Scenario A

Disaster has struck - hard on the heels of the COVID-19 pandemic, another disease outbreak has hit your fair city, Inverkeld. Residents are outraged and worried. There have already been 23 deaths.

The cause of the outbreak appears to be Legionella pneumophila. (Please refer to the Legionnaire’s Disease Fact Sheet for more information about the pathogen.)

False-coloured scanning electron microscopy (SEM) image of a group of Legionella pneumophila cells. Image credit: [CDC](https://phil.cdc.gov/details.aspx?pid=11152)

Figure 1: False-coloured scanning electron microscopy (SEM) image of a group of Legionella pneumophila cells. Image credit: CDC

Each member of your group will play one of the following roles as you attempt to tackle the disease outbreak and save your city:

  1. Provost (head of the city council)
  2. Representative from a national public health org. (Public Health Scotland)
  3. Epidemiologist (on secondment from Public Health Scotland)
  4. Director of the city’s main hospital (Queen Rose)
  5. City planner/civil servant
  6. Microbiologist (working in one of the NHS Scotland clinical labs)
  7. Public communications expert (past and current sci comm campaigns)
  8. Doctor at a major surgery in Inverkeld
  9. Epidemiologist from the local university, an expert on Legionella pneumophila transmission

You must work together, using the information that has been provided for you in the attached information packets, and decide what action(s) should be taken to control the Legionella outbreak currently plaguing your city, Inverkeld. Your actions should be evidence-based – use the peer-reviewed literature to decide on measures that will stop the pandemic in your scenario.

Your action points may include directives to gather more information (e.g., contact tracing of current cases, microbiological testing of food/water, etc.), or specific directives (e.g. public health measures, non-pharmaceutical interventions, etc.). Use the data/expertise of all group members. Be clear, concise, and specific.

You may choose to include mathematical modeling as part of your decision making (for example, using an epidemic calculator or other models); if you do so, you should provide details of your modelling and predictions when you submit your group’s pro forma.

You should submit 3-5 specific actions to control the pandemic, using the workshop 3 pro forma (also available on MyPlace). Submit this by noon, Friday March 1st, via the submission link on MyPlace.

Information Packet A1

You are the provost of Inverkeld, elected in 2012.

Photograph of Inverkeld city centre. Image credit: DALL-E

Figure 2: Photograph of Inverkeld city centre. Image credit: DALL-E

The current population of Inverkeld (as of December 2022) is 152236. The demographic data for the city is shown below.

Inverkeld demographics (Source: Office for National Statistics)Inverkeld demographics (Source: Office for National Statistics)

Figure 3: Inverkeld demographics (Source: Office for National Statistics)

You were elected as a member of the popular “Environment First” party and made a number of election promises regarding a “Green New Deal” for Inverkeld. This is your first full year in office.

Voting intention by Inverkeld residents (Source: YouGov polling)

Figure 4: Voting intention by Inverkeld residents (Source: YouGov polling)

There are currently 43 elected councillors, representing the 5 main political parties in Inverkeld as follows:

Political Party Number of Seats
Revolutionary 3
Social Capital 13
Environment First 20
Wind Power 6
Social Redistribution 1



The overall budget (expenditures) for the 2022-2023 financial year was £596103293. A summary of expeditures by category for this financial year is shown below.

Public expenditures by category for the 2022-2023 financial year (Source: Inverkeld City Council)

Figure 5: Public expenditures by category for the 2022-2023 financial year (Source: Inverkeld City Council)

Your office has recently received a great deal of correspondence regarding the pandemic in Inverkeld. A representative sample of these e-mails is shown below.

From:
To:
Cc: Subject: This Sad Pandemic

Dear Provost,

I am so angry to hear about this new pandemic in Inverkeld. As if COVID wasn’t enough! Has this city not suffered enough, I ask you.

I wish that your office is going to do something about dreadful state of affairs very soon.

Kind regards,
Siobhan

From:
To:
Cc:
Subject: Pandemic Disaster for Businesses

Dear Provost,

This new pandemic in Inverkeld has the potential to crush our businesses. I run a toy store on the high street and almost went bankrupt due to COVID.

I hope you realise that you need to put businesses first now - we were unfairly forced to bear the costs of the last pandemic.

I sincerely hope that your office is going to do something about tragedy very soon, keeping in mind the economic interests of businesses in our city and the fact that we cannot afford face masks and gallons of hand sanitizer.

Kind regards,
Ailidh (Around the Corner, proprietor)

From:
To:
Cc:
Subject: Government Overstep

Dear Provost,

I hate the idea that you and your office are going to use this new pandemic as yet another excuse for government overreach into citizens’ lives. I am sick and tired of government interference with my life, I have the right to go about my life without some do-gooder from a public health agency telling me that I need to wear a mask and can’t visit my grandmother.

Please do not use this disaster as another opportunity for oppressive lockdowns and government control of our lives.

Sincerely,
Kieran (a concerned voter)

From:
To:
Cc:
Subject:

Dear Provost,

I have just learned that my my aunt has passed away due to the new pandemic in Inverkeld. The family are all devastated by this loss.

Words cannot begin to describe our loss.

I am sure that you and your office are doing your best, but I hope that in the fullness of time, there will be a public inquiry into how this pandemic was handled and why so many families have lost loved ones. Especially coming so soon after the lessons that we learned during the COVID-19 pandemic, I would have thought that this tragedy could have been prevented.

Kind regards,
Anika

As Provost of Inverkeld, you are of course familiar with the work of the Standing Committee on Pandemic Preparedness. You are also familiar with:

Information Packet A2

You are a representative from Public Health Scotland, sent to Inverkeld to help with the Legionella outbreak.

Your briefing packet includes the following documents:

Information Packet A3

You are an epidemiologist working for Public Health Scotland, sent to Inverkeld to help with the Legionella outbreak.

A team of scientists working together have cultured Legionella pneumophila from a number of patient sputum samples; isolated genomic DNA from these strains; sequenced this genomic DNA using an Illumina MiSeq platform; assembled the short paired-end reads; and compared these assemblies to the extant Legionella pneumophila sequences available in the NCBI databases. The results of these experiments are summarised in the table below.

Patient NCBI accession of closest database match
1 GCA_022577225.1
2 GCA_022577275.1
3 GCA_022577345.1
4 GCA_022576795.1
5 GCA_022577275.1
6 GCA_022577225.1
7 GCA_022577345.1
8 GCA_022577345.1
9 GCA_022577225.1
10 GCA_022577345.1



Your briefing packet also includes the following documents:

  • Gorzynski, Jamie et al. “Epidemiological analysis of Legionnaires’ disease in Scotland: a genomic study.” The Lancet. Microbe vol. 3,11 (2022): e835-e845.

  • Cameron, R L et al. “Comparison of Legionella longbeachae and Legionella pneumophila cases in Scotland; implications for diagnosis, treatment and public health response.” Journal of medical microbiology vol. 65,2 (2016): 142-146.

  • Khodr, A et al. “Molecular epidemiology, phylogeny and evolution of Legionella.” Infection, genetics and evolution : journal of molecular epidemiology and evolutionary genetics in infectious diseases vol. 43 (2016): 108-22. doi:10.1016/j.meegid.2016.04.033

  • Buultjens, Andrew H et al. “A Supervised Statistical Learning Approach for Accurate Legionella pneumophila Source Attribution during Outbreaks.” Applied and environmental microbiology vol. 83,21 e01482-17. 17 Oct. 2017, doi:10.1128/AEM.01482-17

Information Packet A4

You are the director of Inverkeld’s main hospital, the Queen Rose, which has 500 beds across 8 different wards and 10 operating theatres.

The Queen Rose hospital in Inverkeld. Image credit: [DALL-E

Figure 6: The Queen Rose hospital in Inverkeld. Image credit: [DALL-E

The annual operating budget for financial year 2022-2023 was £1.3 million, and average expenditures are shown by category in the figure below.

Hospital expenditures by category for financial year 2022-2023 (Source: NHS Scotland)

Figure 7: Hospital expenditures by category for financial year 2022-2023 (Source: NHS Scotland)

The Queen Rose has units specialising in coronary care; maternity care; paediatic care; an ear, nose, and throat clinic; an eye clinic; and an orthopedic unit.

There are currently 25 ICU beds (with ventilators) available, an increase from the 17 ICU beds in the Queen Rose in September 2019. Average ICU bed occupancy before and during the COVID-19 pandemic is in Figure 8.

ICU bed occupancy for the Inverkeld Queen Rose hospital (Source: NHS Scotland)

Figure 8: ICU bed occupancy for the Inverkeld Queen Rose hospital (Source: NHS Scotland)

There are approximately 1.1m admissions to the Queen Rose hospital annually, the majority of these being to the emergency (A&E) department.

Admissions to the Inverkeld Queen Rose hospital by category (Source: NHS Scotland)

Figure 9: Admissions to the Inverkeld Queen Rose hospital by category (Source: NHS Scotland)

A&E waiting times have been called “unacceptably high” in recent months, both by the press and by the hospital ombudsman.

ICU waiting times for the Inverkeld Queen Rose hospital (Source: NHS Scotland)

Figure 10: ICU waiting times for the Inverkeld Queen Rose hospital (Source: NHS Scotland)

The Queen Rose has been set a goal of 25% reduction in sepsis mortality (compared to past years)and 50% reduction in the nosocomial transmission of superbugs such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridiodes difficile (C. diff), and Candida auris (C. auris).

Key Performance Indicators (KPIs) related to infectious diseases for the Inverkeld Queen Rose hospital (Source: NHS Scotland)

Figure 11: Key Performance Indicators (KPIs) related to infectious diseases for the Inverkeld Queen Rose hospital (Source: NHS Scotland)

There are currently 54 patients in the Queen Rose with confirmed or suspected Legionnaire’s disease, with 13 of these patients currently in the ICU.

The hospital follows the guidelines set out in the National Infection Prevention and Control Manual.

As a hospital director, you are familiar with the literature surrounding hospital pandemic preparedness, and regularly read papers such as:

  • Mer, Mervyn et al. “Critical Care Pandemic Preparation: Considerations and Lessons Learned from COVID-19.” Critical care clinics vol. 38,4 (2022): 761-774.

  • Tacconelli, Evelina et al. “Challenges of data sharing in European Covid-19 projects: A learning opportunity for advancing pandemic preparedness and response.” The Lancet regional health. Europe vol. 21 (2022): 100467.

  • Adelaja, I., Sayma, M., Walton, H., McLachlan, G., de Boisanger, J., Bartlett-Pestell, S., Roche, E., Gandhi, V., Wilson, G. J., Brookes, Z., Yeen Fung, C., Macfarlane, H., Navaratnam, A., James, C., Scolding, P., & Sara, H. (2020). A comprehensive hospital agile preparedness (CHAPs) tool for pandemic preparedness, based on the COVID-19 experience. Future healthcare journal, 7(2), 165–168.

Information Packet A5

You are a civil servant working in Inverkeld, working closely with the provost, city council and various agencies including the NHS and and SEPA (Scottish Environment Protection Agency).

Some of the key Inverkeld facts and figures at a glance are summarized in the table below.

Community Amenities Details
Schools 5 primary schools, 3 secondary schools, 1 college
Care Homes 4, each with ~50 bed capacity
Restaurants and Cafes 97
Parks and Playgrounds 9
Economic Indicators Details
GDP/capita £45054
Unemployment Rate 7%
Traffic and Transport Details
Traffic fatalities (average/month) 15



Most of the Inverkeld water supply comes from nearby Loch Cairnavar. There are two wastewater treatment plants serving Inverkeld, employing a total of 145 people.

Inverkeld water usage for 2022-2023 (Source: SEPA)

Figure 12: Inverkeld water usage for 2022-2023 (Source: SEPA)

Your briefing packet on Legionnaires’ Disease includes the following information.

  • Legionnaires’ Disease: Use water management programs in buildings to help prevent outbreaks CDC fact-sheet.

  • Currie, S L et al. “Legionella spp. in UK composts–a potential public health issue?.” Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases vol. 20,4 (2014): O224-9.

  • McCormick, D et al. “Public health response to an outbreak of Legionnaires’ disease in Edinburgh, United Kingdom, June 2012.” Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin vol. 17,28 20216. 12 Jul. 2012, doi:10.2807/ese.17.28.20216-en

  • Hyland, J M et al. “Outbreak of Legionnaires’ disease in West Fife: review of environmental guidelines needed.” Public health vol. 122,1 (2008): 79-83.

Information Packet A6

You are a microbiologist working in the bacteriology department at the Greater Inverkeld Clinical Laboratory. Your laboratory is equipped to handle a range of culture samples (including anaerobic and microaerobic organisms), and you routinely process 1897 samples monthly.

You are familiar with the culture requirements for growth of Legionella pneumophila, and UK Standards for Microbiology Investigations (UK SMI): Identification of Legionella species.

Legionella grown on BCYE agar. Image credit: [CDC](https://www.cdc.gov/legionella/resources/materials.html)

Figure 13: Legionella grown on BCYE agar. Image credit: CDC

You are also familiar with the literature surrounding Legionella identification, and often read papers such as:

  • CDC guidance on processing environmental samples

  • Benitez, Alvaro J, and Jonas M Winchell. “Clinical application of a multiplex real-time PCR assay for simultaneous detection of Legionella species, Legionella pneumophila, and Legionella pneumophila serogroup 1.” Journal of clinical microbiology vol. 51,1 (2013): 348-51.

  • Pascale, Maria Rosaria et al. “Use of Fourier-Transform Infrared Spectroscopy With IR Biotyper® System for Legionella pneumophila Serogroups Identification.” Frontiers in microbiology vol. 13 866426. 26 Apr. 2022, doi:10.3389/fmicb.2022.866426

Information Packet A7

You are a public communications expert, often employed by the Inverkeld city council to manage the PR response to different initiatives or crises.

As a public communications expert, you are familiar with the literature surrounding science communication in a pandemic, including papers such as:

  • Matta, G. Science communication as a preventative tool in the COVID19 pandemic. Humanit Soc Sci Commun 7, 159 (2020).

  • Abdool Karim, Salim S. “Public understanding of science: Communicating in the midst of a pandemic.” Public understanding of science (Bristol, England) vol. 31,3 (2022): 282-287.

  • Royan, Regina et al. “Use of Twitter Amplifiers by Medical Professionals to Combat Misinformation During the COVID-19 Pandemic.” Journal of medical Internet research vol. 24,7 e38324. 22 Jul. 2022, doi:10.2196/38324

  • Tait, Margaret E et al. “Serving the public? A content analysis of COVID-19 public service announcements airing from March - December of 2020 in the U.S.” Preventive medicine reports vol. 29 (2022): 101971.

You have assembled the following information/resources for this meeting:

Information Packet A8

You are one of the doctors at the largest surgery in Inverkeld. In the past fortnight, 17 of your patients have recently presented to the surgery with symptoms consistent with Legionnaire’s disease. You have therefore recently been familiarising yourself with the relevant literature:

Information Packet A9

You are an epidemiologist working at the University of Inverkeld, and have been studying Legionella transmission dynamics for the past 9 years. As such, you are very familiar with the relevant literature, including papers such as:

  • Grossmann NV, Milne C, Martinez MR, et al. Large Community Outbreak of Legionnaires Disease Potentially Associated with a Cooling Tower - Napa County, California, 2022. MMWR Morb Mortal Wkly Rep. 2023;72(49):1315-1320. Published 2023 Dec 8. doi:10.15585/mmwr.mm7249a1

  • Mentula S, Kääriäinen S, Jaakola S, et al. Tap water as the source of a Legionnaires’ disease outbreak spread to several residential buildings and one hospital, Finland, 2020 to 2021. Euro Surveill. 2023;28(11):2200673. doi:10.2807/1560-7917.ES.2023.28.11.2200673

  • Zayed AR, Bitar DM, Steinert M, et al. Comparative Genomics of Legionella pneumophila Isolates from the West Bank and Germany Support Molecular Epidemiology of Legionnaires’ Disease. Microorganisms. 2023;11(2):449. Published 2023 Feb 10. doi:10.3390/microorganisms11020449

  • Domazetovska A, Jensen SO, Gray M, Radzieta M, Maley M. Culture-Free Phylogenetic Analysis of Legionella pneumophila Using Targeted CRISPR/Cas9 Next-Generation Sequencing. Microbiol Spectr. 2022;10(4):e0035922. doi:10.1128/spectrum.00359-22

  • Ricci ML, Fillo S, Ciammaruconi A, et al. Genome analysis of Legionella pneumophila ST23 from various countries reveals highly similar strains. Life Sci Alliance. 2022;5(6):e202101117. Published 2022 Mar 2. doi:10.26508/lsa.202101117

  • Slow S, Anderson T, Murdoch DR, Bloomfield S, Winter D, Biggs PJ. Extensive epigenetic modification with large-scale chromosomal and plasmid recombination characterise the Legionella longbeachae serogroup 1 genome. Sci Rep. 2022;12(1):5810. Published 2022 Apr 6. doi:10.1038/s41598-022-09721-9

  • Uldum SA, Schjoldager LG, Baig S, Cassell K. A Tale of Four Danish Cities: Legionella pneumophila Diversity in Domestic Hot Water and Spatial Variations in Disease Incidence. Int J Environ Res Public Health. 2022;19(5):2530. Published 2022 Feb 22. doi:10.3390/ijerph19052530