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The shocking story behind the primary case of LA COVID-19 – Los Angeles Occasions

the-shocking-story-behind-the-primary-case-of-la-covid-19-los-angeles-occasions

The family arrived at Los Angeles International Airport on their way home from a short-lived and uncomfortable Mexican vacation. They were exhausted, the father was struggling with a nasty stomach problem, and before they even settled in their Cancun hotel, they learned of the sudden death of the woman's mother in her hometown: Wuhan, China.

The couple and their young son wanted to go back for the funeral and planned to be in LAX just long enough to change planes. As they passed Tom Bradley International Terminal on January 22nd, the father was overwhelmed by a fever and ache and asked a customs officer for help.

The family did not fly that Wednesday night and, in fact, would not be returning to China for more than a month. The father, Qian Lang, became the first confirmed case of COVID-19 in Los Angeles and the fourth in the United States. He remained the only patient diagnosed with the virus here for five weeks and spent most of the time in top-secret isolation at Cedars-Sinai Medical Center.

The 38-year-old salesman played an important role, previously not widely known, in a frantic race to understand the deadly new virus before it hit the United States in full. Officials and public health researchers viewed it as a real-time flesh-and-blood case study.

Qian (pronounced chee-an) gave them early insight into health worker protection, contact tracing, and treatment. He was the second virus patient in the world to take the drug Remdesivir, experimental at the time and now a standard therapy for seriously ill people with COVID-19.

For his family, Qian's illness and recovery meant a strange and frightening stay in California. Although his preschool-age wife and son tested negative, they stayed with him at Cedars-Sinai in the closest approximation of an acceptable home life infection protocol: adjoining isolation suites separated by glass.

"We realize this is a tremendous burden for this poor woman," said Barbara Ferrer, LA County director of public health. "You yourself. Didn't really speak the language. And to look after a child around the clock all day in a confined space."

Barbara Ferrer, Los Angeles County Director of Public Health, speaks at a news conference with Los Angeles Mayor Eric Garcetti (left) on March 12 in Los Angeles

(Damian Dovarganes / Associated Press)

Ferrer and other health professionals said privacy laws prevented them from identifying Qian by name or disclosing details of his care. However, they agreed to speak broadly about his case, which featured in half a dozen prominent research studies. In one it is called "CA1". In another case "patient 9".

This story is based on published scientific articles, interviews with public health officials and clinicians, ambulance records, an airport police report naming Qian and his wife, and a February interview he posted on a Chinese news blog, Deeper Wuhan, under a Pseudonym gave.

Qian did not reply to messages he left on a social media account. The anonymous author of the Wuhan blog article said she contacted him on behalf of the Times, but he declined an interview request.

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"The husband himself reported to one of his officers that he needed medical attention and that he may be suffering from the flu because he has a bad cough and … a runny nose."

a report from the airport police

Americans didn't pay much attention to COVID-19 when Qian landed in LAX. President Trump's impeachment trial and Iowa rallies dominated the news, and water coolers in LA – and water coolers back then – were less likely to talk about the new virus in Wuhan than "parasites" heading for an Oscar shot for the best picture or LeBron James' endeavor to overtake the living Kobe Bryant on the list of all-time NBA scorers.

However, at the L.A. County Health Department, epidemiologists and other experts were on the lookout for the first inevitable cases. They spoke regularly with the US Centers for Disease Control and Prevention. By mid-January, there was enough awareness of the virus in the medical community that doctors called the county with suspected cases.

"There was a lot of flu at the time," said Dr. Sharon Balter, the district director for Acute Communicable Disease Control, and recalled hundreds of calls her colleagues had received. Many were clearly not COVID-19, she said, but "We expected a large number of trips between LA and China to have a case at some point, so we definitely prepared for that."

Every suspect patient had to be treated as if infected until the test results came back from the CDC laboratory in Atlanta, which was then the only testing facility. More than once, Balter and her colleagues were convinced they had a real virus patient only to get a negative result from Georgia.

Ambulance workers transfer a man on a stretcher from the Life Care Center in Kirkland, Washington, to an ambulance.

Ambulance workers transfer a man on a stretcher from the Life Care Center in Kirkland, Washington, to an ambulance. At the time, the facility was a hotbed of the COVID-19 pandemic.

(Ted S. Warren / Associated Press)

It was the third week of January that COVID-19 was discovered on American shores. On Sunday, January 19, a man was seeking cough and fever treatment at a Washington state clinic. He was the first in the United States to be diagnosed with the virus. A day later, a woman from Chicago was hospitalized with pneumonia. She became the second. Orange County received the third case this Wednesday. All three had been in Wuhan shortly before they fell ill. Everyone would survive.

Qian was next. He, his wife Liu Ying, and their son set off from Wuhan earlier this week on a long-planned Caribbean vacation. They were aware of the virus but "pretty relaxed overall," he later told the blog. The local health commission in Wuhan reported only 62 cases and two deaths at the time of her departure on Jan. 19. Health officials there found that many of those affected had mild symptoms, and the city's best public health doctor told a government news program that "the infectiousness of the new coronavirus is not high".

Still, Qian, the son of a doctor who was marked by safety protocols from a young age, took precautions that public health officials later described as significant. On flights from Wuhan to Mexico City, he wore a mask, one of the few on board to do so, and blew up the vents to increase blood flow to his family.

The couple and their child, who bonded via LAX on their way to Mexico, were examined by the CDC but showed no symptoms. Qian told the blog that his temperature was so low that a screener joked, "Are you a vampire?"

Jose Mendoza uses an electrostatic sprayer to disinfect the cabin of a United Airlines 737 jet in LAX on July 9th.

Cleaning manager Jose Mendoza disinfects the cabin of a United Airlines 737 jet with an electrostatic sprayer before passengers are allowed to board in LAX on July 9 in Los Angeles.

(Mel Melcon / Los Angeles Times)

The family planned to spend time in Mexico City before heading to their Caribbean destination, but tiredness and weakness gripped them, and Qian contracted giardia, a common parasite that affects travelers with diarrhea. The family rarely ventured out of the hotel. On the second day, Liu's father called her and said her mother had a fever. The next day he reported that he had called an ambulance, but it was too late and she had died.

The family packed their bags and headed back through LAX. After putting on the chair, Qian felt hot and, as he told the blog, "powerless". Customs clearance "The husband himself reported to one of his officers that he needed medical attention and may have the flu because he had a bad cough and … a runny nose," an airport police sergeant wrote in a report. He noted that the family "came from Wuhan, where the coronavirus originated".

The situation in her hometown had grown dire in the three days since she left. Authorities reported hundreds of new cases and instead of downplaying the threat, officials prepared to lock down the 11 million-strong city to stop the virus from spreading.

When CDC staff at Qian's airport found out about Wuhan’s connection, symptoms and the sudden death of his mother-in-law, they suspected the virus and called for a Los Angeles Fire Department ambulance specially equipped for COVID patients. The family was taken to Cedars-Sinai Marina del Rey Hospital.

“The information from China was increasingly worrying. No treatment was known at this point. "

Dr. Jonathan Grein, Cedars Director of Epidemiology

The crew, dressed from head to toe in protective clothing, allowed the boy and his parents to sit side by side on the stretcher, Qian told the blog, adding the American authorities, “Your response is very professional, punctual and quick! ”

Tests sent to Atlanta confirmed that Qian was positive and Liu and her son were negative, despite having the flu together. The family was taken to the Cedars flagship on Beverly Boulevard, a celebrity favorite where Kim Kardashian was born and Frank Sinatra died. The blog didn't name the hospital, but Qian described it as "a very famous medical facility," and photos of an isolation unit published with the blog post show staff in teal scrubs worn at Cedars.

Top secret care was taken for granted at Cedars, and many who worked there were unaware of the presence of a COVID patient. A staff member, who spoke on condition of anonymity, said the family was housed in a special wing of the pediatric intensive care unit on the fourth floor, which was protected by a security guard. A photo on the blog shows Qian's room, which is decorated with "Minions" cartoon characters, as the staff member said, adorns the walls of Cedars' pediatric intensive care unit.

The family's electronic medical records were labeled "glass breaking". This classification prevents staff from spying on famous patients by asking them to re-enter their password and provide a reason for viewing the recordings. The staff member asked for anonymity to speak publicly about patient care.

Cedars-Sinai Medical Center

Cedars-Sinai Medical Center in Los Angeles.

(Kirk McKoy / Los Angeles Times)

The Cedars team took aggressive steps to quarantine the hospital's COVID-19 patients, following protocols established for Ebola and other pathogens, said Dr. Jonathan Grein, Cedars Director of Epidemiology. The measures were more extreme than with COVID-19, but at the time, Grein said in an interview, "the team was looking into the void and wasn't sure what was going to happen."

And then Qian got worse.

Grein described a nerve-wracking time with frequent conference calls arranged by the CDC to consult the doctors who care for the 11 other patients in the United States. Of these, Qian was the most seriously ill.

"The information from China was increasingly worrying," said Grein. "No treatment was known at the time."

For days the Chief Medical Officer of the Influenza Department of the CDC, Dr. Tim Uyeki, to recruit COVID-19 patients for experimental treatment. Remdesivir was an experimental antiviral drug developed by Gilead Sciences a decade earlier and briefly tested on Ebola victims. It wasn't particularly effective: of 175 test candidates, 93 had died – most from Ebola and one possibly from treatment.
Qian initially had only common flu symptoms that could be treated with pain relievers and cough medicine. But by the second week his temperature rose, his lungs filled with fluids, and he tried to breathe. He was given oxygen and monitored around the clock. One night, with his wife and child across a glass window, he was tapping a will on his phone, he told the blog.

Doctors told Qian about the experimental trials with remdesivir, but he was concerned, according to the blog. Twice he told the doctors that he did not want to try.

Qian's condition remained grave. While struggling to breathe, he told the blog, he often thought of the bravery his young son had shown when the family had a blood test, clenched his little fist and called out to his father, "Dad, you have to stay tuned! ”

When the doctors approached him for the third time, he agreed to try remdesivir. An interpreter read him a five-page consent form over the phone, and then the drug was given intravenously.

After a day, his fever dropped. Soon he no longer needed the oxygen.

"The doctors were amazed," he told the blog, adding that it had been asked whether his recovery was due to the drugs or his own immune system. “I told him I think it was both. Having a calm, optimistic demeanor also helped. "

Qian's case was included in an encouraging study of remdesivir published in the New England Journal of Medicine last month. Fifty-three patients hospitalized for the virus received the drug in different countries. Seven died. But 68% have improved.

Despite ongoing concerns about side effects, it has become so widespread that hospitals from India to San Francisco are reporting bottlenecks.

A vial containing the drug remdesivir was shown during a press conference.

A vial with the drug Remdesivir was shown during a press conference about the start of a study in Hamburg on April 8, 2020.

(Ulrich Perrey / AFP / Getty Images)

While Qian's recovery was exciting for the medical team, it didn't mean he and his family could go home. Little was known about how long patients remained contagious. Grein said officials decided it would be safest to stay in isolation and after 27 days with Cedars, he was moved to another secret medical facility.

The county was closely monitoring the airport first responders and Cedars staff who had contact with the family looking for signs of illness. At the time, it was not known that asymptomatic people could spread the virus.

Dr. Howard Chiou, a CDC epidemiologist, recalled being cut off in the middle of a weekend dinner to help with Qian's case. Chiou, who is fluent in Mandarin, worked directly with the family to create a list of places and people to keep track of.

"Case research and contact tracing are really hard and complicated jobs that require building a strong relationship and trust in a very short amount of time," said Chiou. "This case was a great reminder that language and cultural skills are critical to building trust and relationship."

Public health officials reached out to their Mexican counterparts so the hotel could be made aware of the case. They also alerted passengers sitting near the family on the flight from Mexico City, as well as the flight crew.

In the end, no one is known to have been infected by Qian. Some health care workers developed respiratory symptoms, but the tests came back negative.

"It really helped us reflect on the issues people are facing in isolation and in quarantine, especially travelers or people without safe shelter."

CDC epidemiologist Dr. Howard Chiou

Epidemiologist David Engelthaler, director of infectious diseases at the Translational Genomics Research Institute in Arizona, said the COVID strain that infected Qian did not recur among thousands of samples shared by researchers around the world. He said the absence suggests Qian is not infecting others and is "a dead end" for the virus, although he warned the tests were limited. Most Cedars employees were not told that there was a COVID patient in their facility at the time and were not offered tests.

"I don't think there was any spread," said Balter. Public health officials believe that the precautions Qian took while traveling and asking for help kept others safe.

"He was very good at wearing his mask when he was around (his family) and on the plane," said Balter.

By mid-February, COVID had crept around the world and started ravaging South Korea and Italy, but Qian was still the only known case from LA. Concerned about the toll that isolation was taking on Qian's wife and son, public health workers bought toys for the boy and worked to ensure that the family had the food they liked.

Ferrer said they learned from the family that in order to isolate successfully, people need personal assistance from health workers.

“It made a huge difference. It wasn't just that they were getting good clinical care, ”she said.

Chiou, the CDC epidemiologist, agreed, saying, "It has really helped us reflect on the problems people face isolated and quarantined, especially travelers or those without safe shelter."

On March 4, 42 days after Qian turned to LAX for help, the county announced it had identified six more cases of COVID-19. In hindsight, officials said, strict restrictions on testing and ignorance of the virus' asymptomatic spread prevented public health officials from discovering many already infected people.

"We clearly had other cases," said Ferrer.

Qian was still isolated when the story of his care in the US was posted on the Wuhan blog. Relations between China and the United States were stressed and deteriorating. Some readers were cynical about the positive portrayal of U.S. medical care.

An air traveler waits to fly to China at the Tom Bradley International Terminal at Los Angeles International Airport.

A passenger waits to depart for China on Monday, May 11th, at the Tom Bradley International Terminal at Los Angeles International Airport.

(Al Seib / Los Angeles Times)

"This person was cured by Remdesivir without paying a dime," wrote one poster. "I very much doubt this article."

It is unclear whether Qian or the Chinese consulate, which was notified of his case, paid anything. Cedars and the consulate declined to answer questions about his case, citing the patient's privacy.

For his part, Qian was grateful.

"He sent the department a very, very grateful thank you letter," Ferrer said.

The Times staffer Alice Su in Beijing contributed to this report.

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