that we could rule out that there was an immediate, imminent pandemic.” It was meant to be reassuring. But his comments acknowledged more about the agency’s fears than officials ever had before.
CHAPTER TEN
Let’s Go Save the World
Her maroon minivan had just edged into Friday morning traffic and already Gina Samaan was troubled. The case just didn’t make sense.
Seated in the backseat, Samaan flipped through the file yet again. This much was for sure. A twenty-nine-year-old Indonesian woman from the east side of Jakarta had died two days earlier. She had suffered from acute pneumonia. She had been ill for at least a week. The victim’s doctors suspected it was bird flu, and indeed her samples tested positive for the virus at a government laboratory.
The specimens also came back positive from another, secretive lab run by the U.S. Navy in downtown Jakarta. This was one of three overseas labs established by the navy to specialize in infectious diseases confronting U.S. forces on foreign terrain. Recently it had been forced to lower its public profile in Indonesia because of rising anti-Americanism fueled by the wars in Afghanistan and Iraq. Still, the lab continued to operate, perhaps ironically, right across from the city’s main prison, where Indonesia had jailed some of its most notorious terrorism suspects. The navy facility was more sophisticated than anything the Indonesians could muster, quietly supporting the government’s efforts to contain the spreading bird flu outbreak. If the lab confirmed the victim had died from the virus, it was sure to be so. But that scientific fact by itself revealed precious little about the case at hand.
Samaan’s van inched through the traffic. Outside, another equatorial morning had settled on the Indonesian capital, air so thick and languorous that breathing was a chore, the sky depressingly gray from the smog hugging Java’s swampy coast. Commuter buses muscled through some of the third world’s worst gridlock while motorbikes swarmed like mosquitoes. Though the van’s front and rear windows were emblazoned with the shield of the United Nations, few took notice of the vehicle or the young WHO investigator inside. Even fewer made way.
At twenty-nine, Samaan was the same age as the victim. Dark eyes earnest and intent behind rimless glasses, brown hair tied back with a pink hair band in a practical ponytail, Samaan pursed her lips as she continued to review the case. The local media were reporting that chickens in the victim’s neighborhood had recently fallen sick and died. But Samaan had access to test results on samples collected by the city’s veterinary department. These seemed to show that the local poultry were healthy. “That makes me a bit worried,” she admitted to me in a broad Australian accent. “Is there anything different here?” she wondered. “If so, what’s different?” If the source of infection w
asn’t chickens, could it be another person? If so, it might mean the virus had mutated into a form more easily passed among humans.
That prospect seemed to grow over the following days as this influenza gumshoe followed a trail of clues leading unexpectedly into a neighboring province and then back again. In its own way, the stakes of her investigation were every bit as high as that of the special WHO mission dispatched to Hanoi seven months earlier to verify whether the virus was perilously mutating. Northern Vietnam had been a source of intense anxiety because of flawed test results that appeared to show that the novel strain had broken the pandemic code. But in the months before Samaan set out on this morning in January 2006, more people had died of the disease in Indonesia than anywhere else. And if a global epidemic were to erupt, there was no place more likely for it to start.
Samaan and the Indonesian health ministry had both agreed to let me accompany her on her investigation as long I respected the victim’s medical privacy by keeping her identity confidential. This afforded me an intimate view, not only of the hunt but of the challenges and frustrations epidemiologists face as they try to run this killer to ground.
Samaan wasn’t taking any chances. She had stashed a bag with masks and plastic shoe coverings in the back of the van. In her bulky brown satchel of a handbag, buried beneath a cell phone, digital camera, and BlackBerry, she kept a small bottle of pink antiseptic hand lotion and a cheap thermometer. She had been taking her temperature twice a day since she had arrived in Jakarta eight months earlier, dispatched by WHO from the Australian health ministry. “It’s important to know your baseline,” she explained, adding that hers was a cool 97.5 degrees. She had also carefully considered her footwear, donning simple shoes with covered tops so her feet would be protected against any contamination on the ground. They had flat bottoms so they were less likely to get cruddy with dirt, chicken droppings, and other possible sources of infection. And because she was constantly removing her shoes according to Indonesian etiquette before entering someone’s home, she settled on a pair that was easy to slip on and off, so she didn’t have to bend down near the ground. After each outing, she washed them in the sink and, as a result, was going through a pair every few months.
