Page 5 of Outbreak Protocol

CHAPTER FOUR

ERIK

The subject line stops me cold: Urgent - Unidentified Disease Cluster Hamburg - Request ECDC Assessment.

The sender's credentials check out immediately—Dr. Felix Müller, emergency medicine, University Hospital Hamburg.

I pull up his professional profile while the email loads.

Pathology residency before transitioning to emergency medicine, published research on diagnostic accuracy in acute presentations, clean academic record. Not someone prone to panic.

His message is direct, clinical, refreshingly free of administrative hedging.

31 cases of what appears to be an unidentified infectious disease with alarming characteristics.

I lean forward, reading more carefully. The mortality rate alone—thirty percent—demands attention, but it's the description of symptoms that makes my pulse quicken.

Neurological complications paired with hemorrhagic manifestations.

Multi-organ failure. Possible zoonotic origin.

I open the first attachment, a meticulously organized spreadsheet tracking cases by date, location, and clinical progression. Each row represents a human being, but my mind immediately shifts into analytical mode, scanning for patterns that might reveal the nature of this threat.

The temporal distribution jumps out first. Cases clustered in the past three weeks, with increasing frequency over the last ten days.

Classic epidemic curve behaviour, suggesting ongoing transmission.

I trace my finger across the geographic data—twenty-seven cases within a fifteen-kilometer radius of central Hamburg, four cases in surrounding municipalities.

Distinct spatial clustering with gradual geographic expansion.

The clinical data is even more striking.

Dr. Müller has documented symptom onset times, progression rates, and outcomes with scientific precision.

Initial presentation consistently includes high fever, severe headache, and myalgia—standard viral syndrome symptoms that any emergency physician sees dozens of times weekly during flu season.

But the progression data tells a different story.

Day two to three: confusion, altered mental status, photophobia. Neurological involvement, suggesting either direct CNS invasion or significant inflammatory response.

Day four to six: petechial rash, epistaxis, gastrointestinal bleeding. Hemorrhagic manifestations indicating either thrombocytopenia or direct vascular damage.

Day seven onwards: acute kidney injury, respiratory failure, altered liver function. Multi-organ system involvement with rapid deterioration .

I pull up our pathogen database, cross-referencing these symptom combinations.

Viral hemorrhagic fevers share some characteristics—Ebola, Marburg, Lassa fever—but the neurological presentation is atypical.

Viral encephalitis presents with CNS symptoms but rarely progresses to systemic bleeding.

Bacterial meningitis can cause rapid deterioration but doesn't typically include hemorrhagic manifestations.

The case fatality rate calculation makes me pause.

Twenty deaths among thirty-one documented cases equals roughly sixty-five percent mortality.

For comparison, seasonal influenza kills less than one percent of infected individuals.

Even the 1918 pandemic influenza, which killed fifty million people worldwide, had a case fatality rate of only ten to twenty percent among severe cases.

Dr. Müller's epidemiological observations are particularly astute.

Multiple patients mentioned sick or deceased pets prior to symptom onset—suggesting possible zoonotic transmission.

Several cases clustered around specific locations: Café Liebermann, a local veterinary clinic, a kindergarten.

This isn't random community spread but focal point transmission, indicating either common source exposure or highly efficient person-to-person transmission in specific settings.

I draft a rapid risk assessment, fingers flying across the keyboard as years of epidemiological training synthesize the available data.

Pathogen: Unknown, likely viral based on clinical presentation and transmission pattern

Transmissibility: High to extremely high, R0 current estimated 3.0-4.5 based on cluster size and temporal distribution

Severity: High, case fatality rate approximately 65%

Geographic risk: Currently localized to Hamburg metropolitan area with evidence of gradual expansion

Public health significance: Urgent investigation required

I save the assessment and immediately dial Dr. Helena Karlsson, our Director of Epidemic Intelligence. Her phone rings twice before her crisp Swedish accent answers.

"This better be worth waking me at six in the morning, Erik."

"We have a potential emerging infectious disease outbreak in Hamburg. Unknown pathogen, sixty-five percent mortality rate, evidence of ongoing transmission."

The line goes quiet for several seconds. "Send me everything. I'll be in the office in twenty minutes."

I email her my preliminary assessment along with Dr. Müller's documentation, then begin pulling additional data from our German surveillance networks.

The routine influenza reports from Hamburg show elevated hospital admissions over the past two weeks, but nothing flagged as unusual.

Either the local health authorities haven't recognized the pattern, or they're not reporting it through official channels.

Dr. Karlsson arrives precisely twenty minutes later, still wearing her running gear but with the focused intensity that makes her one of Europe's most respected epidemiologists. She reviews the data in silence, occasionally asking pointed questions about my analysis.

"Have you verified these case reports independently?"

"Not yet, but Dr. Müller's clinical documentation is exceptionally detailed. His pathology background adds credibility to the diagnostic observations. I've no reason to doubt his conclusions."

"Contact with German authorities?"

"According to Dr. Müller, local hospital administration has dismissed his concerns as a seasonal influenza variation. He's reached out to us directly because official channels have been unresponsive, and he was unwilling to standby while nothing was done."

She closes the laptop and looks at me directly. "Your recommendation?"

"Immediate deployment of a rapid response team. This has all the characteristics of an emerging infectious disease outbreak requiring urgent investigation and potential containment measures."

"I concur. Assemble your team. I'll notify WHO headquarters and initiate formal protocols with German health authorities.

" She pauses at the door. "Erik, if this assessment is correct, we could be looking at the beginning of something significant.

Make sure your team is prepared for extended deployment. "

Within two hours, I've activated our rapid response protocols and assembled the core team. Dr. Sarah Brennan arrives first, her red hair pulled back in a practical ponytail, carrying two coffee cups and a tablet loaded with viral genome databases.

"Sixty-five percent mortality rate?" she asks without preamble, settling into the chair across from my desk. "That's nearly unprecedented territory. You're talking bubonic plague levels of fatality."

"Neurological symptoms are more prominent than typical VHF presentation," I reply, accepting the coffee gratefully. "But yes, the severity profile is very concerning."

Dr. Yuki Tanaka joins us ten minutes later, her laptop bag already over her shoulder and a portable modelling workstation under her arm. She spreads printed epidemic curves across the conference table, her eidetic memory having already processed the raw data I sent her.

"Temporal distribution suggests point source exposure followed by sustained person-to-person transmission," she reports, pointing to specific inflection points on her graphs.

"If we assume a generation time of five to seven days, we're looking at three to four transmission cycles already completed, which means we're already substantially behind this thing. "

Dr. Aleksandr Petrov arrives last, carrying a military-style duffel bag and wearing the expression of a man who's responded to epidemics in places where hospitals are tents and laboratories are whatever equipment fits in a backpack.

"What's our baseline assumption for pathogen containment?" he asks, settling his imposing frame into a chair that seems suddenly small. "Are we dealing with airborne transmission, contact precautions, or full biosafety protocols?"

"Unknown until we establish the causative agent, though if it was airborne it seems likely hospital staff would have already been infected," I reply. "We'll implement maximum precautions initially and scale down as we gather more data."

The team dynamics fall into their familiar rhythm—Sarah's viral expertise complementing Yuki's mathematical modelling, Aleksandr's field experience grounding our theoretical discussions in practical reality.

We've worked together through outbreaks across three continents, and our professional shorthand allows rapid decision-making even in high-stress situations.

"Travel arrangements?" Sarah asks, already pulling up flight schedules on her tablet.

"Commercial flight departing Stockholm at 14:30, arriving Hamburg at 16:15. German health authorities are being notified of our deployment, but Dr. Karlsson expects some resistance given the local response to date."

Aleksandr grunts his disapproval. "Damn politicians, always getting in the way." In a quiet but intense voice, he mutters to Sarah, "Vsegda odno i to zhe. Malen'kiye tsari na svoikh malen'kikh tronakh." I catch it easily: Always the same. Little tsars on their little thrones.