an unknown virus creates panic in New York City can't bre the outbreak strikes without warning threatening 20 million lives all right sir calm down scientists have never seen anything like it the deadly virus resists every effort to treat it as the disease spreads beyond the city to neighboring states Health officials fight to protect the entire country from a new and fatal disease [Music] some of the names in this program have been changed in the summer of 1999 a mysterious vir first appeared in Queens New York a bustling Community just a few miles from the concrete and skyscrapers of [Music] Manhattan on August 12th paramedics arrived at Flushing Hospital Medical Center with a 60-year-old man Bill Turner was dehydrated and had a high fever he was barely conscious Turner had taken a few days off from work because he felt like he had the flu now he was too weak to move Turner's wife Lily was frantic emergency physicians had no way of knowing they were dealing with a virus that had never been seen in the Western Hemisphere let's go ahead and give him a 500 CC bis normal sailing and uh let's get those antibiotics running let's go draw some blood cultures as well doctors ordered IV fluids to stabilize Turner and counter his dehydration based on the symptoms the attending physician thought it looked like a case of pneumonia he reassured Lily Turner with fluids rest and antibiotic treatment he anticipated a quick recovery but within hours Turner became disoriented he was gasping for breath he didn't recognize his own wife nurse Turner became agitated he had to be transferred to the Intensive Care Unit in the ICU Bill Turner developed a frightening new symptom pretty good but he could no longer move his arms or legs and take Lily Turner tried to remain calm as doctors explained her husband's worsening condition with Bill's muscle weakness and his disorientation they believed an infection was causing the dangerous swelling in his brain the director of infectious diseases Dr Deborah asnes was paged by the ER she was alarmed by Turner's rapid decline I was concerned that someone that's 60 years old who's highly functioning individual goes to work and uh is very active could be so debilitated without uh a good answer well the initial lab test look okay just xray is clear really not really sure Dr asnes thought Turner might have incilius and inflammation of the brain yeah to find the cause of the inflammation doctors performed a spinal tap when looking for problems that affect the brain spinal fluid is an important diagnostic tool Turner spinal fluid contained unusually high levels of protein and white blood cells evidence that he had contracted a viral infection doctors were now certain Bill Turner had viral inph itis there was nothing they could do to fight the virus they could only fight the symptoms asnis prescribed steroids to reduce the swelling in his brain and hoped his body would fight off the infection but one of his symptoms didn't make sense I was concerned because I had not seen such severe muscle weakness with uh in sephtis Bill Turner now needed a respirator to breathe in her many years of practice asnes had never seen anything like it no one [Music] had a page pulled her back to the ER days after the first case Herold Marsh of Queens had suffered a massive heart attack he was revived at the scene by paramedics now his temperature was high covering at 105° fevers this high are a dangerous and uncommon symptom in a heart attack patient there was more to the case than heart disease alone DRS hi the lab results on Herold Marsh were surprising in addition to the heart attack he had somehow contracted viral incilius two incilius patients in the same week worried Dr asnis all right thank you 6 days later paramedics rushed Marcus ham into the emergency room Hammond showed the same muscle weakness and high fever as the other two patients his fever Tremors were so severe the entire bed was shaking the third patient eventually needed to be put on a respirator and uh develop severe muscle weakness as well um but before he came to the hospital he was very active person at home um and this came on very suddenly within a 24-hour period And I was concerned in an average year Flushing Hospital treats only two incilius cases now Dr asnis had seen three three cases inside of one week and I thought that this was too unusual to have you know this cluster like this in the Intensive Care Unit so I did think at that point that there was something going on observing Hospital protocol she notified the New York City Health Department's up at the Department's Manhattan offices Dr Annie fine was both skeptical and concerned both of us thought well I guess it could be an um some kind of cluster of En sephtis cases but that's pretty unusual and we both were somewhat skeptical but openminded because viral infections can be highly contagious Dr Fine wondered if the patients could have passed the disease to each other ladies we could to try and find out whether that was a possibility fine and a colleague met with Dr asnis they obtained exhaustive family histories doctors asked a series of questions dealing with the patient's habits diet and daily routine we really racked our brains to think of any way that these people could have been together or had uh people in common with them that could have passed an infection from one person to another no one who had come in contact with the patients was sick apparently the virus was not passed from person to person feeling nauseated Dr as just tried to reassure the families but there was little more she could tell [Music] them the doctors were dealing with something they'd never seen before the difficulty in these cases was that it was hard to tell the family what was causing the disease in their family member I mean we knew that there was in sephtis but the actual agent of what was causing the en sephtis we had no idea to determine how far the disease had spread they contacted area hospitals family health networks they found that three other patients in the Queen's area were being treated for the same symptoms our level of concern by the end of the day was much much higher than it had been at the beginning of the day I think both having additional cases and also having found that we we felt these cases really had certain very striking similarities really increased our level of concern that we had in uh some kind of cluster or Outbreak on our hands that night Health officials sent an alert to the medical community Dr Fine instructed area hospitals to report all cases of En sephtis to the Department of Health normally in New York City we do hear about cases of incilius they get reported to the health department but prior to 1999 the number of cases reported per year in the city was 8 to 12 in a city of 8 million people and here we were in a small community in Northern Queens with possibly six cases at the same time so you can see that that would be something really rather dramatic all of the patients lived in a small neighborhood in Queens for health officials this was more evidence that they were dealing with an unusual cluster investigators from the New York Department of Health Trav Trav to Northern Queens to search for [Music] Clues Dr Dennis Nash an epidemic intelligence officer with the Centers for Disease Control and prevention is assigned to New York City he specializes in tracking diseases to their Source we were actively looking for environmental things things around their home or things about their neighborhoods neighborhood factors that could have resulted in some common exposure causing their illness because we did know that the patients lived um you know within a few square miles of one another typically viral outbreaks thrive in overcrowded Urban neighborhoods but less than 10 miles from Manhattan the neighborhood in Northern Queens was like a different world it seemed like it would be a more urban but in fact it seemed almost Suburban in some areas where these cases live there were lots of trees and single homes and Lawns and and yards and and pools and and this was um not at all what what I had expected investigators visited the home of Harold Marsh he was one of the first patients infected they needed to talk to his wife Paula about her husband's daily routine Paula mentioned that Harold spent a lot of time in the backyard especially when he couldn't sleep ma'am there investigators found several buckets of stagnant water Paula explained that her husband collected rainwater to use in the garden in one of the buckets Nash spotted mosquito larve mosquitoes can act as vectors or carriers of viral disease [Music] he took several samples for testing must be a lot of mosquitoes out here some of the patients provided another possible clue to the source they told investigators that they often took walks along the East River Nash and his colleague drove to the area there the investigators found several tools of stagnant water ideal breeding grounds for disease carrying mosquitoes water samples revealed hundreds of writhing mosquito larae these insects deliver more illness than any other living thing every year nearly 3 million people die of mosquito born diseases okay we were very concerned that we were dealing with a possible mosquito born viral en sephtis outbreak scientist at the New York State Health Department examined the larae there are 25,000 species of mosquitoes they had to find out which one they were dealing with the lab's findings read like a worst case scenario they suspected their culprit was the clex mosquito the most common mosquito in the world highly mobile and with a lifespan of several days every street in America has thousands of them although scientists were able to determine that clex mosquitos were breeding in the neighborhood they could not tell whether the insects were carrying a [Music] virus as doctors struggled for answers the outbreak took a terrifying turn on September 1st 1999 the mysterious virus claimed its first victim Harold Marsh was the second in sephtis case admitted to Flushing Hospital despite the medical team's efforts to save him Marsh had grown weaker each day with no hope of recovery he was taken off life support at aut opsy the medical examiner took tissue and blood samples from Marsha's body the samples were sent to the Centers for Disease Control and [Music] prevention at the CDC the patient's blood serum was mixed with a reagent and viewed under a microscope although the tests were not conclusive all indications pointed to St Louis and sephtis an infection spread exclusively by MOS then a few miles from Queens a vital clue in the investigation appeared workers at the Bronx Zoo discovered dead crows the birds were taken to Veterinary pathologist Dr Tracy mcnamer at the zoo's lab here I am at the zoo dealing with entic crows and anotic zoob birds and I was like wo I wonder if there could potentially be a link between what's going on in the bird kingdom and what's going on in the patients if the deaths were linked she reasoned the human outbreak could not be St Louis and sephtis according to everything that had ever been published birds are part of a cycle where they may be able to infect mosquitoes but generally these viruses don't kill the birds they don't cause disease in the birds okay working on Dr mcnamer was alarmed by the wave of bird deaths she knew that crows have strong immune systems they are normally resistant to [Music] disease to find out why these birds died she launched her own investigation mamera found dark patches and hemorrhaging at the back of the Crow's skulls which are signs of viral [Music] intis she prepared tissue samples from the birds mamera sent them to the Centers for Disease Control and prevention in order to link the birds with the human in sephtis cases Health officials would need the resources of a sophisticated lab I was certain this was a viral problem and I knew it wasn't something I had seen in all my years of experience it was pretty scary at the CDC the samples went to the head of the diagnostic laboratory Dr Robert lanciotti with this unusual finding he decided to test the bird samples and the blood samples from the human victims we were assuming that this was St Louis and sephtis so we did a variety of tests looking for uh four or five different viruses at the same time and the result we got was very unusual we found that the uh the virus did not react with any of our St Louis um tests at [Music] all lanciotti entered his test results into an internet database the search compared the genetic code of the mystery virus to every known virus in the world within seconds he had a match I was shocked in fact I repeated the search over and over again thinking that maybe this was some kind of computer error because it was the most shocking thing that I could have imagined [Music] Dr lanciotti needed to get the word out fast the virus was being passed by infected Birds to mosquitoes which were then passing it on to humans and birds could spread the disease much faster and much farther than mosquitoes alone lanciotti realized millions of people could be at risk of Contracting West Nile Virus in the late summer of 1999 9 the Centers for Disease Control and prevention had identified the strange new mosquito born virus in New York as the West Nile Virus mosquitoes usually transmit viruses by feeding on an infected host such as a bird or a rodent when they bite humans they spread the disease days after the virus first appeared another Resident of Queens was rushed to the emergency room doctor suspected Todd Connelly was also suffering from swelling in his brain he struggled violently as doctors and nurses tried to restrain him Delirious he didn't know where he was based on the symptoms they suspected West Nile could be causing the [Music] infection West is endemic to Africa Eastern Europe parts of Asia and the Middle East somehow the virus made its way across the ocean and into New York City there's really three possibilities that most people consider for how West Nile Virus got into the United States uh either on an infected bird an infected human or somehow an infected mosquito got into this country all three of those theories have been have been looked at in in the best way that we can and to my knowledge there has not been a clear um a clear theory that is that has been proven there's there's just speculation we really don't know some had White Stone Health officials didn't know how the virus got here but they knew it could have devastating effects to stop the deadly virus they had to try to find a way to destroy the mosquitoes we need radio first they contacted the officer of Mayor Rudolph Giuliani they informed him there was an outbreak of West Nile Virus with new cases appearing daily there was no time to waste the mayor's office scheduled a press conference so I uh rode out to the press conference with the health commissioner um very quickly with lights and Sirens met the mayor out there met um officials from the office of emergency management and other City officials so everybody was kind of gathering at this point mayor Giuliani warned citizens about the outbreak he tried to reassure the public you know obviously it's easy to say to people don't panic they shouldn't uh we'll do everything that we can to try to wipe out the mosquito population deal with and treat the people who maybe uh may be bitten and may be affected by it the mayor went on to say that the city would spray for mosquitoes in the affected areas they would begin spraying within 24 hours after the press conference fine met one-on-one with citizens who were concerned about the mosquitoes any F questions for you as a doctor she was worried about the grave implications of this new and deadly virus all to a public health practitioner or a physician that's a very very major finding to find a virus in an entirely new continent where it has never been present before um it's it's a it's a an enormous Discovery and it's a very worrisome Discovery because you don't know exactly how that virus is going to behave there West Nile Virus was a new disease in a city that had no way to fight it there hadn't been an outbreak due to a mosquito born virus in a very long time we didn't have a mosquito control program in place we have a very very large and uh City and a very dense population so there was no telling how many cases really this could cause and as I mentioned it could be very severe so we were very concerned very worried officials launched the largest mosquito eradication effort in the history of New York City aial Spring took place late even evening and early morning hours when the insects are most active workers sprayed pesticides throughout the city to kill adult mosquitoes they also targeted breeding grounds to stop the insects from reproducing once infected a female mosquito can pass the virus to hundreds of her Offspring ground Crews spread pesticides to kill mosquito eggs and larae in the air helicopters took surveys of standing water throughout New York health workers went door too warning residents to get rid of standing water they were also advised to stay inside after dark when mosquitoes are most active and if they had to venture out to use insect repellent and wear long sleeves and [Music] pants the health department set up a 24-hour hotline where concerned citizens could turn for answers calls flooded in many callers had questions about pesticides and mosquito control hundreds of New Yorkers call to report finding dead crows in their yards Dr Fine suspected the dead crows were an ominous sign I was worried about it because I thought this outbreak is actually much bigger than what we were thinking in late September the virus crossed state lines in Greenwich Connecticut a dead crow was found near a golf course oh yeah that's pretty good shape the bird was delivered to the Connecticut agricultural experiment station he say when died Dr Theodore andreadis contacted a Veterinary pathologist to examine the bird and determine the cause of death andreadis instructed his team to set up mosquito traps where the dead bird was [Music] found there was a great potential for a human outbreak to occur here in Connecticut as well so was very important for us to get out and uh test mosquitoes to find out how significant a threat it was and uh to examine this uh Crow mortality to see if we could tie the two together before scientists could begin testing the mosquitoes for viruses they had to identify them by species Connecticut has more than 40 different types of mosquitoes and not all of them feed on humans certain mosquitoes will feed only on on birds some will feed on amphibians and others will feed on mammals if we find the virus and a human biting mosquito then we know we have a significant threat and some Public Health measures have to be put into place after the mosquitoes were sorted scientists tested them for viruses the painstaking process would tell them if any of the insects were carrying some type of virus the same temples were placed in vials of liquid and agitated to break up the mosquito's [Music] Mass scientists then extracted the fluid and incubated it for several days if a virus was present the liquid would appear cloudy let's take a close look at this one in this case there was no doubt about the results [Music] under the microscope scientists confirmed the viral cultures showed evidence of growth technicians at the CDC determined that the mosquitoes were carrying West Nile Virus Kelly how we with the news that West Nile was now in Connecticut Dr andreades shared the Public's concern how many we have finished now I think it's the general fear that you know you could you're out and enjoying yourself and all of a sudden you could get bitten by a mosquito was tiny little mosquito that could be carrying a deadly virus by November of 1999 cold weather had come to the Northeast and the active mosquito populations in New York and Connecticut died off but under the snow millions of eggs were lying in wait only time would tell if the virus would Sur survive the winter freeze to claim more victims in the warmth of the coming summer in the summer of 1999 New York City was gripped by a deadly outbreak 62 patients had been hospitalized seven of them died in addition nearly 15,000 Birds most of them crows died from the infection a winter freeze killed the mosquitoes and appeared to have stopped the virus from spreading but West Nile had [Music] survived as the summer of 2000 approached Health officials were worried the mosquito population was beginning to emerge along with the West Nile Virus [Music] the disease spread throughout the Northeast it claimed victims as far south as North Carolina and as far west as [Music] Pennsylvania elderly patients were most at risk as well as patients with weakened immune systems as the summer of 2000 war on the death toll climbed the virus showed no signs of stopping over the next 2 years West Nile had spread to nearly 30 States Louisiana was hit hardest warm temperatures and abundant waterways made it the ideal breeding ground for disease carrying mosquitoes in Baton Rouge Judy Simmons's mother was the first victim of West Nile virus it's a very bad way to die Judy Simmons was with her mother during the final moments I called both of my children I didn't tell my grown children that their grandmother was dying I just said you need to tell you know your grandmother that you love her and you'll talk to her sooning and then she died 80 people were infected in Louisiana the governor called a state of emergency on oxygen feeding tube she couldn't eat it's horrible Louisiana has spent millions of dollars to track the outbreak and get rid of the mosquitoes but no amount of sprain can wipe out the mosquito population according to Randy bth a biologist with the East Baton Rouge Parish mosquito [Music] control you're not going to be able to completely control the mosquito populations you can uh educate people to where they are not going to be exposed to the mosquitoes carrying it and you can reduce those popul ations down significantly but you're still going to have some mosquitoes and you're going to have some humans bitten Health officials were fighting a losing battle 2 years into the outbreak birds and mosquitoes had spread the West Nile Virus further south and west by Midsummer 2002 the West Nile Virus had infected hundreds of new victims and claimed dozens of lives still Health officials warned that the disease was only Midway through its peak [Music] season so far the virus had attacked the weak and the elderly but that was all about to change in late August of 2002 36-year-old Tracy Hollis drove to Peoria from her house in the Illinois Countryside Tracy worked on the housekeeping in staff at St Francis Medical [Music] Center as the mother of four children Tracy LED an active and busy life but for the past few days she suffered from headaches and fatigue trac's mother Janet Ferris was concerned she said that she just didn't feel right she didn't know what it was she was having slight buzziness but the dizziness was getting worse by the minute as she headed inside her legs gave out she managed to pick herself up and she went a little further hanging on to cars and stop signs and and things like that and she claps a second time Tracy couldn't understand what was happening to her her legs felt shaky hi can I help you she made her way to the hospital's emergency room Teresa can you grab that wheelchair please what's going on today Nurses in the ER took Tracy to an exam room and paged the Emergency Physician here you go Dr Paul Matthews examined Tracy that morning Tracy had symptoms consistent with a flu like illness she had uh fever headache body AES some generalized fatigue and weakness and she also had some cramping in her lower legs although Tracy was weak and disoriented she was able to communicate her symptoms to the doctor she also had a fever of 14.5 she had a headache she had a stiff neck and she also had some weakness in her legs in fact she had trouble walking and trouble maintaining her balance when I do that Dr Matthews believed Tracy's symptoms were consistent with en sephtis and menitis and inflammation of the lining around the brain show me where the West Nile Virus can cause these conditions my fing but West Nile doesn't usually strike someone so young and Tracy had developed a very troubling symptom she was suffering with severe paralysis her poolik symptoms had never previously been associated with West Nile Virus doctors were not certain of a diagnosis they feared that if the paralysis intensified Tracy might not [Music] survive doctors in Peoria Illinois frantically looked for answers to diagnose the illness that threatened the life of 36-year-old Tracy Hollis they believed she had West Nile Virus but were waiting for test results to confirm her severe paralysis puzzled doctors they had never seen anything like [Music] it Dr Matthews ordered a battery of additional tests including a spinal tap and MRI or magnetic resonance imaging they hoped the MRI would allow them to better see the cause of her debilitating paralysis using radio waves the machine performs a scan of the brain it allows doctors to see a two-dimensional model of the tissue in the brain and detect swelling blood flow and any abnormal growth [Music] the test confirmed the swelling in Tracy's brain she had menitis but that didn't identify the source of her paralysis Dr David slagel chief of infectious disease at the hospital was called in to consult on Tracy's case he suspected her fever and the menitis were caused by the West Nile Virus Dr slagel spoke with Tracy's family red theal he told them they weren't certain what was causing the extensive paralysis Tracy's mother was scared Tracy has always been a very healthy young woman she's never been Hospital italized for anything hardly ever has the flu uh I knew that when her legs would not work it had to be something serious of course I was thinking the worst I did not know what it was I was thinking um you know uh multiple sclerosis or maybe a stroke something to that effect samples of Tracy's spinal fluid were shipped to the state lab for testing the lab test would take several [Music] days Dr slagel kept a close watch on Tracy he wanted to make sure she didn't have any other complications as a result of her illness several days later Tracy's test came back doctors now had confirmation Tracy had West Nile Virus but the cause of her paralysis was still a mystery the unusual feature of Tracy's infection was the weakness in her legs the fact that she is younger than most of the patients we see with symptomatic West Nile Virus Infection was also concerning Tracy's family stayed by her side [Music] there was little the staff could do for her Beyond supporting her with intravenous fluids and nutrition she was in and out of sleep uh she drift in and out uh she didn't say much she was very quiet I was very frightened Trac over the following week her family became hopeful that Tracy's life was no longer in danger [Music] Tracy's body began to win the battle against West Nile her fever dropped and the swelling in her brain tissue subsided but partial paralysis in her legs remained the virus had attacked the nerves in her spinal column leaving extensive damage two agonizing weeks after her illness first started Tracy was finally well enough to go home but the question of her paralysis remained unsettled we couldn't tell her how quickly it would get better we couldn't tell her uh to what extent she might have some residual leg weakness after the infection was resolved these are uncertainties uh in regards to an infection that's new in this country that we simply can't tell at this point in time what the ultimate prognosis for many patients will be when Tracy came home from the hospital she needed help from her mother and the rest of her family everyday chores were difficult I'm just not the same person as I was before this happened I I move a lot slower and it takes me about five minutes to go down my steps just because I take one step and rest and take another and rest again and there's pain in my leg after I'm done walking that far so I have to sit down and rest over several months Tracy has worked hard to regain her Mobility her mother has watched the toll the illness has taken on Tracy and her family Tracy she was very active with her children before this happened uh any night of the week you would see her out walking with her children or having them over to the local park playing with them uh they camped a lot but uh she's unable to do these things anymore and uh the children miss that part of their life I'm sure of it throughout her ordeal Tracy has tried to remain positive when something like this happens you have to you sit back and you think of all the things you do have instead of always think about the things you don't have and you tend to appreciate the tiny things like just walking outside in in the fresh air I mean I almost had that taken away it's pretty scary in addition to the of her family Physical Therapy has played a key role in her Rehabilitation any pain on that side cting the therapy wears me out because it's working the leg muscles and my leg just isn't the same as it was before this happened the doctors um believe that I will have 100% usage of my leg but it's just going to take a lot of work and time on my part i' like to be out walking with my children a year from now and doing the same thing I was doing before this happened as Tracy Works to regain her life one step at a time the West Nile Virus races on the news that West Nile can cause paralysis is a terrifying development doctors struggle to understand this disease as it evolves there seems to be little they can do to stop it by the end of the summer of 2002 it was on the move again spread by mosquitoes West Nile Virus first appeared in the United States in a small community in Queens New York in the summer of 1999 within 3 years every state east of the Rockies was battling the deadly [Music] virus West Nile moved like wildfire across the country by the end of the summer of 2002 West Nile reached [Music] California experts believe that in time the virus will reach every state in the US and eventually spread throughout the Western Hemisphere its effects will be far-reaching according to the cdc's Dr Robert lanciotti West Nile Virus has drastically changed the public health uh infrastructure in this country and I've I've seen incredible changes prior to 1999 9 there were only a limited number of of State Public Health Labs that had U extensive testing for mosquito and tickborne viruses the CDC has mounted an enormous effort to diagnose and combat the disease early detection is important and since 1999 State Health Labs have been trained by the CDC to increase their testing of infectious disease they're able to test for West Nile so they don't have to wait for samples to be collected and shipped to us to to do their testing they can test right in their own jurisdiction and learn very early on if there's West Nile but scientists can't test everyone coming into the [Music] country every day thousands of airplanes carry hundreds of thousands of passengers in and out of the United States making it easier to transport disease we need to be really on the lookout and alert for new diseases unexpected diseases things that happen in one place that may not have happened or even been reported in another place like for example bird deaths West Nile has affected over 100 species of birds the future of many more remains uncertain those species that are currently threatened like the bald eagle are most at risk we don't know what impact it'll have on bird populations perhaps over time uh birds will build up some immunity and we won't see these large diars but I think in the short term we're going to see this continue this westnile virus is permanently established here in the United States it's going to persist it won't go away migrating birds will continue to spread the virus No One Is Safe from the bite of an infected mosquito mosquitoes will will never successfully be eradicated there are millions in every backyard in America for now there is no cure or vaccine to fight the disease the best defense is precaution and prevention against the mosquitoes that carry West Nile across the country states are working to control the mosquito populations to keep residents safe we will always have a risk of of an outbreak uh we will always have a risk that this virus could cause an outbreak especially in urban areas since it first appeared in 1999 there have been nearly 4,000 cases of westnile virus reported in the United States and over 200 fatalities scientists are working to develop a vaccine in the next 3 years until then Health officials can only hope to limit the disease's reach and to wait and see what next summer will [Music] bring it starts in America's Heartland a strange and lethal disease that attacks women hospitals struggle to treat the victims as a regional outbreak turns into a national epidemic the crisis grows as the death toll Rises Public Health officials must raise to solve the mystery to track the source of this deadly infection before it can kill [Music] [Music] again some some of the names in this program have been changed December 1979 a cross town bus in Madison Wisconsin a young woman by all appearances in perfect health until her collapse was sudden and terrifying unconscious barely breathing the young woman lay sprawled out in the aisle this2 of pass ambulance right away where the corner 4 responding within minutes paramedics rush to the scene [Music] to you all and what they found concerned them the young woman had a high fever her pulse was weak and her blood pressure was dropping rapidly fortunately the University of Wisconsin Medical Center was only moments Away by the time they reached the emergency room she was going into to shock the ER staff would have to work [Music] fast ready good all right let's start getting [Music] vital they had no clues to work with only a driver's license with her name Emily Murray and her age just 18 years old meanwhile her blood pressure was continuing to plummet and an odd pink rash had appeared on her face and hands as the ER team fought to stabilize her throat and blood cultures as well as blood samples were sent off to the lab I see you the cultures would take 24 hours to grow Emily was moved to the Intensive Care Unit where she was placed on kidney dialysis and her Vital Signs could be closely monitored she seemed to stabilize and then her case took a strange turn the mysterious rash became more pronounced it now covered her entire body I know she hadn't had an ex urologist doctor Russell chzn was called in his first priority to bring her out of shock to figure out what was going on I knew that I'd never seen anybody look quite like this she had this rash this sunburn rash and it was spreading Len I it was something that was affecting all of organs she had bad lungs she had um shock she had profound diarrhea she had kidney failure the sudden onset of Emily's symptoms and the bizarre red rash made Dr chzn suspect she had contracted a severe infection there was no time to wait for lab results he had to act immediately and aggressively do you know where you are so we treated her with a very broad spectrum of antibiotics kind of a shotgun approach if you will and we wanted to make sure that if this were an infection that we were preventing it from spreading and that we were preventing the organisms for persisting the doctors called in Emily's distraught parents trying to find any possible clue to what had made her so sick know what we're doing the parents really indicated that she hadn't been exposed to anything there was nobody else in the family sick she had some siblings and they were perfectly well and the parents were perfectly well nobody was sick at home nobody was sick at school that's examining Emily's chest x-rays Dr chzn tried to understand what had happened her cardiac silhouette is not that full it's narrow like we would see with shock and I she certainly doesn't have congested part Fay or anything there no curly bee lines what he saw was perplexing it didn't make any sense the thing that was confusing to us in looking at her chest it was clear she didn't have pneumonia and she also didn't have a collapse of her lungs or anything like that what she actually had was she had uh Hemorrhage from the lung Emily's lungs were bleeding it was hard for her to breathe Dr chzn recognized this was a dangerous and potentially deadly complication but chzn had no idea what the cause was the more he learned about her case the more baffled he became her symptoms seemed random disconnected it was The Nightmare of any parent that morning their daughter had left the house house a healthy teenager now she was hooked up to IV lines and monitors luckily IV fluids and dialysis eventually began to help Emily's blood pressure started to rise to a safer level and it stayed there for an hour or two and I felt comfortable in going home and trying to find out more about this with the patient finally stable chzn could concentrate on the diagnosis he sought a second opinion from his wife is this the teenager that Dr Joan chzn is the head of the Infectious Disease division at the University of Wisconsin school of medicine I mean what is it that the patient high fever diarrhea and dehydration were all classic symptoms of an infection but she has a lot of other extra features that just don't make sense like what well one of the things she has is a rash that is spreading like crazy total body rash angry looking I really can't figure what's going on to Dr Joan chzn the symptoms sounded familiar let me let me ask you just one question does she have bright red eyes a red rash and red eyes it reminded Joan of a journal article she had recently seen by a doctor in Colorado it just came on article outlined a new syndrome called toxic shock characterized by shock a rash and multi-organ disease the illness was linked to a toxin produced by the bacteria stafilic cacus orius the disease was named toxic shock syndrome in extreme cases it could be fatal the next morning Joan chzn came in to examine Emily Murray in her 11 years studying infectious diseases she had never seen anything like it blood vessels became inflamed when the bacteria released its toxins causing a rash that covered Emily's entire body even her Palms in the journal article the staff orus bacteria was described as infecting the patient bodies through an open wound but Emily did not have any Cuts or wounds for the bacteria to infect so where had it come from my biggest question was um is this toxic shock syndrome as he described it but I was very skeptical about the staff warus particularly because she didn't have any infection site Emily did have many of the same symptoms she even developed small hemorrhages in her eyes chzn was determined to unravel this medical mystery other bacterial infections that can cause shock and multi-stem disease but they they don't generally cause the rash or the red eyes so it was one of those things that you just had a sick sense that there was something not right about this Emily fit the description of toxic shock syndrome but not completely really really sick and it's veryl Joan chzn wondered if they were seeing the birth of a new and terrifying disease you have to make yourself keep an open mind to the fact that it might be a new virus it might be a new bacteria we were wondering if it could have been some kind of chemical reaction that she'd maybe absorbed a chemical through her skin or um taking a drug that nobody knew about then just hours later a second case appeared 19-year-old Kaylee Wilson was rushed to the University of Wisconsin Medical Center like Emily she arrived in the ER with a raging fever extremely low blood pressure and a barar red rash the ER staff pumped her with fluids desperately trying to raise her blood pressure Kay's mother was frantic the girl was fighting for her life Joan chzn was immediately notified we see patients all the time who have very unusual presentations of some disease um but there's only one of them and we don't we often don't don't figure out what it is no matter how hard we try but here we had two great less than 24 hours apart um those of whom were very sick the similarity between the two cases was uncanny Jan's experience with infectious diseases told her this couldn't be a coincidence fluid she recommended supportive treatment massive amounts of IV fluid and a broad spectrum of antibiotics soon after Kaye was admitted Joan learned that a third case of the mysterious illness was being treated at a hospital just across town this was no random event this was the beginning of something widespread something far-reaching this was the start of an epidemic to say my heart rate doubled would be an understatement it was scary knew it was time to bring in the director of the Wisconsin Department of Health Dr Jeff Davis the fact that three cases were occurring in in in one Community simultaneously certainly was of impact we felt it was certainly unusual needed to be investigated right away as Chief epidemiologist for the state of Wisconsin it was Dr Davis's job to make sense of this outbreak to figure out how these three cases were related had the young women all been exposed to something in common what was the source of the illness Dr Davis interviewed the three patients asking about pets allergies dietary habits anything that might provide a link a clue to the origin of this mysterious infection we asked about a lot of activities these were uh fairly far-reaching you know where people shopped you know where they went what their usual activities were Davis then compared the interviews looking for overlapping data the one key point where the patient lives intersected what he found was absolutely nothing except for the fact that they were women and they were from basically the greater Madison area uh they didn't have anything uncommon the mystery was growing and unless doctors in public health officials could identify the source of the toxic infection more young women could be in danger a strange outbreak a mysterious infection and in Madison Wisconsin young women were being rushed to the hospital in each case the symptoms were the same high fever dangerously low blood pressure signs of shock and a bizarre are sunburn like [Music] rash as doctors struggled to keep the women Alive health officials worked Round the Clock to find the cause Wisconsin State epidemiologist Dr Jeff Davis combed through the Women's Medical Records searching for Clues what did these patients have in common the only thing they shared was that they were all young and they were all women it seemed like nothing in fact it was the beginning of an answer so that's when I thought what differentiates women from men and given their age I thought that menstruation may be a factor unfortunately the medical files had no record of menstrual cycles Dr Davis would have to revisit the patients respons Emily Murray the first was in the best shape of the three her kidneys were failing and she had been put on dialysis but she was at least Lucid enough to talk time that you became ill do you do you recall whether you may have been menstrating it not yes was regular since that time normal monthly periods uhhuh over the next day the other patients told him the same thing they had both been menstruating when they got sick at last Davis had found something all the patients had in common but what did it mean was it even significant he shared his findings with infectious disease expert Dr Joan chzn she was skeptical my reaction was well Jeff if you take any group of young women at one point in time you know significant number are going to be having their period and he said well I know but I I just can't find anything else but Davis's interviews uncovered another clue supporting his suspicions one of the women had suffered similar but less severe symptoms a month before the implications were frightening was see [Music] whether had the young women taken a pain reliever that was contaminated a tainted batch of oral contraceptives Davis and Chesney wondered if doctors in the area were seeing the same strange illness it was time to get the word out to get as many brains working on the mystery as possible we felt a real sense of urgency to let other people know as quickly as possible and to see if people had seen it not recognized it to be sure we picked up any additional cases Dr chzn presented her cases at a hospital conference on infectious disease um thank you all for coming we wanted to tell you about three patients that we've seen in the last um two days and we want to bring it to your attention so that if any of you saw a patient with this in the next few months or if you've seen a patient with this over the last six months um please let us know um I'm sure it's not just going on here in Madison but it's probably when she asked if anyone had seen patients with similar symptoms a medical resident spoke up Dr chesne I saw a similar patient 6 months ago he had treated a young woman in her teens a few months earlier Dr chesne asked to look at the patient's records quite concerned about it right now thank you again for letting us come today just beginning before as she reviewed the file Dr chzn saw all the telltale signs look she was in shock at the time and she had a rash just like I told you earlier right and the red eyes you had mentioned to me um key thing is whether anybody recorded the she was having her period when all of this started you find it here it is uh they did document that she was having her period at the time of her symptoms this was yet another documented case of the mysterious illness Wisconsin was firmly in the grip of an outbreak soon another teenager was being admitted to the Wisconson Medical Center like the other women when she arrived at the ER she was disoriented and and covered with a bright red rash is [Music] she Joan have you heard there's another teenager in the emergency room with a fuse rash and shock and they'd like you to come now please hi Alison my name's Dr chzn this new patient was also menstrating she feels we do have clue we think as to what's going on here Dr chzn had been developing a theory about the source of infection since the patients were all menstruating at the onset of illness chzn ordered a vaginal culture to test for bacteria in the lab the culture was incubated on a growth medium 24 hours later it was placed in a reagent solution and identified as staf caucus orius the bacteria associated with toxic shock syndrome Joan Chesney's initial diagnosis had proven correct and sure enough it was a what we call a pure culture that was the only bacteria that grew and it was a heavy growth so that was our first clue hard clue that maybe our thoughts were going in the right direction for Dr Jeff Davis the epidemiologist it was time to place the entire State on [Music] alert he notified over 3500 Physicians that Wisconsin was facing an outbreak of the deadly toxic shock syndrome he requested information and Sample cultures from any patients who displayed symptoms it was important to get this letter out because they needed to learn about the illness they need to know what was occurring we made recommendations for what laboratory tests to obtain and so that expanded their ability to uh get the appropriate tests in a time before email Davis's letter on toxic shock was distributed the oldfashioned way by US mail but all across the state Physicians got the message watch out for unusual cases it was really that very very unique combination of symptoms and signs that we tried to let people know about and you know don't give them some penicillin and send them home cuz they won't be better in the morning you you you need to get them to the hospital right away the response was overwhelming hospitals Statewide reported cases of the deadly illness not just one or two but hundreds of them young women all over Wisconsin were infected with toxic shock syndrome and health officials had no idea [Music] why in 1980 dozens of young Wisconsin women were coming coming down with a disease no one had ever heard of before menstral toxic shock syndrome the local doctors were baffled more cases were appearing across the state and then several weeks into the outbreak the Wisconsin Department of Health learned that three women in Minnesota had also been hospitalized with unusual symptoms epidemiologist Jeff Davis was baffled toxic shock syndrome is not cont ages how would it spread to another state we discussed the importance of reporting this to CDC because clearly this was going on in in a couple of States at the Centers for Disease Control in Atlanta Dr Bruce Dan was part of the investigation to suddenly hear that women in Wisconsin Minnesota were having the same symptoms and not just the same symptoms very strange collection of symptoms you don't have to be a really trained epidemiologist to realize you had a real epidemic on your hands and something very strange was going on fever vomiting diarrhea in all his experience with the cdc's epidemiologic intelligence service Dan had never encountered toxic shock syndrome he tried to learn all he could it was important for us to talk to a lot of experienced investigators uh infectious disease experts who had seen years and years of disease especially in medical centers and un ities where they get referred lots of very unusual cases and they said you know we have never ever seen anything like this before you guys are handling something totally new totally unrecognized as far as we're concerned the cdc's investigative team rolled into action to learn the scope of danger Health departments Across America were contacted by CDC lead investigator Katherine shans we needed to figure out whether this was a regional outbreak or a national outbreak and so we began to put out the word and ask people had they seen this illness in other locations than Wisconsin and Minnesota only two things were certain toxic shock syndrome was dangerous and it was spreading on Sunday February 8th 1980 Ronald and Janette dck were on their way to church jyn their 16-year-old daughter was running [Music] late what happened I came up here she breathing at St Mary's Hospital in Milwaukee an emergency team sprang into action as jaline flickered In and Out Of Consciousness the ER staff charted her vital signs the teenager was suffering from multiple high-risk symptoms her heart was inflamed and her temperature soared to 106° doctors struggled to make a diagnosis until the attending physician received Jeff Davis's letter he recognized his patient symptoms as a textbook case of the brand new epidemic down meeting with jyn's family the doctor asked if she had been menstrating when she became sick she had their answer confirmed his diagnosis toxic shock syndrome he would need to contact the Wisconsin Department of Health to get the latest information on treatment all thanks for your help with her life hanging in the balance geraline was given fluids to rehydrate her and help raise her blood pressure she was also given an antibiotic to combat the staff infection if geralin stood any chance of survival treatment would have to take effect quickly news of the 16-year-old's desperate condition reached Neil Rosenberg a Milwaukee based Health reporter he was intrigued by the mysterious illness when I first heard about gern Dak uh it came came not with a name but fear in the voice of an anonymous caller I was sitting at my desk looking for a story as I usually do when the phone rang and there was a person who said a young woman was seriously ill critically ill he said uh on the south side of Milwaukee from a killer virus tracking the story Rosenberg contacted Dr Jeff Davis at the Wisconsin Department of Health he learned the mysterious illness had a surprising connection he gave me a graphic description of the symptoms and at one point in it I said is there any common link he said they were all minrating and that really threw me for a loop and I said well what do you think that means and he says we really don't know Neil that's what we're looking into Rosenberg Story made front page news for Jeff Davis and the Department of Health it also opened a Floodgate that article had a lot of information about toxic shock syndrome and um I started getting a lot of phone calls a huge number of phone calls and uh so that article had an extraordinary impact understand thep hundreds of calls began pouring in Physicians called to report suspected cases women called to share their stories of surviving about with the deadly syndrome astonished by the response Davis launched a case study to analyze the data Health officials worked non-stop gathering information they had to find the link between toxic shock syndrome and menstration through scores of interviews the team compared 35 confirmed cases of toxic shock to a larger control group of healthy women all the women health the or infected lived in the same area they were all about the same age and shared similar Lifestyles hions Health Department the health department also conducted field interviews with the participants well thank you for letting me come over I just want to ask you a few questions about some of the women described feeling unusually sick every time they got their periods after that but I got this rash like Sunburn and I was just but their symptoms had not escalated unlike gerilyn dck at St Mary's Hospital the teenager was getting worse her condition had been steadily [Music] deteriorating finally after 20 days in the hospital she slipped into an irreversible coma and on February 28th jyn dck died from catastrophic organ failure Wisconsin had lost its first victim to toxic shock syndrome she would not be the last until 1980 the American public had never heard of toxic shock syndrome but now the rare bacterial infection was erupting in the midwest one teenager had already died in Wisconsin now the disease showed up in Iowa on May 16th 36-year-old Chris Lok was rushed to the hospital her liver and kidneys were failing the emergency room team worked hard to stabilize their patient lungs almost they called in the hospital's infection disease expert Dr Charles Helms I got a call from Dr lling Who was the resident on call in the Intensive Care Unit the medical Intensive Care Unit uh about a case that was really had him worried and concerned and wanted an infectious disease consult Dr Helms had never seen anything like it it was as if the patient's entire body was shutting down one organ after another another it's unusual to see a young healthy person uh as she was come in so desperately ill uh particularly with so many systems of her body involved as her condition got worse Chris was moved to the Intensive Care Unit where she could be monitored in addition to her liver and kidneys her lungs were failing and perhaps of most concern to us here her respiratory status her ability to breathe and oxygenate her blood was um uh in Dire Straits doctors rushed to intubate the patient they put her on a [Music] respirator her blood pressure was crashing her organs weren't functioning they were losing her their only hope of keeping Chris alive was to raise her blood pressure to get blood to her vital organs despite the cdc's efforts not all doctors were aware that a strange infection was on the move if it was a bacterial infection that she was on a sufficiently broad range of antibiotics to protect her while we figured out what was going on with her Chris Lok was playing based on life support in the ICU her family Sat by her side as she slipped into a coma but Chris was not alone toxic shock was now a national problem at the CDC the calls were streaming in hundreds of girls were sick and some were dying epidemiologist Bruce Dan tracked the outbreak it was happening nationally in a dozen states all over the country suddenly young previously healthy women who are going about their life going to high school going to college going to work raising kids suddenly get ill uh as if they had the flu and some of them would be dead in the next 12 or 24 hours from a totally unknown cause that's frightening continue to work on this the CDC task force kept running totals of confirmed toxic shock cases reports were coming in from all over the country Nationwide the death toll had risen to seven as the numbers kept pouring in we get more and more calls saying we've seen another case and another case and another case there's a lot of pressure to say we have to solve this very quickly find the answer to stop this epidemic and save a lot of lives the CDC put together an mmwr a mortality and morbidity weekly report on toxic shock syndrome it was an alert to Physicians and hospitals all across the country [Music] the mmwr would help doctors make an early diagnosis of toxic shock patients it's basically the cdc's mechanism for getting information out to doctors nurses Health officials across the country it's also a mechanism for getting information back in the cdc's report arrived at the Iowa hospital just in time I just came back to my desk and on it description Dr Helms recognized Chris lok's symptoms [Music] immediately it was textbook toxic shock syndrome Dr Helms followed the cdc's recommendations massive amounts of fluids and antibiotics to fight infection for now her terrified family could only watch and wait back at the SE DC the numbers continue to rise 107 cases had now surfaced in 33 separate states clearly this was the beginning of a nationwide epidemic but what was causing it your first hunch if you want to play hunches is probably maybe these are women who got a bad batch of some medication that women commonly take during their menstrual period for for aches and pains and so forth but you can't play your hunches when you're dealing with something like this you have to do a real study and so the CDC launched a nationwide hunt to discover the cause of toxic shock you've got the names of 50 women from their medical records uh in hospitals across the United States how do you find them how do you call them where are they now for each patient they needed to interview three control subjects they asked each of the patients for the names of three friends so it's not just a matter of making 200 phone calls but maybe 400 800 thousand phone calls to get hold of all these people that took a huge amount of work we had a very short time to do it with the days passing and more women falling ill health officials race to get to the bottom of the mystery so we devised a questionnaire about 125 15 questions asking everything we can think about about their current health status medications they may be taking certainly everything we can think of about their minstral period do you wear pads or tampons do you exercise during your period do you jog do you take showers you take baths uh what do you do unusual or not do unusual during your period to get an idea of what would make the cases different than the controls why did one group of young women get toxic shock syndrome and get violently ill and other women were totally healthy go to and it was clear to us that if you asked enough questions you would probably find out why women with toxic shock syndrome uh were different than other women turns out the answer surprised us after week of medical detective work the CDC investigators had found the common [Music] link there was one thing that set the women with toxic shock apart 100% of them used tampons what could it be about tampons that would cause this severe disease and cause women to die they've been in use for 50 years 50 million women a month used in the United States there were all kind of Brands out there they were common place and it didn't make a lot of scientific sense from a biological point of view what what could it be about a tampon that could kill you but because of the Potential Threat the solution to one mystery was the beginning of the next shows the dramtic results CDC investigators presented their startling findings to every tampon manufacturer in the country we invited the tampon manufacturers to come down to Atlanta to CDC to discuss with us uh first of all to tell them what the results of our study were so they would be aware and secondly to find out from them tell us about tampons how are they made where are they made what are they made of the executives agreed to provide the CDC with the information but on one point they were unequivocal they had no intention of taking their products off the market they believed the scientific proof was lacking still CDC investigator Katherine shans felt the evidence linking tampons to toxic shock was clear enough the disease needed um two things to occur um one was the presence of staf arus and actually an infection with staf arus the other was um the use of tampons and so the CDC went public with their findings they needed to warn women about the Potential Threat but the mystery was far from solved dozens of questions still lingered investigators needed to conduct a second study to determine why tampons were making women sick what caused the infection had specific Brands become contaminated so we collected tampons to test them in the laboratory to see if any particular tampon any brand any style from any kind of manufacturing location might be contaminated and though we looked at hundreds and thousands of tampons you know hundreds and thousands of hours of laboratory time to look for that we couldn't find any particular tampon that were contaminated with anything that would cause a disease the story of the outbreak made national headlines All Over America women were confused and terrified this was also under sort of a national Spotlight and suddenly not only do you have the spotlight on you from just your local colleagues but the director of CDC the Surgeon General the Department of Health and Human Services secretary and even the presidential office is looking very quickly at you to say hey this a real problem are you guys going to solve it throughout the summer and fall the epidemic raged on and panic began to set in as more and more women found themselves in a battle with a mysterious disease fighting for their lives all across America women were dying and health officials didn't know why as scientists raced to find answers more patients were being rushed to the hospital patients like 25-year-old Pat km the mother of two small children she had early flu like symptoms now she was in the ER and her husband Mike was worried every 15 or 20 minutes I was allowed to enter uh the into the emergency room I could hold her hand she was having such a difficult time breathing she wasn't able to communicate very well with me um but I could squeeze her hand and she could squeeze it back as Pat's condition deteriorated Mike grew more concerned to think that just a few days prior she was the young healthy a mother of my children and we were enjoying life and making plans for our future to see her in a hospital hospital setting uh looking totally unlike her normal self in fighting to take every breath the medical community was now on high alert for patients who showed signs of toxic shock syndrome and Pat km was a classic case admitted to the ICU Pat was treated with antibiotics to fight the infection but her situation was grave and Mike could see she had taken a turn for the worse and was so alarmed at how her coloring had changed and later I understood that that was because her blood vessels were bursting under her skin due to the toxins and the poison in her body then and I said well doctor what's the worst thing I can expect and he said Mike uh that's a good question to ask you know my fear was would she have lung damage or brain damage or or some other organ that could be damaged by all this and he said uh you know that that's a fair question but our fight right now is just to try to keep her alive and at that point it dawned on me just how critical she was I understand even as Pat CM lay on that hospital bed the CDC was working around the clock to pinpoint the source of her infection was it a style of tampon one specific brand that's when investigators had a breakthrough in this particular study one particular brand of tampon accounted for about uh 2third of all the cases and it was a brand of tampon that only about a a fifth of women in the United States were using so something was highly risky about this tampon the brand was a relatively new product that had been aggressively marketed as a superabsorbent tampon the manufacturer had spent millions of dollars promoting it to women Nationwide they told us that they had made changes in the composition of tampons over the last several years um prior to 1975 all tampons had been made of cotton and rayon and they had begun introducing um High absorbency chemical materials into tampons to obviously to increase the absorbency the FDA acted swiftly and pulled the brand from the shelves when they did that the number of cases of toxic shock syndrome dropped off dramatically and not surprisingly if a tampon is responsible for two-thirds of the cases removing that tampon from the market as quickly as you can reduce the number of cases the CDC got the word out tampons were directly linked to toxic shock syndrome but for Pat cam it was already too late despite the doctor's rapid diagnosis she lay in a coma unable to breathe on her own and I would spend the evening with her at the hospital she squeezed my hand and tears were flowing down her cheeks and those tears were red because of the blood vessels bursting in in her eyes and so [Music] on on September 6th 1980 Pat cam lost her battle with toxic shock syndrome another victim of this terrible plague but the story wasn't over although one brand of tampons had been pulled from the shelves more cases of the infection turned up at hospitals around the country women were getting sick while using other brands and no one knew exactly why absorbency levels seemed to be a factor as well as how long they remained inside the body to alert the public the FDA required tampon manufacturers to include information in their packaging about toxic shock syndrome and how to avoid it in Iowa Chris Lok spent weeks lying near death finally the aggressive antibiotic therapy kicked in her body fought off the staff orus bacteria Chris's Doctor Richard Helms credits the research of the CDC for saving her life Chris was fortunate that she came in uh to a hospital in this country at that particular point in the evolution of American Medicine where we had a syndrome where we had an approach to that syndrome and that syndrome included treatment of staf lakasa orus never been nearly a month after she was admitted Chris Lok was released from the hospital today she's still thankful for Dr Helm's quick [Music] thinking they saved my life there's no doubt about it they saved my life they were um on top of it they had to try a lot of different things you have to realize that my kidneys failed my I went into congestive heart failure I was being kept alive um by life support um and they kept me alive and I'm very very very grateful to them in the span of one unfortunate year hundreds of young women were infected with toxic shock syndrome 37 of them died dozens more suffered lingering pain and trauma but women like Chris Lok like Emily Murray and Kaylee Wilson all survived in the end in the following years researchers got a much clearer idea of what had caused the outbreak the tampons were the culprit the new synthetic materials simply worked too well they became tiny incubators for disease the perfect growth medium for the staff orious bacteria manufacturers went back to old-fashioned C in rayon and health officials got out the warning the need to change tampons regularly and watch for flu-like symptoms the outbreak taught larger lessons as well I think one of the lessons of toxic shock syndrome is that just as much as we've learned about biot terrorism Anthrax lately is that you need to have a group of highly trained professionals who at a moment's notice can look into solve and fix an epidemic um one of the things about epidemics is you never know whether they're going to happen or whe they're going to come from the key is early detection and Swift reaction Mike Kim and his wife's sister Carol have become advocates for Women's Health myself and my daughters and our family our goal today is for the next generation of young women who are using feminine hygiene products today today to please read the the warning labels that are on the boxes of these products or inside on pamphlets and have an awareness that if you have any flu like symptoms you could be endangering your life and to remove the product and seek medical attention immediately that simple warning uh came 30 or 45 to days too late to save my wife's life today nearly 20 years after the first outbreak the numbers of syndrome cases caused by tampons have declined sharply but they have not disappeared hundreds of incidents are still reported each year thanks to new diagnostic tools and early detection many of those lives can now be [Music] saved a mysterious illness threatens the lives of three young women the painful disease turns their immune systems against them and and paralyzes them with excruciating pain Panic Rises as the outbreak spreads hundreds are stricken and dozens die as doctors treat The Afflicted Public Health officials race to find the cause of a new disease before it can claim more lives [Music] [Applause] [Music] at a health club in Santa Fe New Mexico Bonnie Bishop started her daily workout with a warm-up in the pool [Music] at 39 Bonnie was in top physical condition as a semi-professional tennis player she worked out regularly and hard but lately she felt tired her muscles were sore she hoped swimming would help loosen her up halfway across the pool something went wrong a seing pain shot through her entire body she seized an Agony unable to swim hold on hold she barely made it to the side of the pool to cat bre down you okay you okay Bonnie was terrified CCH it's all right nothing like this had ever happened to her before this is 24 hours later the had still not subsided Bonnie was a young woman and in Peak condition yet any movement even walking was excruciating nurse let's get some her doctor was perplexed although she was running a low-grade fever the exam showed nothing that would explain her [Music] symptoms Bonnie's doctor ordered a complete blood workup to look for signs of infection at the hospital lab Bonnie's blood showed an abnormally High number of eosinophils a type of white blood cell the condition is called eosinophilia eosinophils are a part of the body's immune system when certain infections are present the cells multiply to fight it off a normal eosinophil count ranges between 0 and 500 cells per cubic mm of blood Bonnie's eosinophil count was over 6,000 a count this High could mean Cancer Bonnie's parents were devastated Murray and Jackie Bishop were very close to their daughter they took pride in her athletic abilities she was doing any activity that was Outdoors bicycle riding uh sailboarding that was the kind of of girl she was kind of a lifestyle she led very very active on October 10th Bonnie was admitted to St Vincent Hospital in Santa Fe New Mexico there she was examined by Dr William bevens an oncologist as a cancer specialist bevens empathizes with his patients as they suffer through the devastating effects of the disease the organs of the body are reacting to some inflammatory process so it's like it feels like an inflammation like a a toake all over your body that just is the worst you've ever had and things aren't functioning well you're getting weaker and your strength is is is going away Bonnie underwent a battery of tests to find find out what was causing the eosinophilia very I just hope people get better it was difficult for Jackie Bishop to see her daughter in such [Music] pain they tested her liver they x-rayed her they took her blood they just did everything because nobody could figure out what was wrong with her and she was just getting sicker and sicker doctors had done all they could to rule out other possible causes of eosinophilia Bonnie had been tested for everything from allergies and Asthma to parasites each test had come back negative well I need to talk to you a little bit about what's going on that we don't have a diagnosis yet even after the doctors feared Bonnie had leukemia cancer of the blood for Murray Bishop it was a terrifying Prospect I knew she was suffering but when he said leukemia that scared the heck out of me because I lost my uh best friend coworker with leukemia a team of Specialists was called in to consult on Bonnie's case after 72 hours in the hospital her condition had become critical her lungs were filling up with fluid she couldn't breathe very well so she was short of breath and hungry for air and her body was swelling and her abdomen was getting swollen with fluid and her liver wasn't working Bonnie couldn't breathe the swelling had constricted her Airway doctors put her on straight oxygen but they were running out of time they had to get rid of the fluid building up inside Bonnie's body [Music] the only way to relieve the pressure was to operate surgeons hoped they would also find the cause of Bonnie's mysterious condition not yeah toxicology is still looking at everything if she did have cancer perhaps they would find tumors the x-rays had missed it was a risky procedure Bonnie was so weak doctors warned she might not survive the surgery over the next 2 hours surgeons drained over a gallon of fluid from Bonnie Bishop's body sque here there were no visible tumors surgeons also took samples from her bone marrow liver stomach intestines and ovaries they would be biopsied in the lab later all right hey come for Murray and Jackie Bishop the weight continued doctors needed lab results before they could determine what was threatening their daughter's life [Music] a pathologist examined the biopsies he found no evidence of leukemia but if Bonnie Bishop did not have cancer what was causing her elevated white blood cell count in tissue biopsies the pathologist could see the eosinophils as purple dots they had now invaded Bonnie's muscles and organs [Music] but until doctors could figure out what was causing her illness they could only treat the symptoms Dr bevens prescribed high doses of prednizone a powerful steroid used to reduce inflammation and swelling he hoped it would relieve Bonnie's muscle pain and lower her eosinophil [Music] count take a deep breath okay in and out okay yeah you move there pretty good you're going to need the oxygen for you know a while I won't touch your stomach very just very lightly it's going to take still there was no guarantee the steroids would work bevens felt it was important to prepare his patient for the worst Bonnie was just so seriously ill I wasn't sure she would respond and I I let her know that you know you you potentially you're going to lose your life and it's hard to tell that to people if she didn't respond to the steroids she would need another surgery a surgery she was too weak to [Music] survive bevin's patient was dying and he still had no answers at this point he was willing to consider anything even a long shot what if Bonnie's illness was caused by something in her environment check I felt it was the possibility is some exposure she had outside um just in her regular life either something that she was taking or something that she had been exposed to he asked Jackie Bishop to bring in any medications her daughter had been taking she also collected bottles of nutritional supplements she found in the medicine cabinet the next day she brought everything to Dr bevens let's take a look at that so just multiple vitamins yeah she basically wasn't taking very much yeah Bonnie had been taking multivitamins and a dietary supplement called el tryptophan yes she went to a Sleep Clinic and they recommended that yeah yeah I know it's been taken for that well I'm not in Markets El tryptophan was sold as a natural sleep aid has it is derived from protein sources such as fish meats and dairy products multiple I was unsure if that was the cause it's essential aminal acid that should not be harmful to our system it's part of our system part of our proteins and the amino acids so we're built with that the supplement had been available over the counter for a decade well thanks for bring no serious side effects had ever been reported it wasn't a likely culprit and neither were the vitamins Levens was still at a loss in nearby Los Alamos another case would add to the mystery youing I'm Dr mayor 43-year-old Kathy lauo told her doctor she was suffering from terrible muscle pain blood tests revealed that that lao's eosinophil count was off the charts fortunately Cathy's physician had consulted on Bonnie Bishop's case in Santa Fe he recognized the symptoms my first symptom was the really rapid heartbeat in the middle of the night my heart was just slamming against my rib cage and I had no idea it would would just wake me up all of a sudden in the middle of the night and at the same time I was having problems with u my extremity the muscles in my extremities you pleas by the time she went to the doctor her muscle and joint pain was unbearable my symptoms just got worse and worse and um the pain in my extremities uh went upward from my ankles up to the top of my head um what was a dull ache became a a burning sensation it was like having acid under my skin I couldn't sleep at all I think I went at least 3 weeks without sleeping 5 minutes just like Bonnie Bishop Cathy lauo had taken El tripan to alleviate her insomnia had both women unknowingly swallowed a dangerous substance if so they were not alone I got a call from the Woman's Health Center and it was from the doctor there who wanted to know about a woman woman who had a high eosinophil count and had muscle aches and I asked please ask this woman right away as she taking El tryptophan and sure enough the patient was taking tryptophan and we had three cases as Bonnie Bishop got worse and the caseless grew longer bevens reached a frightening conclusion they were dealing with an [Music] outbreak leans contacted the New Mexico health department Dr millison idon was the State Environmental epidemiologist she was briefed by Dr Ron Vorhees there were three Physicians who saw middle-aged women previously healthy and they were seen because they had incapacitating mygas just muscle pain so bad they couldn't move they all said they had taken a dietary supplement El tryptophane um which is over the- counter it's not prescription I've recommended it for years as a sleeping aid it's non narcotic it's non habit forming if a common over-the-counter dietary supplement was to blame hundreds of thousands of people could be affected musle Dr idon was concerned she was facing one of the most dangerous epidemic scenarios possible most outbreaks that Health departments deal with are foodborn type outbreaks like salmon Alo or eco coli from contaminated food and those are a lot easier because you have a recognized Illness but this outbreak appear to be a brand new disease the mysterious symptoms only made the Health Department's job more difficult there wasn't any lab test that we could do to confirm what was causing the disease and uh so nothing really in common immediately among these patients so that made it much more of a of a medical mystery to investigate we began to look for more cases PR Dron alerted clinics hospitals and other State Health departments she needed to know if the disease was spreading and if so how fast even as health officials struggled to understand what they were dealing with Bonnie Bishop's condition spiral downward her doctors had no idea that their patient and the two women like her were just the beginning of a public health nightmare in October 1989 a New Mexico woman nearly drowned when her body was gripped by pain and paralysis as her doctors fought to keep her alive the cause of her illness eluded them within days two more women had fallen ill they developed the the same crippling symptoms now facing a potential outbreak New Mexico health officials issued an alert to other State Health departments they needed to know how many cases they were dealing with news of the mysterious illness caught the attention of Tamar steber a health reporter for the Albuquerque Journal somebody mentioned that they knew a woman who had this very weird flu different kind of symptoms pretty severe but it it just wasn't your normal flu and he also mentioned that she happened to be taking the stuff El tryptophan and she was wondering if maybe there was a connection steer's research led her to Dr William bevens I told her what I knew I thought it was very important um that it that it be related that people know that El trip toan could potentially cause a serious life-threatening illness steber was convinced she had stumbled on an urban Horror Story an epidemic that strikes young women in the prime of their lives the list of symptoms was so extensive and so off the wall they all had these astronomically high white blood cell counts that's very unusual I knew I had a story on November 7th 3 weeks after Bonnie Bishop was admitted to the hospital the story ran in the albuquer journal that same day Judy Paulson and her husband were traveling from Albuquerque to the Mayo Clinic in Minnesota Judy was suffering from severe muscle pain her doctors could not diagnose her symptoms she hoped The Specialist at the Mayo Clinic could help her on the plane ste's article caught Judy's attention the words that jumped out at me were rare blood disorder an Al tryptophan as I read on I realized that the three New Mexico women that they had been interviewing had all the same symptoms that I did and the only Common Thread with those three people was the El tryptophan and so I thought I'm the fourth and the EMS Judy contacted steber the minute she landed she told the reporter she had taken El trip defend three times a day for months I wanted her to know that I really felt she was on to something I was relieved to think maybe there was finally an answer for what was wrong with me because all the Physicians had been saying we just don't know it could be this could be that Judy Paulson was not alone well do you have any through throughout the state people responded to steer's front page article hundreds of calls poured into the health department nine women reported identical symptoms to the three known cases bringing the total to 12 there were cases all over the state the disease was apparently [Music] spreading Dr millison idon and the New Mexico health department stepped up their investigation that made us realize that this really could be a a large outbreak that we really were seeing just the tip of maybe a very large Iceberg and it made us motivated to work even harder and faster on the outbreak because if it was Al tripan or due to any other unknown cause it would be really important to find out quickly what it was in order to protect Public Health despite their suspicions about El tripan Dr idon needed to find proof of the source of the outbreak it was really important to have a rigorous epidemiologic study because this was a new disease that we didn't know how widespread it was this product was used worldwide and could have a lot of implications in regards to tens of thousands of people potentially being exposed the potential for a global epidemic affecting women was terrifying idon alerted the Centers for Disease Control and prevention in Atlanta at the cdc's national Center for environmental health Dr Ed kilborne took charge of the case when we were told about the outbreak we were told about a possible lrip Defan link but a clinical observation in a few cases is not the same thing as a real epidemiologic study and we needed those to be done Henry need a word um just got call on the East ailia cases in New Mexico um Dr idon they're trying to sort out duplications right now get an exact case count uh it's hit the papers out there we're starting to hear about cases perhaps before they could make any decisions about the cause of the outbreak the CDC had to have proof they needed hard data linking the victims to El tripan the CDC teamed up with idon staff in New Mexico to design a case control study the in-depth analysis compared sick patients to a control group of healthy people the investigators hope to find answers in their differences and so what we did is send teams out to hospital Laboratories we literally looked through tens of thousands of Records looking for high eosinophil counts any patient record with an eosinophil count over 2,000 in the past 6 months was reviewed patients with high eosinophil levels possibly caused by allergies or parasites were eliminated from the study in all it took a massive Statewide effort to isolate just 11 cases of eosinophilia next Health officials went door too searching patients neighborhoods they needed to find women of similar ages who had not become ill these women would serve as the control group for the study hi hi good afternoon I'm with the State Health Department these people were similar to the ill people in the same kind of Housing and socioeconomic status and and Lifestyles but they were well that's all right my name isene I'm one of nurses that works at the health department what and we give the same questions to the ill people and then to their well neighbors what's your data yes do you take any calcium supplements yes any less of than and then we compare the answers and see are there any differences that may account for why the people became ill it was a difficult and painstaking process it would take several days to gather all the information and analyze the results in Atlanta Dr kilborne issued a CDC alert to Health Department's all over the country just on they needed more data to reveal whether the cases in New Mexico were isolated or whether they were facing a national epidemic they also had to figure out why the disease only appeared to affect women but as Federal and State Health officials fought the mysterious outbreak more people in New Mexico were becoming seriously ill what he got as a mysterious illness swept across New Mexico nearly a dozen young women were stricken all of them suffered the painful symptoms of eosinophilia a rare blood disorder that turns the victim's own immune system against itself she get on 1 2 3 got that epinephrine one Mig I be pushed now no response on the people arterial blood gas right now as the disease progresses the victim's nervous system shut down in extreme cases patients can go into cardiac [Music] arrest all of the victims had taken El tryptophan the amino acid was a popular natural remedy for insomnia PMs and depression [Music] doctors wondered how a common over-the-counter supplement could suddenly cause so many women to become sick State Health officials conducted studies to determine whether El tryptophan was responsible for the outbreak at the Centers for Disease Control and prevention Dr Ed kilborne investigated the extent of the epidemic he issued a nationwide CDC alert on epinet a public health database the response confirmed his worst fears we started to find there were numerous reports in other cases and rather rapidly it became clear that this was a nationwide problem as the number of new cases grew doctors made a surprising discovery in addition to women men were now Contracting the disease hundreds of cases now threaten the nation's health um Albuquerque Journal Health reporter Tamar steber who first broke the story continued to cover the outbreak and where they I started getting information about people in other states and then it started to spread across the country still hadn't hit me yet what exactly I was dealing with it was a story I was taking it day by day um but every day was just expanding exponentially from Health investigators steber learned that there were also multiple cases in Minnesota a few days after the epinet alert went out Dr Ed Balan of the Minnesota Department of Health was dealing with four cases of eosinophilia in his state it was us against this new mystery disease and we desperately needed to find what was causing it because until we knew what was causing it people were still at risk for developing it like their counterparts in New Mexico Minnesota epidemiologists believe there was an association between ELP Defan and the sick patients but without scientific proof they couldn't support their theory if this was El triptan we really needed to get the evidence identified as quickly as possible so that it could be taken off the market because the longer we delayed the more people would be out there buying this at grocery store stores and at health food stores and more people would be getting sick for both New Mexico and Minnesota Health officials The Next Step depended on the results of the [Music] studies in Santa Fe the health department worked Round the Clock to complete its study in Just 4 days Dr millison idon tabulated the results on Sunday evening November 12th what we found is that all of the ill people had taken El tryptophan prior to their illness whereas of the 22 well people only two of them had taken El tryptophan in the same time period this was a highly statistically significant uh difference this wasn't due to just some kind of chance on Monday morning the New Mexico health department issued a public health order prohibiting the sale of el trypan you have in the back also it was taken off store shelves 4 days later the US Food and Drug Administration banned the saale and display of el tripan all over the country they issued a nationwide recall of the supplement and advised anyone who had used it to see their doctors with the ban in place officials hoped they had effectively sto the spread of the illness this was small consolation to the patients who were still fighting for their lives at St Vincent's Hospital Bonnie Bishop was getting worse she had been the first to fall victim to the strange new disease her doctor oncologist William Levens began to lose hope well I felt Bonnie was potentially could lose her life from this disease and whatever was causing it to see a sinophilia people can continue to deteriorate and die from this and in Bonnie's case she was on the verge Bonnie's parents stayed by her side they had to face the possibility that they might lose their daughter I just thought it was impossible for anybody that was as strong as she was to die at her age and her fantastic physical condition I just thought it was impossible for her to die I really got scared as patients around the country struggled for their lives the CDC kept doctors updated together they would fight this new disease the Physicians who were taking care of this illness knew they had something new and they had no literature or or scientific medical basis to guide them in the therapy of these patients so to the the extent we heard about therapeutic uh trials in individual patients at that time that was the most valuable and important information that we could be disseminating Health officials also Enlisted the help of America's leading eosinophilia specialist Dr Gerald GL at the ma Clinic Foundation this was enough to strike Panic into the hearts of The Afflicted individuals because the docs don't know and there's no body of information my phone was ringing off the hook Physicians were calling from all over the country their their wives their daughters their friends were Afflicted could I help them with information [Music] hello don't recall getting this this kind of History before now I think one additional thing we want to know what happens so it'll be important to get blood samples to do blood counts and to get some blood sand there was little information to give them and the lack of of knowledge was taking its toll need a blood gas right now and the central line hang FM 2 mg [Music] 300 on November 16th 1989 the mysterious new disease claimed its first victim how many more would die before they could find the cause of the outbreak [Music] in the fall of 1989 a debilitating disease struck hundreds of people throughout the United States Health officials determined the epidemic was caused by El tryptophan and over-the-counter dietary supplement commonly used as a sleep aid the FDA banned it sale but doctors still struggled to treat the victims one had already succumbed clear others were near death' seen such a dramatic increase weeks after the outbreak began epidemiologist Ed Balan had more questions than answers getting the actual bottles the research team at the Minnesota Department of Health would have to dig deeper individuals who are it seems clear that given the popularity of tryptophan that not everybody who consumes tryptophan is developing this syndrome and yet at the at the moment we don't really have any idea how common tryptophan use is or What proportion of users are actually becoming this investigation was like peeling the layers of an onion with every layer you get one little answer and then you get 10 new questions to look at and as you go deeper into the onion you discover more and more surprises that you never anticipated when this all began let me researchers contacted each of the known victims to learn what brand of el tryptophan they had been taking we wanted to get actual bottles that people were taking before they became sick so that we could initiate a process of tracing them back to find out more about how they were manufactured and by who officials asked victims to send all of their El trip Defan to the Minnesota State Health Department now this one's really important because it's the only botle that they said they've ever used so this is the next step in the investigation was to try and find out more about how alpan was manufactured where did it come from who made it how was it made we didn't know any of that we were on a very steep learning curve uh in a very short time Lots this is from labels investigators learned that the supplements had been bottled by different companies Nationwide there was no way to tell where the amino acid had been manufactured it turns out to be an extraordinarily complex network of procedures from the time tryptophane is initially manufactured until the time it ends up on the Shelf at a a drugstore or a a chain store in all they collected 60 different brands of el tripan they then narrowed their search to the 12 Brands used by the victims all 12 used raw tryptophan from the same [Music] Source we were seeing that there was a particular brand that seemed to be associated with the tryptophan consumed by cases we were ultimately able to Trace that brand back and find out that all of that tryptophan was manufactured by a single company in Japan in Washington DC the Minnesota Health Department held a meeting with Executives of the Japanese company that produced the El tripan the doctors showed their findings to the [Music] executives they agreed to cooperate [Music] fully the company provided Health officials with documents detailing their manufacturing methods because El tryptophan is not considered a drug It Is unregulated by Japanese or American authorities to produce tryptophan a bacteria is grown in a fermentation broth through a series of chemical reactions the bacteria produces raw tryptophan this is then filtered purified and turned into powder form company records indicated they had recently altered their process to increase the yield and get more product they made some genetic changes to this bacteria they tinkered with some of the genes it was like science fiction only real thank you you're welcome now bologan needed to know whether the changes had contaminated a batch of el tryptophan he Enlisted the help of Dr Arthur Mao at the Mayo Clinic Lab Dr Mayo used a process called high performance liquid chromatography hplc creates a chemical fingerprint of each suspicious sample of el tryptophan first the El tryptophan was dissolved in purified water [Music] the solution was then injected into a pressure chamber to separate its chemical components if there was a contaminant present the key to finding it and to stopping the outbreak was contained in this [Music] solution the results were displayed as a series of Peaks each Peak represented a different Trace element elent chromatography had isolated nearly 60 substances other than tryptophan in the samples any one of these could be the contaminant that caused the eosinophilia to isolate the exact substance Dr Mao worked backwards he tested samples of el tryptophan that did not make people sick he then compared the two sets of [Music] results one Peak was present only in the El trip toan taken by sick patients he designated it Peak e for eosinophilia Dr Mao shared his results with Dr GL they agreed that Peak e could be the contaminant that had caused the disease this is now they had to determine its chemical makeup the doctors felt they were close to identifying the cause of the disease but they also knew they were a long way from finding a cure in New Mexico victims had developed troubling new symptoms I was working thinking things were getting better and feeling that they were physically um until I realized that I wasn't able any longer to do my job I knew that I would have to stop working at that point about the same Judy pson saw a neurologist when she couldn't concentrate long enough to perform her job MRI scans showed the disease had created several lesions in her brain this was causing her cognitive difficulties Medical Science had no treatment to offer Judy it was very frightening for me because I had been working for so many years doing the same thing and always being a very active individual and having many many things on my plate at once suddenly I was confronted with going home and sitting and waiting to get better the disease persisted long after the victims had stopped taking El triptan as victims fought for their lives scientists raced to learn the cause of a strange new disease in late 1989 Health officials closed in on a killer hundreds of cases of a strange new disease had been reported Nationwide the Centers for Disease Control and prevention named the new disease eosinophilia myalgia syndrome or EMS EMS attacks the immune system of its victims turning the body against itself now so far officials at the US Centers for Disease Control know of 1,00 cases of the new illness 12 people have died and many are very sick officials believe they are closing in on the cops an over-the-counter dietary supplement called el trapan was linked to the [Music] epidemic by the end of November EMS had claimed the lives of four people experts feared the death toll would [Music] rise in Santa Fe New Mexico Bonnie Bishop began her slow recovery from the debilitating disease after 2 weeks on prednizone a powerful steroid she had gradually regained some strength but the EMS had destroyed so much muscle tissue the former triathlete could barely walk Murray Bishop was moved by his daughter's determination the doctor gave her permission to walk for the first time in the hospital said you can walk around the nurses station once and then come back she walked around three times and then got up an hour and a half later and wanted to do it again at the Mayo Clinic scientists isolated an impurity in the El tryptophan that made people sick for the time being the substance was known only as Peak e its designation on their charts a sample of the impurity was sent to the cdc's division of environmental health Dr Robert Hill a research chemist had found the same peak in samples of el tryptophan that he had tested isolating the chemical was only the first step now Hill had to identify the molecular components of the mysterious compound he used a mass spectrometer to determine its mass his results gave him the chemical makeup of the impurity but they didn't prove it caused EMS next Hill and his team worked closely with National Institute of Health scientists who tried to replicate the disease in laboratory animals none of the animals contracted the disease while this did not rule out Peak e as the cause of EMS in humans researchers may never conclusively prove it made so many people sick to this day the cause remains unknown if we don't know how it happened or why it happened that same thing could pop up again or something similar to that could could happen again somewhere think you know another the CDC identified 1500 cases of EMS with FDA the ones that are 37 people had died the rest were in for a long and painful recovery without scientific proof of the exact cause of EMS medical officials worry the disease may appear again until we really know until we can pinpoint with certainty which contaminants are the responsible ones it's highly probable that this disease will occur again and the scenario that we've gone through will re will be duplicated again at some time in the future the outbreak has frightening implications for nutritional supplement users the EMS example is a gigantic red flag for Tak taking food supplements the food supplements don't go through any testing the patients that took the tryptophane Ed up having their lives ruined many of them died because the contaminant was never identified over-the-counter tryptophan remains banned in the US in Europe where supplements are regulated and the manufacturing process is controlled tryptophan is still available it has been used for years without incident many patients who survived the EMS outbreak continue to suffer its effects after her third MRI Judy pson learned that the lesions in her brain had stopped growing remark but 13 years later she still struggles to regain the life she once had still there but I'm certainly not as active as I once was and stress just puts me over the edge the slightest amount of stress generally I can't deal with at all it's one thing at a time that I have to concentrate on for Kathy lauo recovery has been slow but she remains optimistic after about a year I was able to go back to work and I think I've done fairly well I I keep trying I certainly appreciate life a lot more now and I'm very grateful to be doing doing as well as I'm doing for Bonnie Bishop returning home after a month in the hospital was not the end of her battle with EMS nobody gave up and of course last one that would give up would be her because that's you know that's the way she is what happened well it took years but Bonnie finally got her life back I'm a real and so that's how I approached this situation I think having been an athlete probably prepared me well for it because I can work through pain and I can see slow progress and not be discouraged as long as I see some progress a year after being released from the hospital Bonnie returned to work as a graphic designer the harrowing experience left her with a new perspective I'm very thankful for all the wonderful things that I've experienced since I was supposed to succumb and I'm glad to have had those years for Bonnie Bishop and hundreds of other EMS survivors every day is another victory over the disease that nearly took their lives on Vancouver Island a series of strange and lethal symptoms strikes residents without warning investigators are in a desperate search for the cause of the deadly illness to solve the mystery they must hunt for clues in the most unlikely places but even as they close in on the location of the killer the evidence points to one terrifying conclusion it is all around them [Music] [Applause] [Music] some of the names in this program have been changed Vancouver British Columbia Canada's West Coast metropolis a Hightech City on the edge of wilderness across the bay lies Vancouver Island stretching almost 300 miles along the Canadian Coast this island is home to immense old growth forests ancient Woodlands that make it a mecca for outdoorsmen but for travelers and residents alike that Wilderness would soon reach into the heart of civilization in a most alarming way in 1999 Marie Benson was rushed to the Island's main hospital in the city of Victoria she had been sick for several days with an excruciating headache and a high fever now she was delirious [Music] in the ER doctors diagnosed her with menitis a raging infection that causes swelling around the brain and spinal cord soon her organs began shutting down within hours despite the doctor's best efforts Marie Benson died doctors wondered how had an otherwise healthy young woman died so suddenly at autopsy the medical examiner took tissue samples to find out what they didn't know was that these samples held a rare and dangerous killer that would soon overtake the island over a year later the mysterious disease struck again Arthur La was a self-employed house painter who had lived in Victoria most of his adult life for the past several weeks he had been suffering from flu like symptoms but he thought he could ride out the [Music] illness as the summer of 2001 war on he developed chest pain and a dry cough then he started coughing up blood that evening he told his wife about how he was feeling coup weeks before we left they were scheduled to leave for Germany the next day to visit with family it was a trip they had been planning for years then he started he didn't want to ruin it so we really he uh was feeling pain in his left side and uh I thought probably because he walked a lot and uh he was usually very active and a kind of a workaholic then he told me that he had been spitting up blood so I began to worry and told him he should go to the doctor at the Royal Jubilee Hospital in Victoria Arthur was referred to a specialist in respiratory illness and sent for x-rays a deep breath in hold taking a medical history the doctor asked Arthur if he was a smoker in fact Arthur had quit more than 10 years earlier whenever you uh meet somebody who's been a smoker and who's coughing up blood obviously the first concern is of an underlying tumor or in this case a primary pulmonary malignancy a shaded area on Arthur's chest x-rays troubled Dr pson well those x-rays are actually pretty subtle the right lung was totally clear but at the root or adjacent to the root on the left lung uh there was a very illd defined Shadow Arthur imagined the worst see that area right here he worried how it would impact his wife and his daughter Angela his doctor had suggested it may be a tumor it could be cancer it could be a number of very serious things so dad was scared the doctor recommended Arthur undergo a bronchoscopy an exploratory procedure to determine what the Shadow on his X-ray was inserting a hollow tube fitted with a tiny video camera down the patient's windpipe into the lungs the doctor looked for the cause of bleeding and any tumors as the doctors worked Arthur's Family waited anxiously for news we didn't know what the doctor would find it really depended on whether or not there was something wrong with that if he would be able to go on this vacation that he had planned he wanted to go on this trip so there were a lot of things up in the air at that moment so we were quite nervous the broncoscopy took over an [Music] hour procedure itself went fine it was uh not complicated and he had basically normal Airways you could not see any obvious uh tumor or pup within the Airways in fact I couldn't even find a blood trail on this occasion the test had found no obvious dangers the source of Arthur's symptoms remained a mystery as a precaution the doctor removed a tissue sample and sent it to the lab for testing hello folks once Arthur recovered from the anesthesia the doctors gave him the preliminary results Arthur and his entire family were relieved that his lungs did not look cancerous take a but the doctor couldn't make a final diagnosis until the lab report came back in several days so I was pleased to be able to reassure him somewhat that I didn't see an obvious tumor although uh not having all my samples back I couldn't give him a definite answer with this good news and feeling well enough now to travel Arthur decided to take take his vacation Arthur and Carol flew to Germany the very next [Music] day as the labs were heading overseas lab technicians at Royal Jubilee Hospital tested Arthur's lung sample they found no malignant or cancerous cells but while checking for tuberculosis and other bacteria the Tex did find something unusual [Music] Arthur's lungs were infected with a strange fungus cryptococcus Neo Forman common to Vancouver Island this fungus had almost never before been linked to major health problems among healthy residents but in Germany the lab's dream vacation was quickly turning sour days after they arrived Arthur began complaining of severe back pain his son-in-law took him to the local hospital as they drove Arthur's pain became unbearable it been getting worse than that his head was pounding his fever soaring and he was becoming Delirious to the German doctors the symptom suggested he was suffering from s swelling around his brain a condition called menitis a neurologist took blood samples and withdrew spinal fluid from Arthur to check for what might be causing his illness but because the pain had started in his lower back neither Arthur nor his family connected this sickness to his lung problem they told me that they really didn't know what it was was but he was going to be in the hospital for a while because they suspected menitis then I really got scared the lab detected a high white blood cell count in Arthur's blood which indicated that his body was fighting some type of infection the doctor's diagnosis bacterial menitis they put him on massive doses of antibiotics to fight off any bacteria in his system in all the Physicians tried six different medications but Arthur didn't respond to any of [Music] them his pain became more intense as his condition [Music] deteriorated the German neurologist told Carol he didn't think her husband was going to survive you should probably call your family because we're doing everything we can for him and he's not responding and it doesn't look good so then I really Panic desperate for some way to help her husband she called their daughter Angela in Vancouver and told her of the Grave diagnosis half a world away and Ang Newman was just starting her day when she got the call I'll see what else we might be able to find out and I'll call you back as soon as I've spoken to Dr she was stunned by the news that her father did not have long to live searching for help she consulted with Arthur's doctor in Canada Dr pson had examined Arthur before he left on his vacation ad she hoped he could help she explained what was happening and the doctor reached a startling conclusion I just got some results from the he said your dad's test results came back with crypto caucus which is normally nothing to be alarmed about it's something that people have and uh if their immune systems are intact they they're able to um fight it off and um so I didn't even think twice about mentioning it to you and but in your in your dad's case it has led to menitis which happens in very very rare cases well presumably I don't know if cryptococcus was the cause of Arthur's illness the German doctors had no idea they hadn't been doing anything to cure it because antibiotics only treat bacterial infections they were useless against the cryptococcus fun my first question to Dr pson was can this be cured and he said yes if there's enough time I don't know I don't know how bad it is at this point I don't know what stage it's at Dr pson thought that Arthur's rapid decline was puzzling at the point I met Mr Lea had no evidence that his immune system was not up to par so it's very unusual that he would get is [Music] sick pson contacted Arthur's doctors in Germany hello Dr Hensel it's Dr pson calling from Victoria Canada he relayed his biopsy information there's no cancer scene but I'm growing crypto caucus that's right I understand he then recommended medications to treat crypto caucus I the German doctors put Arthur on the anti-fungal medication right away I think we now all they could do was wait to see if his body would [Music] respond back in Canada Dr pson decided that Arthur's condition was so unusual that he should contact the Vancouver Island Health Authority microbiologist Dr Pamela kibsey had never seen cryptococcus affect a healthy person so dramatically the fungus spreads like pollen on spores through the air normally it's not that dangerous unless it was now changing in some way I think I was worried that there may be more cases out there that we weren't aware of so the first thing I did was alert all my other colleagues in pathology to be on the lookout for more cases even as public health officials put out the First Alert of a severe cryptococcus infection the fungus was spreading some 50 Mi away from Vancouver Island Brian and Cara white lived on the Canadian Mainland an avid Outdoorsman Brian started to feel strangely sluggish in the late summer of [Music] 2001 suffering from chills in a fever he thought he was coming down with the [Music] flu eventually the symptom subsided except the chest pain it only grew [Music] worse within hours Brian was rushed to a Vancouver emergency room convinced he was having a heart attack his wife Cara couldn't believe what was happening to her husband Brian has always been an incredibly fit outdoorsy healthy guy so for him to to get something of this type was was just um kind of like being hit by a bolt of lightning ER doctors hooked Brian up to a heart monitor and did an electrocardiograph the doctors quickly determined that Brian was not having a heart attack as the chest pains continued Cara white became more concerned it was quite clear that this case was uh somewhat perplexing so uh they they right away uh concentrated on the area of the the chest but um you know they didn't even know if it was lungs initially but then as they narrowed it down to lungs then then they saw the growth on the lungs a chest x-ray revealed a large suspicious Mass what I noticed was what I doctors told the whites that it looked like Brian had cancer over the next 2 weeks Brian endured a brutal regimen of testing as well as x-rays he had CAT scan and he had blood tests everything that was possible to go over him with a fine toothed comb was was done with Brian finally Brian underwent a biopsy so that doctors could obtain a sample of his lung the retrieved tissue was sent to a lab where it was examined and cultured the results came back negative for cancer but positive for a fungus the findings were confirmed Brian had crypto cacus these extreme symptoms were so rare to see two cases within several months was more than just unusual it was alarming Health officials feared that the crypto caucus was transforming morphing into something much more dangerous than they'd ever seen before in the late summer of 2001 an unusual infection caused by a fungus known as crypto cacus had struck two residents of Vancouver Island Public Health officials in Canada put out an alert for patients with flu like symptoms who weren't responding to antibiotics Brian White turned out to be one of a half dozen patients who fit that description in an average year doctors would see just one or two cases related to the fungus in patients with compromised immune systems all that was starting to change I think our worst fear is that what we're seeing is the tip of the iceberg in the sickest patients and is this the beginning of an outbreak that is going to affect a whole lot of people searching for Clues Health officials decided to take another look at tissue samples from the infected patients technicians perform serotyping tests to examine the organism's structure and help identify it what they found was surprising they were dealing with a strain of crypto cacus known as neop forman's gadii a strain that had never before been seen in Canada and one that could be deadly the new strain that we're talking about variety gtii is much more virulent it's able to cause illness in people with normal immune systems we'll microscopic spores of the fungus can infect the lungs left untreated the infection can spread to the central nervous system and all through the body resulting in death this strain is most commonly found in tropical parts of the world where it lives in the forests it's been described quite commonly in Australia where it's been associated with the eucalyptus tree and also in South and Central America and Africa where again eucalyptus tree has been a common source for it but some other tropical and subtropical trees as well crypto caucus can also grow in soil and rotting wood leaves and mulch Health investigators took environmental samples from around Brian White's home with this new strain investigators had no idea where it had come from or where to find [Music] it trying to pinpoint the source of the infections epidemiologists began questioning all the people who had become sick now recovering Brian White the one patient who did not live on the island detailed where he had traveled over the past year Brian revealed that he had recently been to Borneo a South Pacific island investigators wondered if he could have picked up the illness there then again he had also recently been to Vancouver Island hiking in the Backwoods investigators would need to turn Elsewhere for answers Health officials next interviewed Arthur LA's wife caroling after 6 weeks of recovery Arthur was too weak to talk to [Music] investigators Carol revealed that they had not traveled at all before Arthur became ill this meant Arthur could have been exposed somewhere on Vancouver Island even his own backyard believing he could have contracted the fungus from the compost or top soil in his garden they collected samples of each for testing sample from both patients yards were sent to the University of British Columbia to be checked for crypto caucus labtech swabbed Petri dishes and allowed the cultures to grow for 48 hours this is a very typical but the findings were not what they [Music] expected the results were all negative we thought we might have a link but we didn't turn up any anything desperate for answers the health authority decided to contact their counterparts at the British Columbia Center for Disease Control the provincial CDC put out a widescale alert two of the cases are from an unusual strain of fungus was on the rise doctors would have to be extra vigilant the responses came in almost immediately the first surprise the CDC began hearing about an increase in cryptococcus infections among wild animals the dead creatures were sent to a lab for autopsy tissue samples were taken for testing we'll take the results clear evidence of the new crypto caucus in this case we had an El elevated number all in animals with no pre-existing disease so right away that was highly unusual beyond the wild animals the island residents were also reporting an increase in respiratory infections among domestic pets something was attacking the animals lungs and nervous systems the Vets took cultures from the sick animals they too were positive for the fungus so around the same time as we were finding cases in humans the veterinaries were finding cases in animals and they assured us that this was a brand new finding so again this was uh just added more uh Intrigue to this whole mystery because where are the animals getting it cryptococcus was proving to be one of the very few diseases that could infect animals and humans alike all living things were potential victims and public health officials began to confront their worst fear that the outbreak might start spreading to the mainland before they could find the source a rare fungal infection known as crypto caucus was attacking residents of Vancouver Island on the west west coast of [Music] Canada investigators from British Columbia CDC had sent out an alert to area doctors trying to determine the scope of the outbreak what they learned was alarming UC car stain is positive which is compatible with crypto cus Dr Jean Adams read the alert and suspected that one of her patients had suffered from the same illness but 2 years earlier in 1999 Marie Benson an otherwise healthy 40-year-old woman had died from an untreatable form of menitis in light of the alert Dr Adams now suspected Marie died of crypto caucus fortunately the doctor had a frozen sample of the patient's spinal fluid she sent the isolate over to the CDC office along with the medical [Music] records at the British Columbia Center for Disease Control scientists thought and cultured the [Music] sample if this woman had died from crypto caucus it meant that Vancouver Island had a killer on its hands and for much longer than anyone had realized soon they had their answer the woman's tissue sample tested positive for crypto caucus Neo foran's Gadi ey it was time to intensify the hunt for the source of the disease they knew that the deadly fungus can live in trees but in an island of forests finding witch trees would be the daunting task as investigators raced to find the origin of the crypto caucus more residents on Vancouver Island were getting sick an outbreak was underway CDC investigators decided it was time to conduct a risk analysis they needed to find a common link between the patients to figure out where the disease had come from local and provincial Health officials reviewed all of the patient information by the winter of 2001 they knew of over 30 cases of crypto caucus west of there to Port Al the age span of the patients ranged from an 11-year-old child to an 87-year-old retiree perhaps associated with they had only one thing in common they had all visited or lived on Vancouver Island that still left several thousand square miles to investigate on the hunt for Clues the researchers turned to the Center for Coastal Health a Veterinary agency because animals tend to stay close to their habitats the investigators thought they might help locate the source of the fungus Dr Craig Ste even began conducting his own study of the animal outbreak by talking to pet owners as well so just like the people we did a case control study for the animals so we would find animals who had the disease and match them to animals that didn't and then ask the owners about what they ate their medical history their travel history medical investigators logged where the two dozen infected pets had lived and traveled with their owners what they found was that the animals and people had in fact intersected at one part of the island it was called the Douglas fur Zone and it contained a large public park for microbiologist Karen Bartlett the idea made sense this particular zone is very interesting because it's a different climate than anywhere else in British Columbia there are different trees that are so associated with that zone and they milder warmer Winters and very dry Summers so that was our first clue that the organism might be localizing because of the climate the wooded land had a number of places where crypto caucus could [Music] Thrive epidemiologists thought they had found the source of the outbreak [Music] now they had to prove it in a park that stretched on for Miles containing thousands of trees the team took tree samples entering in the coordinates with a global positioning system the system is accurate to within 5 ft that way they could find the exact tree again we went through a series of different sampling techniques initially we were looking at taking what we call Bulk samples which is to basically take a baggie and scoop out any Woody debris in for example the bowls of trees or where a limb has fallen [Music] off the team of scientists spread out to process the park in tropical climates the virent crypto caucus is most common ly associated with eucalyptus trees but investigators decided to cast a wide net testing all types of trees in hopes of finding traces of the fungus one of the interesting things about the crypticus ne Forman gtii is that it has as part of its life cycle it needs to live in trees and this was an unusual manifestation uh typically in infectious diseases we studying organ isms that are passed from person to person in this particular case it's different that it's passed from trees to people microbiologists at the University of British Columbia took the samples from the park and prepared them by putting them in a liquid solution then the solution was cultured to see if the fungus was present there are lots of other fungi that grow in and around trees and so I was getting lots and lots of things growing on the plates but not the thing I was looking for as the source of the crypto caucus remained a mystery the number of those suffering just kept growing on Tuesday February 26th 2002 Deborah Chow brought her sister Esther young to a local Vancouver Island Hospital a long sickness of flu like symptoms had taken a ter terrible turn Esther had developed extreme back and neck pain double vision and a tingling in her hands Deborah had never seen her sister so sick she couldn't lay down she couldn't sit up she couldn't stand up the pain was so bad and I was very concerned and worried you're doing really good the doctor put Esther on Mor for her terrible pain infectious disease specialist Dr Wayne gire was called in to assist on Esther's case he ordered a series of tests including a CAT scan and a spinal tap as he reviewed the CAT scan there seemed to be nothing unusual in the results in the hospital lab Esther spinal fluid appeared cloudy an indication she was suffering from a severe infection then further testing showed that Esther's spinal fluid contained cryptococcus Esther's physician was alarmed at how an otherwise healthy woman could be so severely sick he put Esther on anti-fungal medications and reported the case to the British Columbia Center for Disease Control it marked the 40th known cryptococcus case since the outbreak had begun as one more victim struggled for Life the source of her disease remained as elusive as ever and the danger would only keep [Music] growing in early 2002 medical investigator around Vancouver Island Canada pursued a new killer that had sprung up in their area a fungus called cryptococcus neoran [Music] gadii dozens of residents had contracted painful life-threatening infections with an entire Island at risk Health officials were racing to locate the exact source of the fungus before more fell ill [Music] scientists at the British Columbia Center for Disease Control believed it was centered in one specific Park where many of the victims had gone very early on in the process we realized that the cases were clustering on the east coast of Vancouver Island there's a lot of trees on the east coast of Vancouver Island and to be most efficient in looking for the organism then we went to places where either cases of human or or animal had been reported after several weeks of searching scientists had a breakthrough when they located A Douglas fur tree that tested positive for the fungus we finally found a positive sample at which point the whole picture changed and we realized that we were on the right track microbiologists returned to the area where they had found cryp to caucus Dr Bartlett wanted to figure out how it was passed to people Tre Kevin I'm going the primary hypothesis that patients could have inhaled the fungus she decided to test the air the team used handheld Samplers containing small strips that trap particles as they filter the air Dr Bartlett also set up airs slit Samplers on the ground and high in the trees throughout the park these devices hold several Petri dishes within a metal container a battery powered pump pulls air in through the device the unique design mimics the human respiratory system the next day the scientists retrieved their samples from the park they incubated the Petri dishes in hopes that crypto caucus would grow the results this time were conclusive they not only found proof that crypto COA spores were in the park but that massive quantities were floating in the air POS we found not only the organism was in air all around the trees but it was in high concentration around the trees and this was the first time that this has ever been reported in the world the fungus was everywhere they found 1,000 units per cubic meter 40 times higher than ever recorded in the world crypto caua was far too widespread to eradicate even if there was a pesticide type of thing that you could use in the environment that would kill crypto caucus the problem is it's probably going to kill all kinds of other essential organisms that are important for the ecosystem so that really isn't an option even though investigators didn't know how the fungus got there they needed to inform the public it was in a public park that some some 700,000 people visit every year and we had to find a way of getting the information out to people that there was a potential that they could pot get the Disease by being in this really beautiful Park that everybody wants to be in on June 6 2002 the British Columbia Center for Disease Control issued a public health advisory on crypto caucus neop forman's Gadi ey they also held a press conference they have never ever in the world documented a cluster of patients like we have this is the first time ever in the world that they've had so many patients that we consider this to be a new event though previously unknown on Vancouver Island a deadly form of crypto caucus had affected Australia for decades the Canadians sent slides of their strain to Australia for comparison scientists there perform genetic fingerprinting on the samples they found that the Canadian fungus was identical to the Australian strain cryptococcus neoran gadii in the tropical regions of Australia residents rarely develop sickness from The gadii Strain because they build up natural immunities to it somehow the the deadly strain had leapt 10,000 Mi of ocean and appeared half a world away in Australia the rate of infection was only 1 in a million but Vancouver Island had already seen a rate nearly 10 times that we think that what happens is that the majority of people are exposed to this in the environment and their body develops immunity to it without them even becoming ill no one knew how long it would take for the Vancouver Island residents to develop a natural immunity Until then people of all walks of life remained [Music] vulnerable Krypto cacus had already killed one and infected 52 others in the Vancouver Island area it was only a matter of time before the fungus claimed its next victims a deadly fungus was striking residents and visitors on Vancouver Island Canada once a strictly tropical infection a virulent strain of crypto cacus had migrated to British Columbia where the population had little immunity in late summer 2002 nearly 3 years after the outbreak began Esther young struggled for her life against the fungus she was losing significant amount of weight uh um due to the nausea and unable to keep down food her headaches had reoccurred and her overall fatigue uh got to the point where she found it very difficult to cope despite treatment she continued to develop a whole series of complications from the infection she lost 35 lbs and became blind in one eye Deborah Chow watched helplessly as her sister deteriorated I was feeling my sister was dying and those were the words that came out of my mouth when I went and saw the doctor I said my sister's dying you've got to do [Music] something Esther now needed help to breathe despite the therapy Esther's condition did not improve it all in fact she uh was slowly deteriorating doctors gave her morphine for the pain they also performed an MRI to see if the fungal infection had penetrated her brain at this point it was not just a menitis in other words infection around the brain now the infection was inside the brain was now involving very integral parts of the brain uh which was a major change the doctors told Deborah that Esther was not responding to treatment on August 8th 2002 Esther young quietly passed away from pneumonia brought on by the crypto caucus infection for health officials the tragedy was doubly alarming they didn't know why Esther hadn't recovered with treatment and why she was the only one not to respond to medication why the drugs weren't working is still a mystery we still don't know is there something unique about Esther we knew she was a unique lady but was there something unique about her illness was there something unique about the type of fungal infection she had that made this what appeared like virtually impossible to recover from today the big question remains unanswered how to stop it our first year in 99 we had six cases that we know of the next year in 2000 we had 11 cases in 2001 we had 17 cases and about Midway through 2002 we already had 19 cases so our worst fears are that you know the outbreak is going to get bigger perhaps even tourists might be affected uh on brief visits to the island warning signs are still posted in Area Parks informing the public of the dangers posed by the fungus do Pamela kibsey and her colleagues believe that the best defense is awareness we feel it's our responsibility to uh let visitors to the island and people who live here know that uh this fungus uh has the possibility of being a very severe disease investigators still have not been able to track down exactly how the organism was introduced on Vancouver Island but they do have several theories they speculate that crypto is ared from Australia on imported plants or trees once in Canada winds could have lifted the spores and deposited them in native trees and soil for Dr Craig Steven and the rest of the team the animal deaths have also shed light on another possible Source in 2000 several dead porpuses washed up on the shores of van Vancouver Island when Dr Steven examined the animals lungs he found them filled with crypto cacus investigators wondered if the fungus could have been carried around the world on water currents and inhaled by porposes whatever the source health professionals can only prevent more deaths by educating the public to watch for symptoms early and long treatment with anti-fungal medication is the best weapon the only weapon against the organism Arthur lab survived his bout with crypto cacus he continues to live with his wife Carol and his daughter Angela on Vancouver Island life is just getting back to normal Arthur doesn't work as many hours or as long as what he used to Brian White has regained most of his formerly active life life as well he lives with his wife Cara and daughter in North Vancouver having beaten the fungus doctors believe Brian May now be immune to it I think it's made me feel a bit more vulnerable I think I'm got a bit more of a spring in my step a bit more clear about my priorities about getting things done about paying attention to the little things in life to this day today over 50 cases and two deaths from crypto cacus have been reported on Vancouver Island the outbreak is ongoing and the fungus is still reported in high concentrations in the Douglas fur Zone scientists continue to track it hoping to find a way to stop the lethal disease in time the people of Vancouver Island May well develop an imunity until they do the deadly spores are still a threat an ancient killer floating in the air [Music] [Music]