Excerpt from the Diary of Dr. Y. Smith

The first reports of a novel rabies virus came out of China in December. It was a handful of cases, all linked to a wet market in the north of the country, and the descriptions of the disease seemed farfetched and designed as clickbait: a mysterious wasting disease, a brain eating virus, uniform fatality. Skeptical, I chalked up the descriptions in the popular press to a combination of hysteria, xenophobia, and greed, and waited for the medical literature to set the record straight.   

The first case series was published shortly thereafter. The authors described five patients, all young and previously healthy, who presented with an unusual constellation of symptoms. The first symptom was always a high fever, often as high as 105F, followed over the next few days by the development of profuse vomiting and diarrhea. This lasted up to a week, and as the gastrointestinal symptoms were resolving, the patients developed a blue-grey rash, starting at the fingers and toes, that gradually moved inward, until the whole body surface had a blue-grey tinge to it. At the same time, the patients lost their ability to taste and smell, then developed headache and neck stiffness, followed by hallucinations, personality changes and somnolence, then finally coma and death.  

All five index patients were autopsied. In each, the brain had become a gelatinous, semi-formed mass, while the membranes surrounding the spinal cord had stiffened to form a protective shell. The authors noted many inflammatory cells infiltrating the muscles and described early fibrosis in the muscle fibers, which they attributed to the inflammatory response. Microscopic examination of the large nerves showed viral inclusion bodies, and subsequent gene sequencing confirmed what was already suspected: a novel rabies virus.  

By that time, more cases were appearing, though the numbers were still low. We didn’t yet know how the virus was transmitted, and with little data to draw from, the prevailing theory held that transmission must be from animal to human, and that human to human transmission was extremely unlikely. The “classic” rabies virus had never been passed between people, and there was nothing yet to suggest that the novel rabies virus could make that leap.   

But cases of NoRaV, as it came to be known, continued to increase. By the time February rolled around, the first case in the US was reported in Seattle, and it became clear that human to human transmission was occurring, though exactly how was still debated. We knew at that point that the virus was present in high amounts in blood and saliva. A research group in Italy isolated it from stool and vomitus. Then Singapore released the results of its exhaustive case tracing efforts, which suggested that contact of any body fluid onto a mucus membrane could lead to infection. Kissing, or sharing a fork, even a particularly forceful cough leading to a saliva spray into an unsuspecting person’s eye, carried danger. And we were learning, painfully, that though the highest risk times of passing on the infection were when a patient was symptomatic, there was an early asymptomatic phase of infection, in which virus could still be transmitted.

It was about this time that the some of the stranger reports from Brazil came to light. NoRaV had gone like wildfire through the slums of Rio de Janeiro. The New York Times reported that people were dying in such numbers that grave diggers couldn’t work fast enough, and cemeteries were running out of space. With hospitals overstretched, and knowing that there was little that medicine could do to help them once infected, people were dying at home in droves. Lacking money for funerals, or even body removal services, families lived alongside their deceased relatives for days. Sometimes they were able to drag the bodies into the street, where they shriveled, rather than bloating, in the sun. Often, crows and wild dogs would eat their fill, piece by piece, before the street cleaners could arrive to remove the bodies, which they did less and less frequently as time went on. Eventually they stopped going into the slums all together. The head of the worker’s union cited risk of infection, inadequate access to protective equipment, lack of hazard pay, and sightings of reanimated corpses as their reasons. The Brazilian government refused to respond to these preposterous accusations, and also had no comment about the hastily constructed wall now surrounding the most affluent parts of the city.  

***

I was on my way back from a medical conference in Chicago when the first reports of something seriously amiss in New York City broke on CNN. The man sitting next to me on the plane was flipping through TV channels, but stopped and grabbed my arm when he came to the news.

“What the hell kind of a story is this?”

I turned back from the window. “Dead woman found alive…” ran the ticker tape headlines at the bottom of the screen. “…First survivor of NoRaV? Full report later tonight…”

I turned my TV to CNN and put my earbuds in. “A morgue worker in Queens reported finding an elderly women alive this afternoon as he was preparing to embalm her,” the news anchor said. “She had been delivered from the hospital five days prior and kept in a refrigerated unit due to a delay in embalming, caused by the recent uptick in local NoRaV deaths. He reports she was confused and did not respond to his questions, but was able to get up off of the table and even tried to follow him out of the room before he called for assistance. She has been transported back to a local hospital for further treatment. We’ll be interviewing the man who found her on our show later tonight.”   

“It’s certainly unusual,” I said cautiously, thinking of the sensationalized reporting that had come out of Brazil. Could it be that there were NoRaV survivors? Or had this woman- and those “reanimated corpses” in Brazil- been misdiagnosed? It seemed too incredible to be true, but I would have said the same about a novel rabies virus causing an international pandemic if it had been suggested four months ago.

“It’s messed up, is what it is,” my seat mate muttered, pulling me back to the present. “Imagine her alive all that time, stuck in a freezer…”. He lapsed into silence as we each contemplated imagined horrors.  

The overhead intercom dinged. “Medical assist at the front of the plane. If you are a physician, please alert your flight attendant.”

“They’re playing my song,” I said apologetically to my neighbor as I hit the assistance light and stood. A flight attendant hurried over.  

“Are you a doctor?” he asked.

“I am.”

“Follow me.”

He hurried down the aisle, talking over his shoulder as he went. “She was fine at the beginning of the flight, but she started to feel nauseous after the meal.” He paused to offer me a pair of gloves and a face shield, both of which I gratefully accepted. “She’s vomited multiple times since then.”

“What do you have in your onboard medical kit?” I asked.

“Not much,” he said. “A blood pressure cuff, stethoscope, some IV fluids and a few basic medications.”

We arrived at the patient’s seat. She was young and thin, and she sat almost doubled over, an emesis bag clutched tightly between both hands. Her brown hair hung limply around her sweat-covered face, and her skin was flushed. Both eyes were closed, her lips clenched into a thin line, as if she were holding off the next bout of vomiting by shear force of will. 

I knelt beside her and gently touched her arm. “I’m Dr. Smith,” I said quietly. “How are you feeling?”

One eye opened and looked at me before shutting quickly again. She shook her head almost imperceptibly.

“Nauseous?”

Another small head movement, this time a nod.

“Do you have any medical problems?”

Head shake.

“Are you taking any medications?”

Headshake.

“Have you been around anyone who has been sick recently?”

She sat still. Her mouth formed an even smaller line, and a tear began to form at the corner of her eye. I waited as seconds crawled by. Slowly, she nodded.

“Your sick contact, do you know what that person had?”

“No.” Her voice was soft but vehement.

“Was it nausea and vomiting like this?”

She nodded, tears coursing down her cheeks.

“It’s ok,” I said as soothingly as I could. Internally, my brain was taking a swan dive into a pool of terror. “There are many things other than NoRaV that cause nausea and vomiting- norovirus, food poisoning, the flu. However, I think we should do the safest thing and keep you separate from the other passengers as much as possible for the rest of the flight. Let’s get you a fresh emesis bag, too.” An open garbage bag appeared beside me, courtesy of the flight attendant, and I gingerly exchanged the filled emesis bag for an empty one. Just in time, too.

I left her dry heaving and stepped away to speak with the flight crew. “She should be isolated from everyone as much as possible for the remainder of the flight,” I told the group. “If you can, radio ahead to the airport let them know the situation. She should be brought by ambulance to the nearest hospital from the tarmac, and anyone with a possible exposure to her body fluids will need to be quarantined.” 

“Is it NoRaV?,” one of the attendants asked quietly.  

“I don’t know,” I said slowly. “The safest thing to do is to treat it as if it is, and be pleasantly surprised when it’s not.”

There were silent head nods and some muffled sniffles.  

“I can’t believe I switched with Julia to be on this flight,” one of the attendants muttered angrily. Another started crying noisily into her hands.

The remainder of the flight was interminable. I sat across from the vomiting patient, monitoring her heart rate and skin turgor, and encouraging her to drink sips of orange juice and water as she often as she could. In between these ministrations, I scanned my gloved hands, my clothing, any exposed skin for evidence of body fluid exposure. Too terrified to contemplate my own mortality, I let the practical part of my brain take over. I’d have to quarantine, too, of course. It was too late to call tonight, but tomorrow I would have to cancel all of my clinics for the next week at least. I had a grant application due on Tuesday, and now I had much more time than expected to work on it. Once that was submitted, I could…my conscious mind refused to speculate further. I knew what should to be done. Make a will. Make funeral arrangements. Pick out a plot and headstone. Assign an executor. But maybe this woman has something else? And maybe these protections are enough? I can’t have gotten the virus, it can’t be possible, it cannot be!

***

Myself and the exposed flight crew and passengers were taken from the airport to a Best Western on the edge of town to quarantine, driven there by a featureless human swathed in a full body suit, with a face mask and eye protection. He kindly showed us to our individual rooms, and took note of food allergies and other dietary restrictions.  

“You’ll get three meals and a temperature check every day,” he said. “If you feel sick, call the front desk. Please do not leave your room. Otherwise, I’ll see you in two weeks.”  

Time had never moved so slowly. In between editing my grant application, I watched the same string of NoRaV news stories and scoured the internet for evidence of NoRaV survivors. It was scant. CNN had done a follow up story on the woman from New York, but simply said that she remained in critical condition, and the hospital that had initially pronounced her dead was looking in to the matter.

On the third day of quarantine, there was a commotion in the room next door. One of the flight attendants had been placed there.  

“I feel fine!” I heard him insist. “The thermometer must be wrong. Take my temperature again.”

There was a pause, then a quiet beeping. “You have a fever of 102F, sir. You need to be taken to the hospital.”

“No, that must be wrong. That thermometer must be broken!” There were scuffling sounds and more shouts of “But I feel fine,” though these grew softer as my neighbor was marched down the hall.   

There were a few minutes of silence, then a tentative knock through the wall on the opposite side of the room. I crossed to the spot. “I”m here.”

“Do you know what that was about?” It was the crying flight attendant. Her voice held a quaver in it now.

“He’s going to the hospital. He’s got a fever,” I said.

“Oh my god, he got it,” she whispered. She started crying. “We’ve all got it, we’re all going to die!” 

“We don’t know that,” I started to say, but she interrupted me.

“I do, I know I’ve got it, I can feel it!” She was sobbing uncontrollably.

I was feeling shaken, too, but I couldn’t bear to listen to her cry any more and I was too emotionally exhausted to try to reassure her. Anything I said would be empty words, anyway. I’d woken up that morning with some mild muscle aches. I told myself I’d slept funny, that I just needed to stretch, but the aches persisted, and I was starting to get that shivery, taut sensation over my skin that usually comes just before a fever.

I went into the bathroom and ran the water at full volume to mask the sounds of my sobbing neighbor, then sat on the floor, scrolling through the New York Times on my phone. The top headline, a breaking news story, jumped off the page: More Survivors Discovered! Just that morning, an NYC morgue worker had opened one of the overflow refrigerated morgue trucks to find that all thirty inhabitants were moving around in their body bags. Scraping sounds in the neighboring truck had lead him to open it as well. Not only did all of the body bags have signs of life inside them, but one of the patients had managed to escape his bag, and had scratched at the inside of the truck door until his fingernails were gone. Once the door of the truck was open, he walked blindly forward, falling three feet onto his face and breaking his nose. But he didn’t appear to notice, picking himself up and walking wordlessly down the street as the astonished morgue worker stared after him. All of the newly discovered patients were obtunded, incoherent, endlessly moving but seemingly without purpose.  

Could it be? There are known species of fungus that infect the brains of ants and turn them into so-called zombies, focused solely on propagation of the parasite. Why couldn’t a virus evolve to do the same thing? 

I turned off the tap and sat in silence. I needed to think, to plan, to decide. I won't allow myself to become a vector of infection, but I don't know if I have the courage to do what's necessary.