Components

• 7 Pawns and 7 Role cards
• 69 Player cards
• 4 Hospitals
• 1 Outbreaks marker
• 96 Disease cubes
• 4 Research markers
• 48 Infection cards
• 4 Disease cards
• 1 Infection rate marker
• 1 Board
• 14 Purification tokens
• 20 Railroad tokens
• 1 Prevention token
• 5 Reference cards
• Instructions

Setup

1. Set out the Board and Pieces

   Place the board within easy reach of all players. Put the 4 hospitals, 20 railroad tokens, and 14 purification tokens nearby. Separate the cubes by color into 4 supply piles.

2. Place Outbreaks and Research Markers

   Place the outbreaks marker on the "0" space of the Outbreaks Track. Place the 4 research markers near the Researched Disease Indicators

3. Place Infection Rate Marker and Infect 9 Cities

   Place the infection rate marker on the left-most "2" space of the Infection Rate Track. Shuffle the Infection cards. • Reveal 3 of them. Put 3 disease cubes of the matching color on each of these cities.

   • Reveal 3 more cards: put 2 disease cubes on each of these cities.
   • Reveal 3 more cards: put 1 disease cube on each of these cities. (You will place a total of 18 disease cubes, each matching the color of the city).

   Place these 9 cards face up on the Infection Discard Pile. The other Infection cards form the Infection Deck.

   
   

   Use disease cubes matching the card colors.

4. Give each player a role card, a pawn, and a reference card

   Give each player a reference card. Shuffle the Role cards and deal 1 face up in front of each player along with the matching pawn. Remove the remaining Role cards and pawns from the game.

5. Prepare the events and give cards to each player

   Take the Epidemic cards out of the Player Deck and set them aside until Step 6.

   Shuffle all the Event cards and randomly set aside the number of Event cards shown in the table below.

   Add these Event cards to the City cards and return the remaining Event cards to the box without looking at them.

   Shuffle the Player cards (City and Event cards). Deal cards to the players to form their starting hands. Give cards according to the number of players:

   # of players	Events in Deck	Starting Hand
   2- player game	4	4
   3- player game	5	3
   4- player game	6	2
   5- player game	8	2

   Each player looks at the City cards in their hand and selects one of the cities pictured on their cards to place their pawn. If a player doesn't have a City card ( for example if all of their cards are Event cards), they may start their pawn in any city on the board. Players keep their cards face up on the table.

6. Prepare the Player Deck

   Set the game's difficulty level, by using either 4, 5, or 6 Epidemic cards, for an Introductory, Standard, or Heroic game. Remove any unused Epidemic cards from the game.

   Divide the remaining Player cards into face down piles, as equal in size as you can, so that the number of piles matches the number of Epidemic cards you are using.

   Shuffle 1 Epidemic card into each pile, face down. Stack these piles to form the Player Deck, placing smaller piles on the bottom.

   
   
   

7. Begin Play

   The players look at the City cards they have in their hand. The player who has the City card with the earliest founding date goes first.

   Note: The City cards include their approximate founding dates. (Note that humans settled these locations thousands of years ago, before the cities were named).

Game Play

Each player turn is divided into 3 steps:

After a player is done infecting cities, the player on their left goes next.

Players should freely give each other advice. However, the player whose turn it is decides what to do.

Your hand can hold City and Event cards. City cards are used in some actions and Event cards can be played at any time.

Actions

You may do up to 4 actions each turn.

Select any combination of the actions listed below. You may do the same action several times, each time counting as 1 action. Your role's special abilities may change how an action is done. Some actions involve discarding a card from your hand; all these discards go to the Player Discard Pile.

A. Movement Actions

B. Other Actions

Draw Cards

After doing 4 actions, draw the top 2 cards together from the Player Deck.

If, as you are about to draw, there are fewer than 2 cards left in the Player Deck, the game ends and your team has lost! (Do not reshuffle the discards to form a new deck).

Epidemic Cards

If your draws include any Epidemic cards, immediately do the following steps in order:

1. Increase: Move the infection rate marker forward 1 space on the Infection Rate Track.

2. Infect: Draw the bottom card from the Infection Deck. Put 3 disease cubes of that color on the named city. If the city already has cubes of this color, do not add 3 cubes to it.

   Instead, add just enough cubes so that it has 3 cubes of this color and then an outbreak of this disease occurs in the city (see Outbreaks below). Each purification token prevents the addition of 1 cube. Discard this card to the Infection Discard Pile.

   

   If you cannot place the number of cubes actually needed on the board, because there are not enough cubes of the needed color left in the supply, the game ends and your team has lost! This can occur during an epidemic, an outbreak, or infections.

3. Intensify: Reshuffle just the cards in the Infection Discard Pile and place them on top of the Infection Deck.

   When doing these steps, remember to draw from the bottom of the Infection Deck and to then reshuffle only the Infection Discard Pile, placing it on top of the existing Infection Deck.

   It is rare but possible to draw 2 Epidemic cards at once. In this case, do all three steps above once and then again.

After resolving any Epidemic cards, remove them from the game. Do not draw replacement cards for them.

Hand Limit

If you ever have more than 7 cards in hand (after first resolving any Epidemic cards you may have drawn), discard cards or play Event cards until you have 7 cards in hand.

Infections

Flip over as many Infection cards from the top of the Infection Deck as the current infection rate. This number is below the space of the Infection Rate Track that has the infection rate marker. Flip these cards over one at a time, infecting the city named on each card.

To infect a city, place 1 disease cube matching its color onto the city. If there is a purification token in a region adjacent to the city, however, remove 1 purification token from an adjacent region (returning it to the supply) instead of placing a cube. (If there is more than one adjacent region with a purification token, the current player decides which token to remove).

If the city already has 3 cubes of this color, do not place a 4th cube. Instead, an outbreak of this disease occurs in the city. Discard this card to the Infection Discard Pile

Outbreaks

When a disease outbreak occurs, move the outbreaks marker forward 1 space on the Outbreaks Track. Then, place 1 cube of the disease color on every city connected to the city (or remove a purification token if any).

If any of them already has 3 cubes of the disease color, do not place a 4th cube in those cities. Instead, in each of them, a chain reaction outbreak occurs after the current outbreak is done.

When a chain reaction outbreak occurs, first move the outbreaks marker forward 1 space. Then, place cubes as above, except do not add a cube to cities that have already had an outbreak (or a chain reaction outbreak) as part of resolving the current Infection card.

As a result of outbreaks, a city may have disease cubes of multiple colors on it; up to 3 cubes of each color.

If the outbreaks marker reaches the last space of the Outbreaks Track, the game ends and your team has lost!

Turn End

After infecting cities and discarding Infection cards, your turn is over. The player on your left begins a turn.

Event Cards

During a turn, any player may play Event cards. Playing an Event card is not an action. The player who plays an Event card decides how it is used.

Event cards can be played at any time, except in between drawing and resolving a card.

After playing an Event card, discard it to the Player Discard Pile.

Player Cards

Place your cards face up in front of you, for all players to see. Only Player cards count towards your hand limit. Your Role and your Reference cards are not part of your hand. Players may freely examine either discard pile at any time.

End of the Game

The players win as soon all 4 diseases have been researched.

There are 3 ways for the game to end and the players to lose:

• if the outbreaks marker reaches the last space of the Outbreaks Track,
• if you are unable to place the number of disease cubes actually needed on the board, or
• if a player cannot draw 2 Player cards after doing their actions.

Influx of Patients Challenge

This challenge simulates the rush of patients into the new, fledgling hospitals in the 19th Century Iberian Peninsula. In this period, hospitals were built for the treatment of specific diseases, and people tried to reach these cities in order to receive it.

Setup

Use the setup rules for the base game with the following changes:

• Add the Influx of Patients Challenge reference card over the Play section of the board. This shows the new order of play, and will help you remember to take the new "Move patients " step each turn.

• Only 6 purification tokens are available in the supply for use at the beginning of the game. Divide the remaining 8 purification tokens into 4 stacks of 2 tokens, placing a hospital on each stack.

Game Play

Building Hospitals

Building a hospital now has additional benefits. Whenever you build a hospital, after placing the hospital onto the board, do the following:

• Put the 2 purification tokens that were underneath the hospital into the supply. They are now available for use.

• Remove the disease cubes (matching the color of the hospital, if any) from the city where you built the hospital and return them into the supply.

The downside to building hospitals, however, is that players must now move one disease cube (referred to as a "patient" from now on) toward each hospital each turn. This means that the hospitals can quickly become overrun with patients.

Move patients after doing actions, but before drawing Player cards, according to this new order of play:

1. Do 4 actions
2. Move patients (1 per color)
3. Draw 2 Player cards
4. Draw Infection cards

Moving Patients

During step 2, for each hospital, move the closest patient (i.e., disease cube) matching the color of the hospital 1 step toward it.

When counting distance to determine the closest patient, count line segments but ignore the railroad tokens. If there are 2 or more patients the same distance away, you may choose the patient to move from the closest patients.

When moving, patients will move the fastest way they can - which means they will take use railroads if it's the fastest means to reach the hospital. If there are 2 or more routes that take the same amount of time, you may choose the route the patient takes from the fastest routes. Moving patients are not affected by purification tokens or the Nurse's prevention token.

If moving a patient causes a city with a hospital to have 4 disease cubes of the same color, it is overrun.

If an outbreak happens in a city containing a hospital (by an Infection or Epidemic card) place the 4th disease cube into the city (a 5th or 6th cube of the same color are never placed), then follow the rules for Overrun Hospitals.

Overrun Hospitals

If a city with a hospital ever has 4 or more patients of the same color in it, the hospital is overrun and everyone flees the city. Instead of doing a normal outbreak when this happens, move every patient of that color in the city into adjacent cities. Players may decide which cities the cubes are moved to.

In some cases this may result in one or more outbreaks.

When this happens, resolve the outbreaks normally. After moving cubes out of the city with the overrun hospital, mark an outbreak on the Outbreaks track.

Historical Diseases Challenge Background

In this challenge you must fight as an experienced team against even more powerful diseases. Each disease will now appear with a different, terrible behavior: more dangerous outbreaks, more rapid infection, harder to treat… City life was not so easy in the 19th Century!

Although many diseases devastated the world during 19th Century, only four of these dangerous enemies appear in this game. At the time, humanity began to learn how the diseases originated, how to fight them, and how to prevent them.

And although these diseases have now been eliminated from much of the developed world, millions of people continue to suffer from them.

Setup

Shuffle the Disease cards and randomly select one, two, three, or four of them to play with. The more you select, the harder your game will be.

(You might want to start with just one and gradually add more in future games as you get better at the game). Place the cards you've randomly selected to the side of the board and the others back into the box.

Game Play

Play as usual, but note the special effects of the historical diseases that are now in play:

Historical Informations

Events

• 

  Good Season

  Epidemics and new disease outbreaks have decimated populations over the course of human history. Many terrible diseases have been controlled or even eradicated from some regions thanks to advances in science.

  
  
• 

  Overseas Migration

  In the last decade of the 19th century, Spain controlled some overseas territories: Islas Canarias, Ceuta, Melilla, Cuba, Puerto Rico, Filipinas, Guinea and Sahara Español, among others. Portugal had territories in Açores, Madeira, Africa, Índia Portuguesa (Goa, Damão), Macao, and Timor-Leste, among others.

  In the Peninsula, there was also a third but small country named Andorra, and a British colony, the City of Gibraltar.

  
  
• 

  Government Mobilization

  The Royal Philanthropic Expedition was led by Doctor Francisco Javier de Balmis, a deputy surgeon, 3 nurses, 2 first-aid practitioners, 2 assistants, a rectoress, and 22 orphan boys.

  
  
• 

  Purify Water

  Asepsis-having clean food, water, and medical instruments-was one of the most important discoveries for fighting diseases and a powerful tool against infections.

  
  
• 

  Hospital Founding

  There were specialized hospitals for every kind of illness. Sick people would move to a city for its hospital, although their capacity for curing them was very limited.

  
  
• 

  Ring Railroads

  In 1855, the General Law of Railroads was the first plan to build a national train network, using a characteristically wider railroad than the rest of the European countries. In Portugal, the main railroad network was built from 1856 to 1890.

  
  
• 

  Mail Correspondence

  The postal mail business is as old as the Roman age. The first Spanish stamps were launched on January 1, 1850. In Portugal, stamps were approved two years later and started to be used in 1853.

  
  
• 

  Science Triumph

  Humanity started to win against diseases thanks to many scientific and medical discoveries, mainly asepsis and the microbiologic origin of infectious diseases

  
  
• 

  New Rails

  The first railroad and train travel in the Iberian Peninsula was from Barcelona to Mataro, inaugurated on October 28, 1848 (The first one in Spain was in Cuba in 1837). The first Portuguese railroad, from Lisboa to Carregado, was inaugurated on October 28, 1856.

  
  
• 

  Second Chance

  Different diseases struck cities one after another, or at the same time. As modern medicine advanced, so did life expectancy

  
  
• 

  One More Day

  Researchers and scientists dedicated many efforts to fight against diseases. The main scientific institutions were universities and royal academic centers. When the first plans for public education started, around 90% of the adult population was illiterate.

  
  
• 

  Ships Arrive

  Until the end of the 19th century, ships and boats were the fastest long-distance transports and the main way to move resources.

  
  
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  Telegraph Message

  The first telegraph message in Spain, from Madrid to Irun, was a speech Queen Isabel II gave to inaugurate a new congress period on November 8, 1854. The public service of telegrams started on February 25, 1855. In 1855, a submarine line connected Lisboa to Azores Islands. Portuguese public service of telegrams started in 1857.

  
  
• 

  When the Plans Were Good

  The Royal Philanthropic Expedition was a medical mission from 1803 to 1806. Its objective was to bring a smallpox vaccine to the overseas Spanish lands, carried inside the blood of 22 orphan boys. It was the first healthcare expedition in World history.

  
  
• 

  Travel Day and Night

  The main way of transport, before the train age, was carriages and coaches.

  
  

Diseases

Roles

Each player has a role with special abilities to improve your team's chances.

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