by Bobby Akart
“Even a nation with isolated pockets of population centers?” asked Mac.
“Yes. While the rate is significantly lower in the rural parts of Guatemala, for the highly populated areas like Guatemala City, the rate is much higher than 20X.”
Mac shook her head in disbelief. She stared at the number on the whiteboard — 20X. 20X! In highly populated areas, gone unchecked, this disease could wipe out humanity in less than two weeks. Mac wasn’t even sure the rest of the figures were necessary at this point, but she received the numbers from Patterson just the same.
The plague had spread into nearby Honduras and Mexico, in much smaller numbers, but it was early. She was anxious to get started on formulating a final hypothesis on the widespread impact of the plague outbreak when Patterson added one more bit of information.
“Finally, Dr. Hagan, I’m sorry to report that the couple stricken with the plague did not respond to the colistin therapy. They both died this morning.”
“What about their children?”
“They’re both symptomatic. Brown said he will continue the regimen, but he doesn’t have high hopes. I’m sorry.”
It’s antibiotic resistant. God help us.
Chapter 67
Day Twenty-Two
CDC
Atlanta
Mac replayed the words Hunter had used while they were in Guatemala City—we’re in the beginnings of the biggest war known to mankind—not just a run-of-the-mill terrorist attack—Final Jihad. Her thoughts were clouded as she repeated those words and related them to the numbers she’d just received from her team. Creating an epidemic curve, an epi curve, was a necessary element in determining the potential of a given outbreak, but all one had to do was look at the notes on the whiteboard. Folks, the proverbial crap is about to hit the fan!
An epi curve was a graph representing the frequency of new cases over time based on the date of the onset of the disease. There are three types of epi curve graphs.
There are those that involve a common source, or point source, such as contaminated food or an infected food handler. These are used most often because exposures tend to occur in a relatively brief period and all of the cases tend to fall within a single incubation period.
Next, for cases such as cholera, where there is a continuous, common source but the cases don’t all occur within the span of a single incubation period, the downslope of the graph may appear sharp following the initial spike, but then smaller peaks and valleys will appear as the outbreak rejuvenates itself. The ongoing infection resonates from the single common source.
For this outbreak, Mac applied the propagated epidemic curve utilized when there is a progressive index case that then infects a number of other individuals. The difficulty in applying the propagated epi curve is that there were at least three people identified as patient zero in unconnected geographic regions.
Once the index case was identified, the progressive curve would reflect the person-to-person transmission, creating a series of successively larger peaks that were one incubation period apart. The classic pattern resembled a ripple in the ocean that generated a slightly larger wave, followed by a tidal wave, and culminating with a wall of water in the form of a tsunami.
For some outbreaks the descriptive information—person, place, and time—was all that was needed to figure out the source, and control measures could be undertaken rapidly. In other cases, this descriptive information helped generate hypotheses about the source when it wasn’t obvious what the source was.
Under those scenarios, like the case at hand, it was necessary to test the hypotheses by conducting an analytical study—either a case-control study or a cohort study. This required collecting data and analyzing it in order to identify the source. Unfortunately, there wasn’t time for that.
Mac began to plug in the data. This outbreak was a bugger because of the remote locations and the lack of available test results. They were finding the infected after they died. Further, her data didn’t include an increasing number of infected persons who would not be detected by their country’s surveillance systems. Instead of being discovered, many would remain in their homes and communities throughout their illness, further spreading the disease and ultimately dying.
She worked with an incubation period of eight days, which, as they surmised, was double the four days typical for pneumonic plague. This provided her an x-axis, or interval, of two days. The interval would apply to the bottom of the graph.
Next, she began to fill in the left side of the graph, which was labeled number of confirmed cases, or the y-axis. Because of the large number, she calculated the cases in millions. Based upon the 10X spread factor, this took the graph off the charts.
“This is impossible,” Mac muttered to herself. She modified her spread factor but returned to 10X, which was below the Guatemala rate but slightly above the European data. Within ten days, thirty million people would die from the plague. Three weeks from now, two hundred million human beings would die per day.
Based upon identifiable cases, nearly half the planet’s population would be dead by day fifty. Over three billion people—gone. The significant drop in the death and infected count was based upon unidentified persons and the likelihood that social distancing would be utilized as people fled populated areas. The disease would still exist until the spread stopped, perhaps at the sixty-day mark. There was no cure to arrest its propagation to every corner of the earth where human-to-human contact existed.
Mac sat there alone, staring at the monitor, unaware that a figure stood in her doorway, watching as she struggled with the reality that mankind might be in the beginnings of an extinction-level event.
Chapter 68
Day Twenty-Two
CDC
Atlanta
“Dr. Hagan,” Baggett said finally as he lightly knocked on the open door, “may I interrupt?”
“Sure,” said Mac as she spun around in her chair.
“I’ll get right to the point, Doctor,” said Baggett. “I’ve learned that you’ve had several conversations with Director Spielman without my knowledge. I’m going to give you the benefit of the doubt here and assume that those conversations excluded me because I’m not a physician or a scientist. Nonetheless, I am a fast learner and I insist upon staying in the loop regarding your activities. I can’t do my job unless I have all the information. Are we clear?”
Whatever, she thought sarcastically.
“Oh, yes, sir. Absolutely,” said Mac dryly. She contemplated laying the truth on him and seeing if he’d take his pudgy self out the door and head for a bunker in the Appalachians. “He approached me after a briefing and I kept the dialogue open between us. I’ll keep you abreast of our findings.”
Baggett seemed to relax. Mac sensed he was the typical bureaucrat protecting his turf, but she still wasn’t going to give him a break.
“Thank you,” he said and turned to leave. “Say, it’s late. You wanna grab a drink?”
Ugh.
“No, thanks,” she replied with a faint smile. “I need to finish up this epi curve and alert our CEFOs of our findings.”
“May I ask what your findings show?”
Mac decided to hit him with it. “Absolutely.” She tapped on the keyboard and powered up the large monitor in her office. She then mirrored her own computer so that Baggett could see the results.
“Okay,” he started. “What am I looking at here?”
“This is a progressive epidemic curve based solely upon the early results of our investigation. The information was aggregated by region and was used to create our hypotheticals.”
He stared at it for a moment, and then asked, “May I assume the bottom number reflects the number of days since the first cases were discovered?”
“Yes,” Mac replied.
Baggett walked closer to the screen and ran his fingers along the darker shaded areas from left-to-right in an attempt to gauge the death toll. He shrugged and turned to Mac.
“Looks li
ke it gets pretty bad about days thirty to forty-five, but then it tapers off. But still, one hundred to two hundred deaths per day isn’t as bad as I expected.”
Mac stared at him and waited for the punch line. She never thought of Baggett as someone with a sense of humor. After an awkward moment, when he didn’t offer a smile or a chuckle, she realized he was misinterpreting the graph.
“Mr. Baggett, those numbers on the left side of the graph are in millions. By day thirty-five, fifty million people will die per day from this disease.”
He went back to the monitor and studied it again. He traced the upward curve and asked, “This line is in millions?”
“Yes.”
“How many, um, millions would die by day fifty?”
“Three—” Mac delayed the remainder of the answer for effect. It was time that D-Bag took this seriously and quit worrying about saving nickels and dimes. “—billion.”
Chapter 69
Day Twenty-Three
CNN Center
Atlanta
“Okay, Dr. Gupta, we’ll be counting you down now,” said the young producer as they performed the final light and sound checks on the set of Vital Signs, hosted by CNN’s Dr. Sanjay Gupta. The program provided a global perspective to health issues from both a medical and sociological aspect.
As director of the CDC, Dr. Spielman had been a frequent guest on the program. Today’s episode was focused on the recent plague outbreaks and the CDC’s response. As always, it was Dr. Spielman’s goal to reassure the public that the CDC was in control of the situation, whether he believed it or not. This was neither the time nor the place to raise red flags. The person responsible for that job occupied the Oval Office.
A production assistant quickly powdered the guests’ faces to avoid appearing shiny under the bright studio lights, and the stage producer reappeared to begin the countdown. “Okay, gentlemen. And, five, four, three…” The last two counts were expressed with his hands. Dr. Spielman checked his poster and turned his attention to Dr. Gupta.
The viewers’ screens filled with an aerial video of the northwestern part of Guatemala, revealing its beautiful jungles and mountains, separated by rivers flowing toward both Mexico and deeper into Guatemala.
Dr. Gupta began the introduction to this segment. “From above, the northwestern region of Guatemala is a picturesque, unspoiled jungle filled with mountains, rivers, and teeming with natural resources. But below these treetops lie villages filled with dead indigenous Guatemalans from an infectious disease that has reared its ugly head with a vengeance. With me today is Dr. Tom Spielman, the director of the Centers for Disease Control and Prevention, to discuss this horrific outbreak and provide us an update on the CDC’s ability to contain it. Welcome, Dr. Spielman.”
“Thank you for having me.”
Dr. Gupta continued. “Doctor, what we are dealing with here is the plague. Oftentimes, the plague comes from jungle environments like these that our viewers are looking at now. Pathogens living inside of animals, like the spider monkey, somehow get into humans via direct contact. Like Ebola, the plague is scary because it’s a swift, efficient and very bloody killer. In fact, unless treated, nine out of ten people who become infected actually die from this. It can take anywhere between four and eight days for someone to start to get sick after they’ve been exposed. That’s called the incubation period. And during that time, they can travel around the country or even between countries. That’s the concern. But here’s a little bit of good news, and that is, for the most part, during this incubation period, you’re really not contagious. You aren’t going to spread the disease to other people until you’re sick yourself.”
Dr. Spielman shifted nervously in his seat, but not because he was camera-shy. He wanted to be careful in his contribution to the program without leaving a false sense of security.
“This is true in part,” Dr. Spielman said. “This disease is very deadly, and based upon our limited analysis, it has proven to be zoonotic, meaning animal-to-human transfer occurs. But it is highly contagious between humans as well. We have more case studies to conduct, but it’s likely that a human carrier is contagious at least four days before they become symptomatic. That is very different from Ebola and other diseases. But, let me stress, the CDC and our counterparts at the World Health Organization have a significant amount of work to do before we can define the characteristics of this outbreak.”
“How can this disease be spread?”
“Of course, exchange of bodily fluids is one way. But also, based upon the deluge of new cases in Guatemala, it’s clear that the disease is airborne and the plague bacteria can survive on surfaces for up to seventy-two hours. Surface-to-human infection is very likely.”
Dr. Gupta took a sip of his coffee. He lifted it up to the camera. “Let’s use this coffee cup as an example. If I was a carrier of the disease—in that four- to twelve-day contagious period—and touched my hand to my mouth and gripped this handle, the plague bacteria would be present on the cup, correct?”
“Yes, for up to seventy-two hours,” replied Dr. Spielman.
“If my production assistant picks up this cup after our interview, she would also become a carrier.”
Dr. Spielman nodded. “If she didn’t properly wash her hands after touching the cup, then she too would become infected. Keep in mind, the average human touches a foreign surface, like this desk or your coffee cup, just over three times per hour. On top of that, we touch our eyes, nostrils or mouth around four times an hour. Now ask yourselves, how many times a day do you wash your hands? I mean properly, not running cold water over them and wiping them on your jeans. The odds are high that your assistant will become infected under this scenario.”
Dr. Gupta hesitated as if he was contemplating the likelihood of the spread of the plague bacterium. He continued by asking, “Have any cases been reported here in the United States?”
“Not yet, but let me say that we are pretty confident that any large hospital could handle an infected patient with plague-like symptoms. The key is to seek treatment as soon as you think you’ve come into contact with another person, or animal, that appears symptomatic. Do not delay, or the antibiotics may not be effective.”
“Well, if a case of the pneumonic plague were to show up at our doorstep, hospitals using traditional isolation measures with a negative-pressure room as well as traditional droplet and respiratory precautions can assist the patients toward recovery.”
Dr. Spielman leaned forward and looked toward the camera and decided to speak directly to the health care providers who put their lives on the line to save others. “Let me add for those health care professionals who are watching this program, the CDC says a mask, goggles, face shield, a protective gown and gloves can provide all the protection you need for most situations. However, we urge you to take extraordinary precautions if you suspect a patient has been infected with the plague bacterium.”
“Finally,” Dr. Gupta began to conclude the segment, “I should point out that the World Health Organization is now declaring this a public health emergency of international concern. That’s going to have an impact on airline travel and also screenings at airports. They are also advising all the nations where they have cases of pneumonic plague currently to declare a state of emergency.”
Dr. Spielman smiled at the camera, glad that it was over.
“Thank you for discussing this topic at length with us,” said Dr. Gupta, who then turned toward the camera and announced the topic for the next segment. “Next, I will have Dr. Spielman’s counterpart at the Public Health Agency of Canada, who will discuss the new superbug threatening the planet—Candida auris. If you think the plague is bad, wait’ll you learn about a fungus that our next guest calls one of the scariest threats facing our planet. We’ll be right back.”
Chapter 70
Day Twenty-Four
CDC Conference Room
Atlanta
The director of the Office of Public Health Preparedness and R
esponse, the PHPR, called a meeting of his top staff and requested that one senior member of the other departments sit in as well. When Mac heard that he was going to give a briefing on newly reported cases of Candida auris, abbreviated to C. auris, she insisted upon attending.
Dr. Malcolm Braswell, a rear admiral and assistant surgeon general in the United States Public Health Service, was the acting director of the PHPR. In the last ten days, Mac had worked closely with his office as she considered the possible repercussions of the plague spread around the world. If the United States was not prepared to respond quickly and appropriately, outbreaks could escalate into pandemics and the human toll of a terrorist attack could mount, as her epi curve predicted.
“As you know, our state and local health departments play a vital role in responding to potential outbreaks and must stand ready to handle many different types of emergencies,” said Dr. Braswell. “Having people in place who know what to do, and having the resources available to help them do their jobs, will absolutely save lives. That’s part of our job at the CDC. We have an obligation to capture information, analyze data, and formulate the best plan of attack in the war against infectious disease.”
Dr. Braswell reached for the remote control off the conference table and powered on the monitor. “May I introduce you to Candida auris?”
“We now have sixty-one cases of C. auris in six states, primarily New York and New Jersey,” continued Dr. Braswell. “The fungus has been found on the skin and clothing of patients and hospital workers. C. auris has shown its ability to move from one person to another in hospital settings, unlike other invasive yeast infections. The likelihood of outbreaks within medical care facilities is high because the fungus can live on contaminated surfaces such as bedrails, fabrics, and equipment, not to mention on skin.”