Pat Harford woke with a crushing headache. It was as though the world and his cranium were closing in on his brain. He really shouldn't have that last can (or four) of beer last night, he thought, but he couldn't help himself. He had spent two months backpacking around India and Nepal and couldn't wait to catch up with his college mates. And of course, seeing his girlfriend, Shirley again. Smiling, Pat drifted off into semi-consciousness. He was strumming his guitar with his band and they were the headlining act at The Basement, a hip live venue tucked into an arc of the viaduct. The crowd were going mad, stomping feet to the beat. Pat opened his eyes again but the thumping continued. His neck felt stiff. He hated how jet lag interrupted his sleep patterns. He must have been throwing some weird contortions in his sleep last night, he reasoned, before slipping back into streets of Delhi, inhaling the smells of cumin and ripening fruits whilst mopeds whizzed past.
"You're in a bad way", Shirley's voice resounded around the market place. Her breathing appeared rapid. She must have been running to keep up with him. "I can sympathise. I spent most of the morning throwing up. So much for starting the week as I intend to go on."
"What time is it?" Pat mumbled, trying to muster up the energy to look at his watch.
Shirley sat at the edge of Pat's bed and placed her black painted fingernails against his forehead. "My God, you're dripping in sweat! I don't know how you are. My hands and feet are like icicles. I'll open a window anyway. The place reeks of an ashtray."
Shirley yanked the heavily lined curtains aside. Pat yelled in agony.
The neon red 7.29 became 7.30 and the radio went off. Cynthia dived under her pillow. She wasn't ready to get up to Wogan. It was Wednesday after all, time for a mid-week break. She was going to just lie there and let his caramel tones fill her room with stories about the loveliness of normality. Wogan must have had other ideas and dusted off a 45 of some crusty old crooner propelling Cynthia straight from her bed into her shower in five seconds flat. After dumping her towels into the laundry basket, Cynthia emptied her potpourri into the kitchen bin. It was time she changed it. Holding the glass bowl she had got for her 21st birthday, she went into her storage room and cursed herself when she remembered where the refill was kept. She was going to have to take down the sleeping bag, picnic rug, iron and her collection of instruction manuals just to have the scent of the sea in her en-suite. Placing the bowl on top of the boiler, Cynthia momentarily noticed the adjunct stack of spare tea lights. She blinked. They were stacked. When did she do that? A chill passed through her body. She ran to her front door and tentatively turned the handle. It was locked – for now. She recalled his last words to her. It would only be a matter of time before he found her.
"This is pathetic", Ishani gestured at her computer screen. "This machine is so slow, if I posted my emails, they'd be there faster."
"Tell IT", Rose suggested as she watered the plants on the filing cabinets.
"I'm sick of telling IT. All they do is log my calls. I've told them that it's a software issue. Previous users have deleted files. All they have to do is upload Windows again. I'd do it myself if they give me the disks."
"Have you told them that?"
"In person but they just logged my visit!"
"Morning Rose!" Mike chirped as he marched into the open plan office. "Welcome back, Ishani! Did you have a good trip?"
"Yes thanks."
"Good, good. Glad to have you back. Morning Cynthia! Have you two met?"
Cynthia slipped her handbag off her shoulder and looked at the slender Asian woman with enviable thick long black hair. "No, I don't think so."
Ishani reached across to shake Cynthia's hand. "Hi, I'm Ishani Mehta. I saw your name on the circulation lists from the public health training programme. You're a transfer from another Deanery."
"That's right."
"First? Second year?"
"Second."
"Pre or post Part A?"
"I'm taking it next January. You?"
"Just did the Part B."
"Okay, enough with the chit-chat", Mike interrupted as he flicked through his post. "You two can become acquainted later. Cynthia, what do you know about meningitis?"
"It's the inflammation of the meninges."
"Causal agents?"
"There are many infectious agents, although acute meningitis is nearly always viral or bacterial. The most common viruses that can cause meningitis are echovirus and coxsackievirus. Mumps can also cause meningitis, though it's rare in countries with a high uptake of the MMR vaccine. The commonest cause of bacterial meningitis is meningococcal disease. It can also be due to haemophilus influenzae or Hib, though the introduction of the Hib vaccine has reduced the incidences".
"And don't forget pneumococcal – one of the main causes of meningitis in children under the age of two in this country. They're introducing a new vaccine, a polysaccharide conjugate vaccine into the childhood immunisation schedule."
Mike heaped a pile of paper into Cynthia's arms. "I'm off to the hospital now but I'll expect you to familiarise yourself with the literature in my absence. When I come back, we can head to the Immunisation meeting together and you can fill me in on how you're going to lead on implementing the changes in Castelshire."
Seeing Ishani's mouth drop with jealousy, Mike added "And Ishani, about that computer of yours, I'd have a word with Paul. He was Olympic Hacker Champion twice over."
The main reception at Castle Infirmary was serene in its emptiness. A lone cleaner waxed the tiled floor with a humming circular machine. Mike took the stairs and worked his way through the myriad of corridors, frowning disapprovingly at passing young surgeons wandering the floors in their smocks and clogs. He seemed to be whizzing through the ward checks today and before long, he was in the A & E department. As usual, the waiting room was full of solemn looking individuals in various slings, queuing for X-ray. A spare chair here and there belied those who had got bored during the night and went home. There was a bunch of screaming toddlers fleeing from a four-year-old boy, welding a plastic hammer bigger than him.
"The duty nurse will be with you in a minute, Dr Burton", the middle-aged ward clerk said as her eyes looked up and down the smartly suited man. Good genes she thought to herself as she hacked a cough. Smoking prematurely ages, his eyes flashed back.
"Doesn't it bring back happy memories?" Phil drawled as he sauntered around the desk in an open neck shirt, trainers and a white coat greyed by too many cycles in the dryer.
Mike snorted. "Did you even do a shift in A & E?"
"I'll pretend I didn't hear that".
"What are you doing here?"
"I do work too."
Mike just looked at him.
"What?" Phil met Mike's gaze. "You want me to tie a stethoscope around my neck!"
"Going to the flu pandemic meeting at the PCT?"
"It's in the diary. Don't know why evil bitch queen needs me at it!"
"Emma is Director of Public Health. It is her call."
"You know she does ward rounds," Phil smirked. "Every morning at 9.30am, checking that everyone's at their desks."
"Maybe that's not such a bad idea, Phil. How is infection control going these days? I believe the MRSA rates are going up!"
Phil shot Mike a dirty look but said nothing. The ward sister was approaching.
"Hello Dr Burton and Dr Doyle, how may I help you today?" She greeted them, blessed with a smile that wherever she was she would always look like she was delighted to be there.
Feeling like he should have asked for fries on the side, Mike listened as the nurse related that they had only one case of a possible meningococcal disease.
"I don't know this name", Mike furrowed his brow as he looked at the case notes.
"It's a new case. Maybe since it's only a possible case...."
"All cases, possible, probable or confirmed are notifiable. Where is the child now?"
"I think Dr Mehta has moved her to the children's ward, oh hold now, she's still here. Curtain 7."
"Dr Mehta, that's Ishani's man isn't it?" Phil interjected to Mike as they followed the nurse to the patient, a now sleeping 10-month baby, accompanied by worried parents. Her face was red from a cankerous bawl.
"She was admitted an hour ago", Dr Mehta related to Mike. "Symptoms of pyrexia, vomiting, irritability and raised anterior fontanelle tension."
"Any pre-hospital dosage of benzlpenicillin?"
"No", the mother spoke up. "Lucy has been so ill since her last vaccination. She got suddenly worse last night so I rushed her straight here. Her older sister had an allergic reaction to a vaccine before."
"Any rash?" Mike continued to Dr Mehta.
"No."
"She does now." Phil raised Lucy's left leg. There was a red petechial rash on her thigh. Mike grabbed a glass from the sink and handed it to Phil, who gently pushed it against the skin. The rash did not blanche.
"Start an intravenous treatment of antibiotics", Mike barked at Dr Mehta. "This is a probable case of meningococcal septicaemia."
The mother gasped and clutched the father.
"Nice going Mike", Phil muttered under his breath. "While you're at it Dr Mehta, I'll need some blood samples for cultures and a PCR."
"I've got a possible meningococcal disease on line 1, any takers?" Rose released the mute button as Cynthia volunteered. She grimaced at Ishani, indicating that this was her first encounter with a meningococcal case. Ishani listened attentively to Cynthia's call, offering support through bodily presence.
"What do you have?" Ishani asked as Cynthia hung up.
"A three year boy admitted to Castle Infirmary with possible meningococcus."
"Which means?"
"They're considering other diagnoses."
Ishani nodded. "Go on."
"Child admitted with fever and possible mild meningism. GP gave the boy 600 mg of benzylpenicillin before admission. I know I'm meant to input into the meningococcal database whether benzlypenicillin was administered or not but I'm not sure why is that important?"
"Because meningococcal disease has such a rapid progression, it is essential to start prompt antibiotic treatment. Starting on benzylpencicillin as soon as possible can greatly reduce serious outcomes from the disease and save lives. Downside is it makes it difficult for us to isolate the causative organism but the benefit to the patient far outweighs that. So what are you going to do next?"
"Given it's a possible, there's not much I can do now."
"True, though I'd still get details of close contacts just in case we may need to give them prophlaxis. Remember meningococcal disease can result in meningitis or meningococcal septicaemia, though meningitis is the most common presentation. Did the child have any rash?"
Cynthia blushed. "I forgot to ask."
"Okay, for now I'd gather info on the contacts and check with Paul. He deals with the enhanced meningococcal surveillance so he can tell you if this child relates to another case or if we have a cluster in a neighbourhood. Mike called in a case of probable meningococcal septicaemia earlier, a little girl called Lucy Walsh. You could check with Paul if the children have a nursery in common. Oh Cynthia", Ishani added with a laugh. "Be warned, Paul likes to paint the big picture. You will be there for some time!"
"Glad you found your way down here", Phil said to Ishani while peering down his microscope. "Hunting in pairs. It's neisseria meningitides all right. A gram-negative diplococci. Poor little Lucy."
"Do you know what serogroup?"
Phil faced Ishani. "Not yet. I've sent a specimen off to the reference lab in Manchester for a polymerase chain reaction. I'll know in 48 hours."
"You couldn't hazard a guess?"
"No, the reference lab is better set up for characterising phenotypically."
Ishani looked quizzically at Phil. "And you can't?"
"That involves studying the capsular polysaccharide to determine the serogroup and deriving serotype from the class 2 and 3 outer membrane proteins and the serosubtype from the class 1. I don't the time or the resources. Unless, you care to be my beautiful assistant!"
Ishani remained stone faced.
"Then again maybe not!" Phil moved towards his collection of notes on the steel counter. Ishani was the only woman he knew who was immune to his charms.
"Lucy had her Men C vaccine, I was just wondering."
"Ishani, as you well know there are about 13 serogroups. Lucy could have a group B strain of meningococcal rather than a group C. She may even have a group A, Y or W-135. I could do a latex antigen testing, if you are really anxious, but it's not a particular good test. It will pick up Group C but not Group B."
"It's okay. And the three year old boy, Jack McCloud?"
"I've done the gram stain but I found gram-positive diplococci. Jack has good old fashioned tonsillitis!"
"I'll let Cynthia know."
"Anyway, I didn't ask you down here to talk about these cases. I got a necropsy report on a nineteen-year-old student, Shirley Brown. She was found dead in her room on Tuesday morning at one of the University of Castel's halls of residence. Cause of death is meningococcal septicaemia. The causative organism was confirmed as neisseria meningitides, group C, serotype 2a."
"How come I didn't know about this? Blasted IT system." Ishani grabbed the case notes and ignoring Phil's declarations of theft, darted upstairs to the office.
Cynthia pulled up a chair to Paul's desk and nursing a coffee, she listened to Paul's epidemiological talk. He meanwhile was delighted to get to rant about one of his favourite infections to survey.
"Since the mid 1990s, the UK has seen increasing incidences of lab confirmed meningococcal diseases. Although, I myself think this rise could be due to the introduction of PCR testing. Group B accounts for the majority of all isolates in the UK but Group C is increasing proportionately more than any other sub-group, thereby indicating a true rise. Outbreaks of Group C tend to occur in closed or semi-closed communities like schools and military barracks."
"Has the introduction of Men C not reduced this?"
"It most certainly has. There has been a marked reduction in serogroup C diseases in all groups targeted for vaccination. Men C has been really effective in reducing carriage."
"I've just been reading that the new pneumococcal conjugate vaccine will do the same thing. It reduces carriage of the organism in the risk groups – in this instance, young children – and in doing so you also protect those who are unvaccinated like adults."
"Correct. Plus for Men C, there is no evidence of other serogroups filling the niche."
"So who are the groups that are at highest risk from meningococcal disease? I heard that after the age of 24, the risk is minimum."
"It's true that meningococcal disease is a largely a young person's disease. The majority of cases are in infants under 1 year, followed by the one to five year old age group. Mortality is highest in the 15 to 19 year olds."
"What are the risk factors?"
"Ooh, age obviously, gender too – we have more males affected than females. Season is another factor. Meningococcal cases rise in the autumn, peak in winter and decline to virtually no cases in late summer."
"Why is that?"
"Well, there is some association with influenza activity but it is likely that outside summer, people tend to live in crowded confined places where there is a lack of ventilation and too much humidity from heating. Another factor is of course smoking as this makes people more susceptible."
"Well, I have two cases here – one probable and one possible: Lucy Walsh and Jack McCloud. I just wanted to check if they had a nursery in common."
Paul tapped the details into the system.
"Ishani has just updated the records. Jack's tests have come back negative for meningococcal disease and Lucy's gram stain showed gram-negative diplococci. Given the age difference, it is unlikely that they would be at nursery together or play mates. Mike has written that Lucy has an older sibling who attends Merry-Go-Round nursery whilst Jack goes to Tiny Tots. Jack and Lucy are neighbours so it could be that his mother was over cautious."
"Should I let Merry-Go-Round nursery know?"
"I'd ask Mike about that. In my experience, about 97% of cases are sporadic. But it is autumn now so I'll keep my eye on the cases and if there are two or more within 4 weeks at either nursery, I'll ring the alarm bell".
Ishani had to buzz a number of doorbells before footsteps were finally heard clanking down the iron cast stairs. Ishani always hated it when a hall of residence was involved. Each block was a collective of individual rooms all with separate doorbells and telephones. It made contact tracing a nightmare. A plump red-haired girl pushed the door out and wiped her tear stained cheeks with her sleeve.
"Hi, my name is Dr Ishani Mehta, I'm with the Castel Health Protection Unit", Ishani flashed her identity card. "I'm here regarding the death of Shirley Brown. I tried calling the general phone number but it rang out."
"You mean the pay phone downstairs? No one uses that."
"Did you know Shirley?"
"Yes, we lived on the same floor."
"Do you mind if I come in?"
"No, that's fine."
The girl ascended the stairs and Ishani followed her into a large communal kitchen.
"How many people live here?"
"I don't know really. I think about twenty but not everyone is here yet. Uni hasn't started."
"So who's here now?"
"About four of us."
"Do you know why I'm here – sorry, what's your name?"
"Amy. Not really, well, I think so. I was given this leaflet about meningitis."
"That's right. Shirley had meningococcal septicaemia, which is serious so I'm going to have to ask you a few questions about who lives here."
"How did she get it?"
"From someone else. The germ is carried at the back of people's throats and it can be passed onto people through close contact."
"Like sharing of drinks?"
"No, saliva is quite good at inhibiting the bacteria. It would be through intimate kissing or if someone coughed and exerted droplets from the nasopharynx and another person breathed it in."
Amy's red-rimmed eyes widened in alarm, "Oh my God, we could all die!"
"No. What people don't realise is that getting ill from meningococcal disease is very rare. Most people breathe it in and the germ doesn't affect them at all. In fact, it can protect us by building up our resistance to other germs. Most people who are infected become asymptomatic carriers. About 10% of the population carry the bacteria at any one time."
"Why Shirley?"
"You know, we really do not understand why some people get ill and others don't. It has to do with our different immune systems and the environment we're in."
"Are you trying to find the person who killed her?"
"It's not like that. What I want to do is find out who has been in close contact with her and I'll then arrange for antibiotics to be given."
"Treatment? Isn't it a little late now?"
"It's not treatment. It's what we call chemoprophylaxis. By giving antibiotics to close contacts, we can eradicate carriage of the bacteria in established and new carriers. That way we can prevent more people from getting the disease."
"Like me?"
Ishani smiled at the teenager. "Like you. So tell me, who was staying here in the last seven days?"
Amy sniffled. "Me, Joanne, Rachel and Michaela."
"Anyone else? Did anyone visit and stay a night?"
Amy shook her head.
"And Shirley, was she here every night? Did she stay in anyone's house in the last week?"
Amy thought for a bit. "She wasn't here on Saturday and Sunday night. I don't know where she was. I think she had a boyfriend. I think she said something about him coming back from abroad."
"Do you know his name?"
"No, I never met him. I don't know Shirley that long. I've only just met her when I moved here to start university. It's my first time away from home and she was the first person I met here. She, she was alive on Monday, it is all so weird."
Amy broke down in tears. Ishani felt awkward. She was never good at comforting patients or family members.
Amy raised her head and exhaled. "There is something. Rachel and Shirley went to The Basement on Saturday night. I think Shirley's boyfriend was in a band. Yes, that's right. They asked me to come but I couldn't. I think the band were playing there."
"Thank you Amy. I'm going to arrange for the GP to give you and your housemates a dose of ciprofloxacin. Make sure you all take the antibiotics. And I think it's a good idea that you all get vaccinated with the Men C vaccine."
"Will I be alright?"
"You should be."
"Cynthia Taylor, Specialist Trainee in Public Health", Cynthia said, holding the receiver between her jaw and shoulder blade. She was sorting the papers on immunisation on her desk, satisfied that she had an action plan for the PCV introduction.
"Ah, hello", the caller began. There was an anxiety in her voice. "I've just heard that a child at my son's nursery got antibiotics for meningitis. Her sister is in hospital and I don't think this child should be allowed at the nursery."
"No, there's no need. The child poses no risk to others."
"That's alright for you to say. You can't be sure of that. She could be spreading the germs to the rest of them."
"No she can't." Cynthia paused to choose her words carefully, confidentiality being of the utmost importance. "If this child's sibling has been admitted with meningococcal disease then the close contacts, i.e. the family, will have been given antibiotics to prevent them from developing the disease. This course of antibiotics will also prevent them from spreading the germs to other people."
"Why isn't the rest of the nursery getting antibiotics? I want my child safe too."
"Antibiotics are only given to close contacts. They're the people who live with the ill child. You have to have prolonged exposure to meningococcus before you get the disease and even then only a very small number of people get ill. It's safe practice not to give out antibiotics to everyone. The antibiotics strip the throat of the natural flora, leaving the person exposed to more invasive bacteria. For instance, most children carry bacteria called nesseria lactamica in their throats. These bacteria actually protect children from getting meningococcal disease. If we gave all the children antibiotics, the antibiotics would remove this bacteria and the children would then be vulnerable to meningococcal disease."
"Okay then, but what if another child gets this?"
"Meningococcal disease is a serious disease but it is rare. The chance of another child having it is unlikely. If you like I can contact the head of Tiny Tots and arrange for leaflets..."
"Tiny Tots? My child is at Merry-Go-Round nursery. Oh my God, Tiny Tots have it as well! Oh my God".
The woman hung up. Cynthia paled. She looked around the office but Gillian, Rhonda and Paul were all too immersed in their own work to have noticed. She slid down her chair and prayed that she wouldn't be made to regret this mistake.
"Hi Rhonda, I've managed to locate the manager of the band", Ishani said into her mobile phone. She was standing outside the live music venue, The Basement. "I've got the names of the band members. They don't all live together and the manager only had an address for the lead singer. But they are second year students at the Castel Polytec and I have their phone numbers. I was wondering if you could check the names against the hospital records."
"I can go one better," Rhonda responded. "I got hold of Rachel, the girl you said accompanied Shirley last Saturday night to the concert. She told me that the boyfriend's name is Pat Harford. He was admitted to St. John's Hospital two days ago with meningitis. He's in a critical condition. I spoke with the register on duty and arranged for all housemates to be given prophylaxis."
"You're a star. Have you got the address?"
"I sure do. It's 26 Rosehip Gardens."
A diesel train roared past.
"I'm sorry Rhonda, can you say that again? Okay, 26 Rosehip Gardens. Got that....Yes, I know where that is. I'll call round. Given the band connection, I have an inkling that a bunch of people may have stayed over for a party after the show. I'll need to find them."
Ishani opened her car door and slipped into the driver's seat. She adjusted the rear view mirror towards her and reapplied her lip-gloss. Brushing away flakes of hardened mascara from under her eyes, she admired how well her skin looked for a 32 year old. The Indian sun had darkened her face but there wasn't even the faintest trace of a wrinkle. The reflection of the nearby newspaper stand caught her eye. Ishani turned around. There on the billboard for the local tabloid was the headline "Star Crossed Lovers in Meningitis Tragedy". Ishani's heart almost stopped.
"I can't believe you never thought to issue a press statement," Mike bellowed at Ishani the following morning.
"With all due respect", Ishani responded in defence. "You're the appointed liaison..."
"Ishani, there was a death. You should have contacted the press officer at the PCT and prepared a press statement. You know the drill."
"Mike," Rose interrupted. "I've got Emma on the line. The PCT are inundated with calls from parents about why the PCT didn't prevent the outbreak."
"Outbreak? There's no outbreak!"
"Well, Romeo and Juliet are causing problems here too", Gill piped in. "Our phones have been hopping with calls about why the Men C vaccine has failed to protect our children."
"What!"
"I know Mike, I told them all about the different groups that can cause meningococcal disease and that the Men C vaccine only protects against Group C and that there is no vaccine for Group B, the commonest cause."
"No, I mean, children? We only had one case of a baby who's in a stable condition now."
"Maybe I can help", Phil coolly added as he strolled into the office. "I've got the results of the PCR tests. Lucy Ward has a Group B and the interesting thing is that Shirley has a Group C but lover boy, Pat has a W-135."
"So they're not connected. Pat must have picked his strain up on his travels." Mike turned to Ishani. "Are all household contacts accounted for?"
"Yes", Ishani replied, still holding her own. "I arranged prophylaxis for all those who lived with Shirley and since Shirley stayed at Pat's place on Saturday night, I also arranged prophylaxis for those household mates and all those who stayed the night for the party."
"Good, I better talk with Emma and reassure her that there is no outbreak."
"I don't know about that," Cynthia looked up meekly at Mike and Ishani from her desk. "I've just got a call from A & E at Castel Infirmary. Jackie Allen, a first year student at Castel Polytec has been admitted with possible meningitis. She got pre-admission benzlpencillin and has been started on treatment."
"Ask for a throat swab." Phil interjected. "The drugs may interfere with organism and the swab will help me with the identification of the serogroup. We may need it if there's a link."
"I better take this call from Emma. Ishani and Cynthia find out if this girl Jackie has anything in common with Shirley or Pat. Paul, what do you think?"
Paul mulled over the question. "It is unusual to see this number of cases so close together at this time of year. However, anytime there's a meningitis report in the newspaper, we do see an incline in numbers of suspected cases reported. People panic about meningitis."
Rose cleared her throat. "Mike, I've now got an incoming call from administration at Castel Polytechnic College."
"And I've got the owner of Tiny Tots nursery on my phone," Rhonda added.
"Right, Rose, tell Emma I'll call her back. I'll take the Castel Polytec call in my office. Ishani and Cynthia get cracking and Rhonda, assure the owner that there was no case of meningitis at the nursery. Offer information and point out how to alert parents to early signs. It may help alleviate fears. Rose, can you call the press officer at the PCT. We'll have to sort something out with the media before the rumours escalate into something worse."
Mike headed into his office.
"I thought you covered all contacts", Cynthia whispered to Ishani.
"I did. However, there is no guarantee that even after organising prophylaxis that a contact doesn't develop the disease. You need to find the contacts within 48 hours of the onset of illness in the index case. Shirley and Pat both fell ill on Monday. It's now Thursday."
"I hate to break this to you," Rose took off her headset for the phone. "I have another notification, this time a probable meningococcal disease. A fifteen year old boy, Alan Collins."
Phil sat on the steps to the Castel HPU building, munching his sandwich. He took a swig of his fizzy drink and savoured the golden hues of the late September sun. A mini-tornado whisked the fallen browned leaves up and rustled them along the paved road.
"You know Britain has the largest number of tornados in the world", Phil remarked to Cynthia who had joined him outside. After the bustle that was yesterday, Cynthia was hoping that Friday would be kinder to her nerves.
"Rose said you had some results for me", Cynthia said, eyeing Phil's can of coke.
"I need the sugar," Phil smirked and dusted down his hands.
"I haven't got any confirmation on the Collins case – not enough organism. They took a CSF by lumbar puncture from Jackie Allen. The CSF shows a raised neutrophil count and high protein count and a lowered glucose concentration."
"In English?"
"It's looking like meningococcal."
Cynthia sighed. "I messed up."
"On what?"
"I accidentally gave out the name of the nursery to a member of the public. I'm to blame for Rhonda and Gillian's horrendous day yesterday."
"It can happen to any of us. Look at it this way, a whole bunch of people are now very au fait with how to recognise meningitis."
"I know but they could have done without it. I think Mike is contemplating offering prophylaxis to the wider group of first and second year students. Setting up the centre for that and offering them all immunisation will be a huge task. Gillian and Rhonda are going to be busy."
"I'm surprised Mike is thinking about it. You found no links between Jackie, Shirley and Pat."
"No, other than they all were at The Basement on Saturday night."
"I guess he knows what he's doing. Last time he cost the PCT £ 40,000. Emma wasn't at all happy. But then she never is where Mike is concerned."
"How do you mean?"
"How shall I put this? Emma is very politically inclined and Mike, well, Mike is more of the dictator style."
Stephen approached with a tall remorse looking young man. He gently patted the boy on the back and encouragingly told him to go in to Mike.
"What's this?" Phil inquired.
"That boy wandered into our offices today. He is anxious to 'turn himself in' to Mike, whatever that means. I hear you've been up to your elbows in meningococcal."
"You heard right", Ishani's voice came from the top of the steps.
"Hey, I heard you're back. How were the in-laws?"
"Hell as usual. My mother-in-law is still convinced I'd be better off making onion bhajis in the kitchen!"
"No woman is ever good enough for a mother's son! Oh Cynthia, remember that house we looked at last week, you know the one that I suspected the landlord was illegally letting again? Well, I went back and it was fine, building wise. The landlord claims he's giving it to his son to live in with his new wife. But the weird thing was that this was 11 o'clock in the day and there was this huge group of men meeting around the kitchen table. I don't think I'm being sexist but it struck me as odd that they weren't out working."
"Maybe they're on the dole", Phil suggested.
"Maybe but it seemed like quite an intense meeting. I don't know. It's been bothering me. I get the feeling something's brewing but I can't think what."
Carl Collins knocked timidly on Mike's door. Mike beckoned him in and finished his phone call.
"Dr Burton," the teenager stammered. "I think you've been looking for me. I'm the one who killed Shirley."
Mike raised his eyebrows in surprise.
"I'm Carl Collins. I'm a friend of Pat Harford. We're in a band together. He's been away recently and Shirley and I ended up spending a lot of time together. I really like, I mean, liked her. We got together and we were really getting on but then Pat was coming back and Shirley wanted to be with him. I was really annoyed with her so I got drunk after the gig on Saturday night and snogged this girl, Jackie Allen but then Shirley got ill and Pat and Jackie and now my little brother, Alan. I googled meningococcal disease and found out people get infected by someone close to them. It's me, I'm sure of it. Take a throat swab and you'll have your evidence. This is all my fault."
"Carl, this is nobody's fault. You're certainly not to blame. We share this world with a whole load of micro-organisms and they seem to have their own agendas. Every time I think we've won the battle against them, they mutate and cause more havoc."
"But I carried it," Carl protested.
"Believe me, you have no reason to feel guilty. I know that it is hard to make sense how someone so young and healthy can die so quickly. Life isn't fair. We have very little control over when or how we get ill. You've done a good thing by taking your antibiotics and so have all the others who have taken theirs. Alan, Pat and Jackie are going to be fine. Carl, I don't know how I can convince you but you must trust me. This is not your fault."
Mike got up and escorted Carl outside to the nurses. Women are always better at dealing with emotions, he thought to himself. As the nurses fussed around Carl, Mike asked Rose to find Carl a name of a good bereavement counsellor.
Returning to his office, Mike paused at the door. Paul hurriedly minimised the web-page he was reading.
"I know I can't be 100% sure," Mike remarked to Paul with a smile. "But I think our meningococcal week is over."