I had the honor of being the first case reported officially from the United Arab Emirates (UAE). It was 3 am on Sunday, 17th May when I arrived at Dubai Airport, via Calgary and Heathrow, after spending a week with my family in Saskatoon, Canada. Later that day I returned to my department at the university where several colleagues passed by my office to welcome me back. That night l developed a sore throat, high fever, and cough. At 8 am the following day, feeling lethargic and generally unwell and fearing the worst, I went to the emergency department of our local hospital and presented myself to the on-duty infectious diseases consultant.
As a public health physician, I had taken stock of the situation before my travel to Canada on 8th May. At that time, the World Health Organization was not recommending restrictions on travel, although some individual national authorities were advising against non-essential travel. The advice on the various websites seemed very pragmatic: observe basic hygiene, hand-washing and cough etiquette; do not travel when ill and seek medical advice if becoming ill after returning. My route took me through London (34 cases reported in the UK at that time) and Toronto (61 cases in Ontario) to Saskatoon (2 cases). By the time I was due to return to UAE via Calgary, cases in Canada had increased from 242 to 496 with 19 in Saskatchewan and 67 in Alberta. During my stay in Saskatoon I had not encountered anyone with respiratory symptoms and I was quite well as I set out on my journey home.
At hospital, I discussed any possible exposure to H1N1 with the physician. A combined influenza A and B antigen screen on a nasopharyngeal swab was positive, and so an additional swab and a blood sample were sent for further testing. I was prescribed oseltamivir 75mg orally twice daily for five days, and advised to remain at home until the confirmatory test results were available.
By the following morning, my fever and sore throat had subsided and I was feeling better. Despite the possibility of H1N1 influenza, the situation was still uncertain and I had to make some important decisions. I cancelled all my appointments for the day, but decided to go ahead with a very important engagement – a ten- minute presentation of a research grant proposal to six of my peers. I returned home immediately after the presentation.
On Sunday 24 May, I received a call from the Health Authority confirming Influenza A (H1N1) infection. I was therefore in the unenviable position of being the first reported case of H1N1 infection in the UAE. I was admitted to hospital with airborne and contact isolation, where I completed the rest of the maximum recommended 10 days quarantine period. Browsing the CDC website enabled me to ascertain my own risk for complications and the likelihood of succumbing to this infection. I recall a sense of apprehension with real or imagined breathlessness as I read about the presenting symptoms and signs of severe cases, but my symptoms and fears soon abated and I was finally discharged home and allowed to return to work.
This case raised issues for my place of work and the wider public health. Measures taken by the UAE to prevent an influenza epidemic include the installation of thermal scanners at the airports. I was afebrile and symptom-free on arrival, and so was not detained for further enquiry. The thermal scanners will detect individuals with fever from whatever cause, but will not necessarily detect those with early H1N1 infection. This technology also has a low predictive value for a positive screen. (1)
It was felt that there should be a coordinated effort regarding the provision of information at the medical school and university. Enquiries from local newspapers were directed to a senior administrator to ensure a consistent response. A message was sent to all staff and students emphasizing the importance of basic good hygiene to limit transmission.
I had not had any contact with students, and had only transient contact of not more than 15 minutes in the same area with colleagues at work. Colleagues with whom I had face-to-face contact were contacted personally and advised of what had happened. My contacts were asked to be watchful for the development of fever or other influenza symptoms and to contact our infectious disease consultant if they had any concerns. Doctors, nurses and ancillary healthcare staff who looked after me were briefed about infection control procedures for H1N1, and provided with N-95 masks, gloves and aprons as appropriate.
Our local public health department took swift actions. Family members with close contact were quarantined at home, and given a prophylactic course of oseltamivir. Adequate supplies of food and provisions and maintenance of phone communication was confirmed. The public health department fielded all enquiries from the public following media publicity about my case. The official release of information and contact with the WHO was through the federal Ministry of Health. The airline with which I had travelled from Canada to the UAE sought to contact passengers in the rows adjacent to my allocated seat. As far as I am aware, no cases were detected from this exercise.
Where new epidemics of infectious diseases appear, history has shown that the cases have often included healthcare workers, and their family members. (2) The early cases of SARS and H5N1 infection included doctors and nurses.(3,4) The likelihood of healthcare staff being affected in such infections is high, especially in the absence of adequate infection control measures, or if there is poor compliance with recommended
precautions. In my experience as the first reported case of H1N1 infection in the UAE, I like to think that prompt action on my part and by the authorities minimized the chance of transmission to others, and that the timely and coordinated provision of information reduced worry and anxiety. To my knowledge, I did not spread H1N1 to others in the UAE.
Inevitably stories about me appeared in the local media, reflecting enormous public interest in this new infection but also tinged with some understandable anxiety because of the uncertainties at that time. We now know that H1N1 usually causes a mild typical influenza-like illness, although there have been serious outcomes reported in those with pre-existing medical conditions and in pregnant women. Fortunately, I was in neither category, although the fact that I was a public health professional caused some amusement!
1. Bitar D Goubar A, Desenclos JC. International travels and fever screening during epidemics: a literature review on the effectiveness and potential use of non-contact infrared thermometers Eurosurveillance 2009;14(6):19115, available at: www.eurosurveillance.org.
2. Collins C, Aw TC, Grange J, (1997). Microbial diseases of occupations, recreation, and sports. London: Butterworths
3. Koh D. (2006). Emerging infections among health care workers: Lessons from severe acute respiratory syndrome (SARS). J UOEH:28 (Suppl May 20, 2006):30-33.
4. Reilley B, van Herp M, Sermand D, Dentico N (2003). SARS and Carlo Urbani. NEJM 348;20:1951-1952
Syed M Shah (MBB MPH PhD) is Associate Professor at Faculty of Medicine and Health Sciences at the University of United Arab Emirates in Al Ain. He is also an adjunct Associate Professor at School of Public Health, University of Saskatchewan, Canada.