Scenario I

Disaster has struck - hard on the heels of the COVID-19 pandemic, another disease outbreak has hit your fair city, Ardkeld. Residents are outraged and worried. There have already been 10 deaths.

The cause of the outbreak appears to be Bacillus anthracis. (Please refer to the CDC Anthrax Fact Sheet for more information about the pathogen.)

Scanning electron micrograph of Bacillus anthracis endospores. Image credit: [CDC](https://phil.cdc.gov/details.aspx?pid=10123)

Figure 1: Scanning electron micrograph of Bacillus anthracis endospores. 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 (Riverview)
  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 Ardkeld
  9. Epidemiologist from the local university, an expert on Bacillus anthracis 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 outbreak currently plaguing your city, Ardkeld. 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 I1

You are the provost of Ardkeld, elected in 2016.

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

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

The current population of Ardkeld (as of December 2022) is 157072. The demographic data for the city is shown below.

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

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

You were elected as a member of the popular “Progressive Earth” party and made a number of election promises regarding a “Green New Deal” for Ardkeld.

Voting intention by Ardkeld residents (Source: YouGov polling)

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

There are currently 34 elected councillors, representing the 5 main political parties in Ardkeld as follows:

Political Party Number of Seats
Sovereign People 1
Green Evolution 12
Progressive Earth 15
Unconditional Unity 5
Universal Prosperity 1



The overall budget (expenditures) for the 2022-2023 financial year was £460010956. A summary of expenditures by category for this financial year is shown below.

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

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

Your office has recently received a great deal of correspondence regarding the pandemic in Ardkeld. 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 Ardkeld. This seems to be too much to bear on top of COVID, the cost of living crisis, and the war in Ukraine. It is just one tragedy after another.

I expect that your office is going to do something about tragedy immediately.

Kind regards,
Graham

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

Dear Provost,

This new pandemic in Ardkeld has the potential to destroy our businesses. I run a bookshop on the high street and practically had to shut our doors during COVID 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 expect that your office is going to do something about tragedy as soon as possible, 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,
Anna (Around the Corner, proprietor)

From:
To:
Cc:
Subject: Government Overreach

Dear Provost,

I abhor the idea that you and your office are going to use this new pandemic as yet another excuse for government overreach into citizens’ lives. Machiavelli said that power corrupts absolutely, and he was absolutely right - look at what happened during the last pandemic.

You must not allow the city to suffer through another round of lockdowns, face-masks, and other punitive restrictions that destroy people’s lives.

Yours truly,
Roman (a concerned voter)

From:
To:
Cc:
Subject:

Dear Provost,

I have just learned that my my sister-in-law has passed away due to the new pandemic in Ardkeld. Words cannot begin to describe our loss.

This is especially terrible coming hard on the heels of all of our losses due to COVID-19.

I don’t understand why we haven’t learned how to deal with pandemics better, after all our experiences with COVID-19, I don’t understand how this could have happened.

Best wishes,
Madison

As Provost of Ardkeld, you are of course familiar with the work of the Standing Committee on Pandemic Preparedness, the UK Pandemic Preparedness plan, and the latest COVID-19 health protection guidance released by Public Health Scotland.

Information Packet I2

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

Your briefing packet includes the following documents:

Anthrax: how to spot and report the disease (ScotGov)

Exotic notifiable animal diseases contingency plans - Scottish Regional Resilience Partnerships’ framework: August 2022

Public Health Scotland: Gastrointestinal and Zoonoses Biennial report 2020 to 2021 Cross AR, Baldwin VM, Roy S, Essex-Lopresti AE, Prior JL, Harmer NJ. Zoonoses under our noses. Microbes Infect. 2019;21(1):10-19. doi:10.1016/j.micinf.2018.06.001

Inverarity DJ, Forrester VM, Cumming JG, et al. Injectional anthrax at a Scottish district general hospital. Epidemiol Infect. 2015;143(6):1311-1321. doi:10.1017/S0950268814001885

Information Packet I3

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

A team of scientists working together have in a PHS lab have isolated and cultured B. anthracis (using a standard tissue culture model) from a number of patient samples taken during this outbreak; isolated B. anthracis genomic DNA from these cultures; and sequenced this DNA using an Illumina MiSeq platform; assembled the short paired-end reads; and compared these assemblies to the extant B. anthracis 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_022220665.1
2 GCA_022220665.1
3 GCA_022220665.1
4 GCA_022220665.1
5 GCA_022220665.1
6 GCA_022220665.1
7 GCA_022220665.1
8 GCA_022220665.1
9 GCA_022220665.1
10 GCA_022220665.1



Your briefing packet also includes the following documents:

Anthrax - Annual Epidemiological Report 2021 (ECDC)

González AA, Rivera-Pérez JI, Toranzos GA. Forensic Approaches to Detect Possible Agents of Bioterror. Microbiol Spectr. 2017;5(2):10.1128/microbiolspec.EMF-0010-2016. doi:10.1128/microbiolspec.EMF-0010-2016

Information Packet I4

You are the director of Ardkeld’s main hospital, the Riverview, which has 550 beds across 9 different wards and 10 operating theatres.

The Riverview hospital in Ardkeld. Image credit: [DALL-E

Figure 6: The Riverview hospital in Ardkeld. Image credit: [DALL-E

The annual operating budget for financial year 2022-2023 was £1.5 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 Riverview has units specialising in coronary care; maternity care; dermatology; gastroenterology; 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 14 ICU beds in the Riverview in November 2019. Average ICU bed occupancy before and during the COVID-19 pandemic is in the figure below.

ICU bed occupancy for the Ardkeld Riverview hospital (Source: NHS Scotland)

Figure 8: ICU bed occupancy for the Ardkeld Riverview hospital (Source: NHS Scotland)

There are approximately 1.3m admissions to the Riverview hospital annually, the majority of these being to the emergency (A&E) department.

Admissions to the Ardkeld Riverview hospital by category (Source: NHS Scotland)

Figure 9: Admissions to the Ardkeld Riverview hospital by category (Source: NHS Scotland)

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

ICU waiting times for the Ardkeld Riverview hospital (Source: NHS Scotland)

Figure 10: ICU waiting times for the Ardkeld Riverview hospital (Source: NHS Scotland)

The Riverview 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 Ardkeld Riverview hospital (Source: NHS Scotland)

Figure 11: Key Performance Indicators (KPIs) related to infectious diseases for the Ardkeld Riverview hospital (Source: NHS Scotland)

There are currently 145 patients in the Riverview with confirmed or suspected DIS-NAME, with 16 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 I5

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

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

Community Amenities Details
Schools 4 primary schools, 4 secondary schools, 1 college
Care Homes 2, each with ~50 bed capacity
Restaurants and Cafes 99
Parks and Playgrounds 6
Economic Indicators Details
GDP/capita £48993
Unemployment Rate 5%
Traffic and Transport Details
Traffic fatalities (average/month) 16



Your briefing packet on anthrax includes the following information.

Guidelines for the public health management of tetanus, botulism or anthrax among people who use drugs (Public Health Scotland)

Official Veterinarian Anthrax Instructions (Animal and Plant Health Agency)

Construction micro-organisms: Anthrax from contaminated land and buildings (Health and Safety Executive)

Kyriacou DN, Dobrez D, Parada JP, et al. Cost-effectiveness comparison of response strategies to a large-scale anthrax attack on the chicago metropolitan area: impact of timing and surge capacity. Biosecur Bioterror. 2012;10(3):264-279. doi:10.1089/bsp.2011.0105

Information Packet I6

You are a microbiologist working in the bacteriology department at the Greater Ardkeld Clinical Laboratory. Your laboratory is equipped to handle a range of culture samples (including anaerobic and microaerobic bacteria, as well as viruses), and you routinely process1733 samples monthly.

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

Bacillus anthracis cultured on sheep's blood agar. Image credit: [CDC](https://phil.cdc.gov/Details.aspx?pid=17097)

Figure 12: Bacillus anthracis cultured on sheep’s blood agar. Image credit: CDC

Tyśkiewicz R, Fedorowicz M, Nakonieczna A, Zielińska P, Kwiatek M, Mizak L. Electrochemical, optical and mass-based immunosensors: A comprehensive review of Bacillus anthracis detection methods. Anal Biochem. 2023;675:115215. doi:10.1016/j.ab.2023.115215

Wang D, Chen G, Lyu Y, et al. A CRISPR/Cas12a-based DNAzyme visualization system for rapid, non-electrically dependent detection of Bacillus anthracis. Emerg Microbes Infect. 2022;11(1):428-437. doi:10.1080/22221751.2021.2012091

Witt N, Galante D, Andreotti S, et al. Identification of Universally Applicable and Species-Specific Marker Peptides for Bacillus anthracis. Life (Basel). 2022;12(10):1549. Published 2022 Oct 6. doi:10.3390/life12101549

Information Packet I7

You are a public communications expert, often employed by the Ardkeld 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:

Steelfisher GK, Blendon RJ, Brulé AS, Ben-Porath EN, Ross LJ, Atkins BM. Public response to an anthrax attack: a multiethnic perspective. Biosecur Bioterror. 2012;10(4):401-411. doi:10.1089/bsp.2012.0041

Clarke, L., Chess, C., Holmes, R. and O’Neill, K.M. (2006), Speaking with One Voice: Risk Communication Lessons from the US Anthrax Attacks†. Journal of Contingencies and Crisis Management, 14: 160-169. https://doi.org/10.1111/j.1468-5973.2006.00491.x

Quinn SC, Thomas T, Kumar S. The anthrax vaccine and research: reactions from postal workers and public health professionals. Biosecur Bioterror. 2008;6(4):321-333. doi:10.1089/bsp.2007.0064

Information Packet I8

You are one of the doctors at the largest surgery in Ardkeld. In the past fortnight, 75 of your patients have recently presented to the surgery with symptoms consistent with DIS-NAME. You have therefore recently been familiarising yourself with the relevant literature:

  • NICE guidelines: Anthrax Treatment and post-exposure prophylaxis

  • BNF: Anthrax vaccine

  • BMJ Best Practice - Anthrax

  • Treatment of Anthrax infection (CDC)

  • Elbahr US, Tekin R, Papić M, Pandak N, Erdem H, Can FK, Alpat SN, Pekok AU, Pehlivanoglu F, Karamese M, Petru PC, Kulzhanova S, Tosun S, Doğan M, Moroti R, Ramosaco E, Alay H, Puca E, Arapovic J, Pshenichnaya N, Fasciana T, Giammanco A. Factors leading to dissemination of cutaneous anthrax: an international ID-IRI study. New Microbes New Infect. 2022 Sep 7;48:101028. doi: 10.1016/j.nmni.2022.101028.

  • Palmateer NE, Ramsay CN, Browning L, Goldberg DJ, Hutchinson SJ. Anthrax infection among heroin users in Scotland during 2009-2010: a case-control study by linkage to a national drug treatment database. Clin Infect Dis. 2012;55(5):706-710. doi:10.1093/cid/cis511

  • Liu Y, Zheng G, Li J, et al. A Case Report of Cutaneous Anthrax Diagnosed by Using a Metagenomic Next-Generation Sequencing (mNGS) Approach. Infect Drug Resist. 2023;16:3601-3606. Published 2023 Jun 7. doi:10.2147/IDR.S411717

Information Packet I9

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

Minogue TD, Koehler JW, Stefan CP, Conrad TA. Next-Generation Sequencing for Biodefense: Biothreat Detection, Forensics, and the Clinic. Clin Chem. 2019;65(3):383-392. doi:10.1373/clinchem.2016.266536

Keim P, Grunow R, Vipond R, et al. Whole Genome Analysis of Injectional Anthrax Identifies Two Disease Clusters Spanning More Than 13 Years. EBioMedicine. 2015;2(11):1613-1618. Published 2015 Oct 6. doi:10.1016/j.ebiom.2015.10.004

Price EP, Seymour ML, Sarovich DS, et al. Molecular epidemiologic investigation of an anthrax outbreak among heroin users, Europe. Emerg Infect Dis. 2012;18(8):1307-1313. doi:10.3201/eid1808.111343

Tourasse NJ, Jolley KA, Kolstø AB, Økstad OA. Core genome multilocus sequence typing scheme for Bacillus cereus group bacteria. Res Microbiol. 2023;174(6):104050. doi:10.1016/j.resmic.2023.104050

Booth M, Donaldson L, Cui X, et al. Confirmed Bacillus anthracis infection among persons who inject drugs, Scotland, 2009-2010. Emerg Infect Dis. 2014;20(9):1452-1463. doi:10.3201/eid2009.131481

Braun P, Beyer W, Hanczaruk M, et al. Reoccurring Bovine Anthrax in Germany on the Same Pasture after 12 Years. J Clin Microbiol. 2022;60(3):e0229121. doi:10.1128/jcm.02291-21

Metrailer MC, Hoang TTH, Jiranantasak T, et al. Spatial and phylogenetic patterns reveal hidden infection sources of Bacillus anthracis in an anthrax outbreak in Son La province, Vietnam. Infect Genet Evol. 2023;114:105496. doi:10.1016/j.meegid.2023.105496