MDHHS Legionnaires Emails

MDHHS #1
This is the first email MDHHS has that documents then-MDCH staff knowledge and
involvement. At the time of all these emails, the department is the Michigan
Department of Community Health (MDCH) as the merger to create the Michigan
Department of Health and Human Services (MDHHS) does not take place until midApril, 2015.
From:Johnson,Shannon(DCH)
Sent:Monday,October13,201412:02PM
To:Bohm,Susan(DHHS)<bohms@michigan.gov>;Fiedler,Jay(DHHS)<FiedlerJ@michigan.gov>;Collins,Jim(DHHS)
<CollinsJ12@michigan.gov>
Cc:Bolen,Timothy(DHHS)<BolenT1@michigan.gov>;TyndallSnow,Leigh(DHHS)<TyndallSnowL@michigan.gov>;
Rudrik,JamesT.(DHHS)<rudrikj@michigan.gov>
Subject:GeneseeCo.Legionnaire'soutbreak
Hello,
IspokewithTimlatelastweekabouttheongoingLegionnairesincreaseinGeneseeCounty.Theyvehad30casesof
LegionnairesDiseasereportedintotheMDSSfromJunepresentthisyear,whereinpreviousyears(20092013)theyve
hadarangefrom29casesreportedduringthissametimeframe.Geneseeinitiallythoughttheincreasewasassociated
withMcLarenFlintHospitalasasource,butafterTimandIbothreviewedthepreliminarydataitwasprettyclearthat
manyofthecasesdidnotfitwiththishypothesis.Inaddition,thepicturehasbeencloudedbythefactthatmostcases
beingreporteddidnothaveonsetdatesrecorded.Thecurrenthypothesisisthatthesourceoftheoutbreakmaybethe
Flintmunicipalwater.TiminformedmethatFlintswitchedfromtheDetroitmunicipalwatersystemtogettingwater
fromtheFlintRiverlastyear.Iran5yearepicurvesforthe6counties(Saginaw,Shiawassee,Livingston,Oakland,
Lapeer,andTuscola)surroundingGeneseeandnoneofthosecountiesareexperiencinganincreasesimilartowhat
Geneseeisseeing.TheothercountiesareatnormalorbelownormallevelsofcasecountsforJunepresent.Ispokewith
theGeneseeEpi,Shurooq,againtodayandshetoldmetheyhavemappedtheircasesandfoundthatnearlyallofthem
arewithinthecityofFlintandonthemunicipalwater.Theyalsofoundthatthemajorityofcasesarenotoccurringclose
tothetreatmentplant,butfurtherdowntheline.Thiswouldnotbesurprisingsincechlorinationanddisinfectionlevels
dropthefurtherawayyougetfromthetreatmentsource.TheLHDmetwiththecityswatertreatmentdepartmentand
confirmedtheydonotconductanyLegionellatestingatthefacility.IletShurooqknowthatwecouldassistwithand
facilitateenvironmentaltesting,whetheritbethroughourlaborDEQ.TheLHDismeetingwiththewaterdept.this
weeksoshesaidshewouldletmeknowwhattheirplanis.Ialsorequested,again,thatshelettheareahospitalsknow
iftheyseeanynewcasesofillnesstocollectarespiratorycultureinadditiontotheurineantigentestsothatif
environmentaltestingisdoneandLegionellaisrecovered,thereisaclinicalsampletocompareitto.Sheletmeknow
thatMcLarenconductedenvironmentaltestingontheirsystemandfoundlowlevelsoflegionellabacteriaandhave
sincehyperchlorinatedtheirwatertodisinfectthesystem.McLarenreceivesitswaterfromtheFlintmunicipalsystem.
TimandIhavebothtriedtoofferourservicestoGeneseeandthusfarhavegottenverylittleinformationand/or
willingnesstoreceiveassistance.AsthisverymuchappearstobeconfinedtoGeneseeandnotamulticountyissue,Im
notsurehowmuchtopushasitssolelytheirjurisdiction.Weknowitsonlyamatteroftimeuntilthishitsthemedia
though
TimPleasefeelfreetocorrectanydetailsIhavewrong,oraddanyothersyoumighthave.
1

Thanks,
ShannonAndrewsJohnson,MPH
InfectiousDiseaseEpidemiologist
MichiganDept.ofCommunityHealth
201TownsendSt.,CVB5thFloor
Lansing,MI48913
Phone:5173358165
Fax:5173358263
MDHHS #2
Shortly after a MDCH epidemiologist elevated this internally, MDCH was
contacted by DEQ regarding Legionnaire's Disease in Genesee County.
From:Bohm,Susan(DCH)
Sent:Friday,October17,20144:31PM
To:Johnson,Shannon(DHHS)<JohnsonS61@michigan.gov>
Cc:Fiedler,Jay(DHHS)<FiedlerJ@michigan.gov>;Collins,Jim(DHHS)<CollinsJ12@michigan.gov>
Subject:QueryfromDEQreGeneseeCountyLegionnaire'sDiseaseCluster
IreceivedacalljustnowfromtheDEQChiefoftheOfficeofDrinkingWaterandMunicipalAssistance,LianeShekter
Smith,aboutacallthatcameintoherOfficefromtheGeneseeCountyHealthDepartmentreLegionnairesDiseasein
GeneseeCounty.FortunatelyIhadShannonsgreatsummarytoworkwith.Lianewasconcernedthiswasasituationjust
breakingsoIwasabletotellherithadbeenunderinvestigationbytheGeneseeCountyHealthDepartmentforseveral
weeks.Shewasconcernedthatweweregoingtobemakingsomeannouncementsoonaboutthewaterbeingthe
sourceofinfection,soItoldhertheFlintwaterwasatthispointjustahypothesis.SheaskedwhetherGeneseehadthe
capabilitytotestwaterandIrepliedthatwewouldbeworkingwithGeneseetocoordinateanywatertesting.Whatshe
didsharewithmewasinterestingthattherehavebeennumerouscomplaintsabouttheFlintwater,thatthe
GovernorsOfficehadbeeninvolved,andthatanyannouncementbypublichealthaboutthequalityofthewater
wouldcertainlyinflamethesituation.
ShegavemethenameofSteveBusch,theFieldOperationsActingChief,DistrictSupervisorforthePublicWaterSupply
ProgramforthedistrictthatincludesGenesee.CommunicationswithDEQaboutthisinvestigationcangotoSteve.His
telnumberis5176432314.Andshewaspleasedthatwewereawareofwhatwasgoingon.
Susan
From: Johnson, Shannon (DCH)

Sent: Monday, October 13, 2014 12:02 PM
To: Bohm, Susan (DCH); Fiedler, Jay (DCH); Collins, Jim (DCH)
Cc: Bolen, Timothy (DCH); Tyndall, Leigh (DCH); Rudrik, James T. (DCH)
Subject: Genesee Co. Legionnaire's outbreak
Hello,
IspokewithTimlatelastweekabouttheongoingLegionnairesincreaseinGeneseeCounty.Theyvehad30casesof
LegionnairesDiseasereportedintotheMDSSfromJunepresentthisyear,whereinpreviousyears(20092013)theyve
hadarangefrom29casesreportedduringthissametimeframe.Geneseeinitiallythoughttheincreasewasassociated
withMcLarenFlintHospitalasasource,butafterTimandIbothreviewedthepreliminarydataitwasprettyclearthat
manyofthecasesdidnotfitwiththishypothesis.Inaddition,thepicturehasbeencloudedbythefactthatmostcases
beingreporteddidnothaveonsetdatesrecorded.Thecurrenthypothesisisthatthesourceoftheoutbreakmaybethe
Flintmunicipalwater.TiminformedmethatFlintswitchedfromtheDetroitmunicipalwatersystemtogettingwater
fromtheFlintRiverlastyear.Iran5yearepicurvesforthe6counties(Saginaw,Shiawassee,Livingston,Oakland,
1
Lapeer,andTuscola)surroundingGeneseeandnoneofthosecountiesareexperiencinganincreasesimilartowhat
Geneseeisseeing.TheothercountiesareatnormalorbelownormallevelsofcasecountsforJunepresent.Ispokewith
theGeneseeEpi,Shurooq,againtodayandshetoldmetheyhavemappedtheircasesandfoundthatnearlyallofthem
arewithinthecityofFlintandonthemunicipalwater.Theyalsofoundthatthemajorityofcasesarenotoccurringclose
tothetreatmentplant,butfurtherdowntheline.Thiswouldnotbesurprisingsincechlorinationanddisinfectionlevels
dropthefurtherawayyougetfromthetreatmentsource.TheLHDmetwiththecityswatertreatmentdepartmentand
confirmedtheydonotconductanyLegionellatestingatthefacility.IletShurooqknowthatwecouldassistwithand
facilitateenvironmentaltesting,whetheritbethroughourlaborDEQ.TheLHDismeetingwiththewaterdept.this
weeksoshesaidshewouldletmeknowwhattheirplanis.Ialsorequested,again,thatshelettheareahospitalsknow
iftheyseeanynewcasesofillnesstocollectarespiratorycultureinadditiontotheurineantigentestsothatif
environmentaltestingisdoneandLegionellaisrecovered,thereisaclinicalsampletocompareitto.Sheletmeknow
thatMcLarenconductedenvironmentaltestingontheirsystemandfoundlowlevelsoflegionellabacteriaandhave
sincehyperchlorinatedtheirwatertodisinfectthesystem.McLarenreceivesitswaterfromtheFlintmunicipalsystem.
TimandIhavebothtriedtoofferourservicestoGeneseeandthusfarhavegottenverylittleinformationand/or
willingnesstoreceiveassistance.AsthisverymuchappearstobeconfinedtoGeneseeandnotamulticountyissue,Im
notsurehowmuchtopushasitssolelytheirjurisdiction.Weknowitsonlyamatteroftimeuntilthishitsthemedia
though
TimPleasefeelfreetocorrectanydetailsIhavewrong,oraddanyothersyoumighthave.
Thanks,
Lansing,MI48913
Phone:5173358165
Fax:5173358263
MDHHS #3
MDCH epidemiologist reaches out directly to the Genesee County Health
Department Health officer and Medical Director. No record they ever responded.
From:Bohm,Susan(DCH)
Sent:Tuesday,October21,20149:47AM
To:Valacak,Mark<mvalacak@gchd.us>;Johnson,Garry<gjohnson@gchd.us>
Cc:Fiedler,Jay(DHHS)<FiedlerJ@michigan.gov>;Johnson,Shannon(DHHS)<JohnsonS61@michigan.gov>;Bolen,
Timothy(DHHS)<BolenT1@michigan.gov>
Subject:Legionnaire'sDiseaseClusterinFlintarea
Goodmorning,
WehavebeencontactedacoupleoftimesnowbytheDEQChiefoftheOfficeofDrinkingWaterandMunicipal
Assistance,LianeShekterSmith,abouttheLegionnairesDiseaseclusterintheFlintarea.Weletherknowthatthe
clusterhasbeenunderinvestigationbytheGeneseeCountyHealthDepartmentforseveralweeks.Shewasconcerned
thatanannouncementwasgoingtobemadesoonaboutthewaterasthesourceofinfection;ItoldhertheFlintwater
wasatthispointjustahypothesis.IwouldliketogiveLianecontactinformationofsomeoneattheGeneseeCounty
HealthDepartmenttospeakwithdirectlyabouttheinvestigation.Pleaseletmeknowwhothatmightbe.
Asalways,shouldGCHDneedanyassistancewiththeinvestigation,wewouldbemorethanwillingtoassist.Thanks.
SusanBohm,MS
Manager,Enteric&RespiratoryIllnessesEpidemiologyUnit
SurveillanceandInfectiousDiseaseEpidemiology
DivisionofCommunicableDisease
MichiganDepartmentofCommunityHealth
201TownsendSt,5thFlr
Lansing,MI48933
5173358165 or5173735508(Cell:5179303100) 5173358263
bohms@michigan.gov www.michigan.gov/mdch
ConfidentialityNotice:Thismessage,includinganyattachments,isintendedsolelyfortheuseofthenamedrecipient(s)andmaycontain
confidentialand/orprivilegedinformation.Anyunauthorizedreview,use,disclosureordistributionofanyconfidentialand/orprivileged
informationcontainedinthisemailisexpresslyprohibited.Ifyouarenottheintendedrecipient,pleasecontactthesenderbyreplyemailand
destroyanyandallcopiesoftheoriginalmessage.
MDHHS #4
MDCH epidemiologist begins the process of facilitating questionnaire

development with the Genesee County Health Department epidemiologist.
Sent:Friday,January23,201510:38AM
To:Collins,Jim(DHHS)<CollinsJ12@michigan.gov>;Fiedler,Jay(DHHS)<FiedlerJ@michigan.gov>
Subject:FW:LegionellaQuestions

Sent: Friday, October 17, 2014 1:52 PM
To: 'Hasan, Shurooq'; Bolen, Timothy (DCH)
Cc: Cupal, Suzanne
Subject: RE: Legionella Questions
HiShurooq,
Great,thanksforsendingthatalong.Attachedistheextendedquestionnairethatweputtogetheranumberofyears
agotouseinconjunctionwiththeMDSSforminordertocollectadditionalexposureinformationwhenwereseeinga
highnumberofcases.PerhapsonceyoulookitoverwecanfigureoutaGeneseespecificversionbycombiningsomeof
thequestionsandaddinganyothersthatmightbeneeded.
Thanks,
Shannon
Lansing,MI48913
Phone:5173358165
Fax:5173358263
From: Hasan, Shurooq [mailto:shasan@gchd.us]

Sent: Friday, October 17, 2014 1:44 PM
To: Johnson, Shannon (DCH); Bolen, Timothy (DCH)
1
Cc: Cupal, Suzanne

Subject: Legionella Questions
Hi,
ThequestionsbelowarewhatwedeterminedshouldbeaskedtothosewhoarediagnosedwithLegionella.Pleaseshare
withusanysuggestionsorconcernsyoumighthave.Thanks!
1) Whatkindofwaterdoyoudrink?(Wellvs.City)
a. Ifcitywater,fromwhatlocation?
2) Haveyourecentlytraveled/stayedinanyhotels?
3) Doyouuseanairconditionerathome?Ahumidifier?
4) Doyouhaveapool,saunaorspayouuseregularlyuseathome?
5) Hastherebeenanyrecentremodelinginyourhouse?
6) Doyouhaveproperventilationinyourbathroomathome?
Shurooq
Shurooq Hasan, M.P.H

Epidemiologist
Genesee County Health Department
630 S. Saginaw Street
Flint, MI 48502
(810) 257-3815
shasan@gchd.us
MDCH Supplemental Legionellosis Questionnaire

To be used in addition to the MDSS Legionellosis form
Health Status Risk Factors (please check all that apply):
Smoking- packs per day:_________
Emphysema
Chronic lung disease (e.g. COPD)
Cancer
Compromised immune system
Liver disease
Heart disease
Oral steroid use
Previous dx of pneumonia- when?:___________________
Onset Date:
Asthma
Diabetes
Kidney problems
Organ transplant
Other- detail:___________________
Dates to consider for exposure (2 weeks prior to onset): ___/___ - ___/___
During the 2 weeks prior to the onset of symptoms, did the patient do any of the following?:
Use respiratory equipment (e.g. nebulizer): No / Unk / Yes - what? ____________________________
Shower/ bathe outside of home: No / Unk / Yes - where? ____________________________________
Use a hot tub or whirlpool: No / Unk / Yes - where? ________________________________________
Use a public or private pool: No / Unk / Yes - where? ______________________________________
Visit a splash pad or water park: No / Unk / Yes - where? ___________________________________
Been near a lake or pond No / Unk / Yes - where? _________________________________________
Been near a fountain: No / Unk / Yes - where? ____________________________________________
Been near a cooling tower: No / Unk / Yes - where? ________________________________________
Visit a hospital or doctors office: No / Unk / Yes - where? __________________________________
Visit a spa: No / Unk / Yes - where? ____________________________________________________
Visit a grocery store: No / Unk / Yes - where? ____________________________________________
Visit a church: No / Unk / Yes - where? _________________________________________________
Visit a casino: No / Unk / Yes - where? __________________________________________________
Visit a movie theater: No / Unk / Yes - where? ____________________________________________
Visit a car wash: No / Unk / Yes - where? ________________________________________________
Visit a hair salon/ barber shop: No / Unk / Yes - where? _____________________________________
Work in a garden: No / Unk / Yes - where? _______________________________________________
Fill your cars windshield washer fluid tank with water instead of washer solvent: No / Unk / Yes
_____
___
Additional Questions:
Patients job title:________________________ Name of worksite & location: _______________________
Do you have a window air conditioning unit: No / Yes If yes, age of unit? __________
Are you aware of any other family members, friends, or co-workers who have similar symptoms or illness?
No Yes If yes, relationship to other ill person(s)____________________________________________
In the 2 weeks prior to the onset of your symptoms, what other stores, shopping malls, restaurants, and
friends houses did you visit?________________________________________________________________
_______________________________________________________________________________________
During the 2 weeks prior to the onset of your symptoms, did you do anything different from your normal
everyday routine?_________________________________________________________________________
Version 2.0
MDHHS #5
As epidemiologists continue to elevate this internally, the MDCH Communicable
Disease Division Director makes another offer of assistance to the leadership
of the Genesee County Health Department. We then identify a consistent point
of contact within the local health department.
From:Collins,Jim(DCH)
Sent:Friday,January23,201511:40AM
To:gjohnson@gchd.us;bchilds@gchd.us;jhenry@gchd.us;scupal@gchd.us;shasan@gchd.us;mvalacak@gchd.us
Cc:TyndallSnow,Leigh(DHHS)<TyndallSnowL@michigan.gov>;Bohm,Susan(DHHS)<bohms@michigan.gov>;Johnson,
Shannon(DHHS)<JohnsonS61@michigan.gov>;Fiedler,Jay(DHHS)<FiedlerJ@michigan.gov>;Miller,Corinne(DHHS)
<MillerC39@michigan.gov>;McFadden,Jevon(DHHS)<McFaddenJ1@michigan.gov>
Subject:LegionellaInvestigations
HelloColleagues,
Imcertainlyawareofthepressuresonyouragencyoflatefromthepublicandmediaalikearoundthewaterquality
questionsinFlint.Honestly,Ireallydonotwanttoinconvenienceyouwiththisrequest,butitisonethatwefeelneeds
tobeaddressed.
Asyouknow,therehasbeenamarkedincreaseinconfirmedcasesofLegionellainfectioninGeneseecounty(which
likelyrepresentsthetipoftheicebergrelativetotheactualnumberofcasesofillness).Webelievethatthisincrease
warrantsadditionalevaluationonthepartofpublichealth.CommunicableDiseaseDivisionstaffarecertainlyavailable
tosupportthateffortatyourrequest.Ivegottensomemixedmessagesaroundtheleveloffollowupthathasbeen
completedonthesecasessofar.Itseemsthat,ifcompletefollowupistakingplace,theinformationisnotbeing
enteredintotheMDSS.Thisinformationcanprovidethecriticalfirststeptowarddirectingenvironmentalassessments
ofexposure,sourceidentificationand,hopefully,elimination(ifacommonsourceoftheseinfectionscanbeidentified).
Canweprovideanyassistance(onsite,orremotely)toyourprogramforthisinvestigation?Again,CDDivisionstaffand
ourcurrentCSTEfellowarereadytoassistinanywaythatmightlessentheburdenonyourstaff.
IdolookforwardtoschedulingatimefordiscussionnextweekandIthinkShannonJohnsonisworkingtothatend.
ThankYou,
Jim
JimCollinsMPH,RS
Director
CommunicableDiseaseDivision
201TownsendSt.
Lansing,MI48913
Desk:5173358586
1
Cell:5179306932
MDHHS #6
After a phone call with Genesee County Health Department on 1/27/15 and
internal discussion at MDCH led to the development of guidance for how the
investigation needed to proceed and made specific offers of assistance to move
a comprehensive investigation forward.
Sent:Tuesday,January27,20153:45PM
To:gjohnson@gchd.us;bchilds@gchd.us;scupal@gchd.us;jhenry@gchd.us;shasan@gchd.us;mvalacak@gchd.us
Cc:Collins,Jim(DHHS)<CollinsJ12@michigan.gov>;Fiedler,Jay(DHHS)<FiedlerJ@michigan.gov>;Bohm,Susan(DHHS)
<bohms@michigan.gov>
Subject:GeneseeLegionellosisInvestigation
GreetingsGCHD,
Thankyoufortheopportunitytospeakwithyouthismorning.AfterbeingupdatedonwhereGCHDisinthe
investigationprocess,wehaveidentifiedsomeitemsthatneedadditionaldetailsand/ormayrequireadditionaldata
gatheringefforts.Inaddition,wevelistedareaswherewecanprovidepersonneltoassistwithdatacollection/analysis
oraidincommunicationbetweentheinvolvedgovernmentaldepartmentsduringtheoutbreakinvestigation.Atthis
point,theprioritiesinthepublichealthinvestigationaretodeterminethescopeoftheoutbreakandtodefineasclearly
aspossiblethecharacteristicsofthecasesofLegionnairesDiseaseandPontiacFever.Thesedatawillbecriticaltohelp
informandprovidedirectionfortheenvironmentalsideoftheinvestigation.
DatabeingrequestedbyMDCHand/orsuggesteddatacollectionneedstobeaddressed:
1)PleaseprovidethenameoftheprimarypointofcontactfortheoverallGCHDlegionellosisinvestigation.
2)ThecurrentcopyoftheGCHDLegionnairesDiseaseoutbreakdatacollectionlinelistisrequestedandupdatessentto
MDCHonaregularbasis.
3)Onsetdatesorestimatedonsetdatesneedtobedeterminedforallcases.
4)Acurrentmapofthemunicipalwatersystemneedstobeobtainedandcasesresidencesmappedinrelationtothe
watersystem.
5)TheinvestigationneedsaGeneseespecificsupplementalquestionnairebeyondtheMDCHsupplementalformand
the6questionsintheemailmessagedated10/17/14.
6)Allpreviouscases(since5/1/14)andnewcasesshouldbereinterviewedassoonaspossiblewiththenewoutbreak
specificquestionnaire.Ifcasesarenotavailable,thenaproxyshouldbeinterviewed,ideallysomeonefromthe
samehousehold.
7)TolookforcasesofmilderillnesssuchasPontiacFever,thequestionnaireshouldaskifthereareotherhousehold
memberswhohavehadasimilarrespiratoryillness.Anyhouseholdcontactswithlegionellosisconsistentillness
shouldalsobeinterviewedwiththeoutbreakspecificquestionnaire.
8)Clinicalculturespecimens,inadditiontourineantigentesting,shouldbecollectedfromallsuspectcaseswhere
individualsareseekingmedicalcare.
9)Hospitalsshouldbequeriedtodeterminewhetheranypreviouslydiagnosedcaseshadrespiratoryculturescollected
andwhetheranyoftheseculturespecimenswereretained.Ifso,itshouldberequestedthatthesesamplesbe
helduntiladeterminationonenvironmentaltestingcanbemade.
1

AssistancethatMDCHcanprovidetoGeneseetoaidintheoutbreakinvestigation:
1)MDCHcanprovidelanguagetoGCHDfordistributiontothemedicalcommunityregardingtherequestforclinical
respiratoryculturecollectiononallsuspectcasesoflegionellosis(LegionnairesDiseaseandPontiacFever).
2)MDCHstaffisavailabletoconductmedicalrecordextraction,asneeded.
3)MDCHstaffcanassistwithdataentryintoMDSS,asneeded.
4)MDCHstaffcanhelpwiththedevelopmentofaGeneseespecificoutbreakquestionnaire.
5)MDCHiswillingtoassistwithsupplementalquestionnairedatacollectionbyconductingcaseinterviews(on
previouslyand/ornewlydiagnosedcases)andalsobyassistingwithdataanalysis,asneeded.
6)MDCHcanassistwiththecoordinationandcommunicationwithMDEQforspecificdatarequestsbyGCHD.
7)TheMDCHPIOcanworkwiththeGCHDPIOtodevelopacoordinatedpublichealthmessagetorespondtopublicand
mediainquiries.
Ifthereareotherissuesthatwehavenotaddressedwhereourassistancewouldbehelpful,pleasedonothesitateto
ask.Weappreciateyoureffortsandrecognizethedelicatesituationyouaredealingduringthisinvestigation.Welook
forwardtocontinuedcommunicationandcollaborationwithyou.
Regards,
ShannonJohnson
Lansing,MI48913
Phone:5173358165
Fax:5173358263
MDHHS #7
MDCH is forced to lay out exact steps to be taken with dates that we expect the
Genesee County Health Department to complete tasks by in order to accomplish
the work needed to be done by the locals.
Sent:Wednesday,February04,20152:39PM
To:Hasan,Shurooq<shasan@gchd.us>;Henry,James<jhenry@gchd.us>
Cc:Cupal,Suzanne<scupal@gchd.us>;Childs,Bonnie<BCHILDS@gchd.us>;Johnson,M.D.,Gary
<GJOHNSON@gchd.us>;Valacak,Mark<MVALACAK@gchd.us>;Fiedler,Jay(DHHS)<FiedlerJ@michigan.gov>;Bohm,
Susan(DHHS)<bohms@michigan.gov>;Collins,Jim(DHHS)<CollinsJ12@michigan.gov>;Miller,Corinne(DHHS)
<MillerC39@michigan.gov>
Subject:RE:GeneseeLegionellosisInvestigation
DearGCHD,
Thankyouallforyourresponse.IhaveattachedtheWorddocumentwithadditionalMDCHanswerstoyourquestions
(inblue).Movingforward,weveidentifiedsomenextstepsinourcollaborationontheinvestigation.Ispokewith
Shurooqtodayandwemadedecisionsonthedivisionoflaborforthesepoints.
1) GeneseewillsendMDCHacopyoftheircurrentlinelistbythisFriday,Feb6th.Wewillusethisasthemasterline
listfortheinvestigation.
2) PleaseprovideanestimateddateofwhentheHANdiscussingclinicaltestingwillbesenttoprovidersinthe
community.WewouldappreciateseeingacopyofthefinalHANpriortoitbeingsentout.Idiscussedsome
pointsofclarificationabouttheHANlanguagewithShurooqonthephonetoday.Thehospitalswillbefollowing
theirownprotocolsforrespiratoryculturetestingtoattempttoisolatelegionella.Geneseemaywanttoinclude
languageintheHANsuggestingbronchialwashesbeusedastheyaremorelikelytocontainsufficientbacteria
forculturegrowthcomparedtoasputumspecimen.Ifthelegionellabacteriaisidentifiedatthehospitallab,
thoseisolateswillbesentalongtotheMDCHlabforadditionaltesting.
3) Wewouldliketohaveanoutbreakspecificquestionnairefinalizedbytheendofnextweek,FridayFeb13th.Per
Shurooq,GeneseeiscollaboratingwithJoanRosefromMSUonwatersystemspecificquestions.MDCHwill
begincreatingaquestionnairetemplatetobecombinedwithGeneseesquestionsandafinalversionwillbe
reviewedbybothagencies.
4) MDCHhasrequestedmedicalrecordaccessforthelegionellosisinvestigationfromGenesys,Hurley,and
McLarenhospitals.AfterdiscussingwithShurooq,MDCHwillbegintocollectinformationonprevious
hospitalizations(dates,admissioncomplaint,etc.)forcases.
5) Onsetdates(orestimatedonsetdates)forallcasesneedtobedetermined.Geneseewillworktocollectthis
informationonnewcases(since1/1/15).MDCHwillreviewmedicalrecordsinMDSSandcontacthospitalsas
neededtodetermineonsetdatesforpreviouscases(6/1/1412/31/14).
6) Considerationsfordefiningtheinvestigation.Inthissituation,thetermoutbreakisbeingusedinthe
epidemiologicsense,meaninganincreaseincasesofabovebaseline.Basedonthis,thecurrentGenesee
outbreakbeganinJune,2014with5reportedcases.Untilfurtherinformationiscollectedandanalyzedthe
definitionwillbegeneral:Casesoflegionellosis(LegionnairesDiseaseandPontiacfever)inGeneseeCounty
since6/1/14.Inthefuture,wemaybeabletorefinethedefinitionasadditionaldataisobtained.IfGenesee
prefers,theymaymarkallcasesinMDSSmeetingthecurrentdefinitionasoutbreakassociatedandassignan
outbreakID.ThisisgenerallymoreusefulwhenneedingtosearchtheMDSSforasubsetofcasesinthesystem.
SincetheoutbreakcurrentlyincludesallGeneseelegionellosiscasessince6/1/14,itisnotasurgent.
Ifthereareotherinitialstepsyouwouldliketoincludepleasefeelfreetoaddthemtothelist.
Bestwishes,
Shannon
Lansing,MI48913
Phone:5173358165
Fax:5173358263
From: Cupal, Suzanne [mailto:scupal@gchd.us]

Sent: Friday, January 30, 2015 3:22 PM
To: Collins, Jim (DCH); Johnson, M.D., Gary; Childs, Bonnie; Henry, James; Hasan, Shurooq; Valacak, Mark
Cc: Fiedler, Jay (DCH); Bohm, Susan (DCH); Bolen, Timothy (DCH); Miller, Corinne (DCH); Johnson, Shannon (DCH)
Subject: RE: Genesee Legionellosis Investigation
DearMDCHColleagues,
WeappreciatedtheopportunitytodiscusstheincreaseinlegionellosiscasesthatGeneseeCountyisexperiencing.
Collaborationisoneofourcorevaluesasalocalhealthdepartment.MDCHhasbeenavaluedpartnerwhobrought
resourcesandexpertisetoassistinsolvingsomeverychallengingsituationsinthepast.Welookforwardtothepositive
elementsyoucanbringtothisinvestigation.
Asdiscussedduringourcall,wehaveconcernsnotonlyaboutlegionellosis,butareinvolvedinmultipleinvestigations
concerningthesafetyoflocalwater.Wewereappreciativeoftheopportunitytoshareourinvestigationtodateandour
plansforcontinuedinvestigativework.WearealsoappreciativeoftheopportunitytorequestMDCHsassistancein
movingourinvestigationforward.Welookforwardtocontinuedandimprovedcommunicationandcollaborationand
appreciateyouroffersofassistance.
Weappreciateyouracknowledgmentofthesensitivenatureofourworkinanenvironmentofanxietyandsuspicion.
Wedonotwanttojumptoconclusionsbaseduponverylimitedandinconclusiveevidenceandyourassistanceinfilling
someoftheinformationgapswehaveidentifiedwouldbeofgreathelp.Wespecificallyaskedforyourassistancein
identifyingsomeoneatMDCHwithexpertiseintype1watersuppliesandcommunicabledisease.Thatwasnotreflected
inyourresponse.PleaseletusknowifthereisanidentifiedresourceforthisatMDCH.Inaddition,werequestedyour
supportinidentifyingsomeoneonyourstaffwhocouldfunctionasaliaisonwithyourfellowstatecolleaguesatMDEQ
2
sinceanumberofquestionshavecomeupregardingthetype1watersupplywherethestatehasregulatoryauthority
andaccesstoimportantdata.
Asweindicatedinourcall,wecontinuetoidentifyandreachouttothosethatcaninformourinvestigationandprovide
moreinformationregardingwaterandlegionellosis.Thefeedbackthatwearereceivinghasbeenveryhelpfulin
evolvingourinvestigation.However,additionalexpertiseisbeingsoughtastheinvestigationunfolds.
Wehavemetinternallyandcollaboratedonourresponsestoyourquestions.Inyourresponse,youmakereferenceto
thescopeoftheoutbreak.WeencourageyoutoreviewthecasenotesinMDSS.Ifwearereferringtothisasan
outbreak,wewouldliketorequestthatwedesignateitassuchandincludeanoutbreakidentifierinMDSS.Wewould
alsoliketodiscusscriteriaforinclusionforthisoutbreak.Duringourcall,weinformedyouofourworkinidentifying
closecontactsofourcasesthatsubsequentlybecamecasesthemselvesortestedpositivebutdidnotmeetthecase
definitiontobereportedasaconfirmedcase.Wealsodescribedthechallengesinrecordingonsetdates(seethenotes).
Youhaverequestedlinelistingsonaregularbasis.Wewouldliketoproposeregularmeetingsviaconferencecallto
discussdetailsofhowwerecordinformationinMDSSaswellastoshareourmutualfindings.Basedonourexperiences
regardingthisinvestigation,wewouldalsoliketomakerecommendationsregardingthereportingprocess.
Welookforwardtoourcollaborativeprocess.Wewanttoremindyouthatinadditiontoourlegionellosisinvestigation,
wearealsoinvestigatingwaterrelatedissues.Aswecontinuetolearnmorethroughthisprocess,wehopetobeina
positiontoshareourfindingswithothers.
YourGCHDColleagues
Suzanne Cupal, M.P.H.

Public Health Supervisor
Suite 4
Flint, MI 48502
(810) 768-7970
scupal@gchd.us
From: Collins, Jim (DCH) [mailto:CollinsJ12@michigan.gov]

Sent: Friday, January 30, 2015 1:21 PM
To: Johnson, M.D., Gary; Childs, Bonnie; Cupal, Suzanne; Henry, James; Hasan, Shurooq; Valacak, Mark
Cc: Fiedler, Jay (DCH); Bohm, Susan (DCH); Bolen, Timothy (DCH); Miller, Corinne (DCH); Johnson, Shannon (DCH)
Subject: RE: Genesee Legionellosis Investigation
Importance: High
GoodAfternoonAll,
WhileyouallattheGeneseeCountyHealthDepartmentarereviewingShannonspostfromacoupleofdays
ago(Copiedbelow.Welookforwardtohearingyourthoughtsonthisaswell),IthoughtIdgoaheadand
providesomeadditionalinformationthatwevecompiledaftertheconferencecall.
3

Duringourconversation,therewasarequestforinformationaboutthepublichealthoutreachtotheclinical
communityinresponsetoanincreaseinlegionellainfectionsbeingreportedfromthemetropolitanDetroit
areaandseveralotherstates(spring/summer2013).Specifically,wediscussedthetextofahealthalert
messagethatwassharedwiththeregionshospitalsviatheMichiganHealthAlertNetork(MIHAN)andany
accompanyingdocumentation.
Ivegotbothtooffertoyoutoday.
Iveattachedthedocument,LegionellosisGuidanceforCliniciansthatwasdistributedwiththefollowing
MIHANmessage:
Text from SE Legionellosis increase HAN in 2013:

Subject: Legionellosis in S.E. Michigan
Detroit City, Wayne and Macomb Counties have reported 35 cases of Legionellosis in June. This
represents the highest number of Legionellosis cases for the month of June over the past decade and
new cases continue to be identified in these jurisdictions. Most patients were or are still hospitalized
(some in the ICU) and symptoms reported include fever, vomiting, abdominal pain, nausea and
diarrhea. The CDC has also provided notification indicating an increase in Legionellosis cases in the
Northeast (NY, DE, CT & PA).
Investigations are ongoing in Southeast Michigan to determine common sources of exposure. We are
asking that the clinical community assist in this investigation through accurate identification, testing and
reporting of all suspect cases of Legionellosis.
Attached, please find guidance that has been prepared to assist clinicians in case evaluation and
facilitate specimen collection/testing as well as an updated "Supplemental Interview Form" for local
health department use in evaluating reported cases.
Pleasenotethatintheattachment,thereisintroductoryroomtoofferalocalassessmentofthesituationand
therationalebehinddistributingtheMIHANmessage.WefeelthatGCHDisbestpositioneddistributea
messagetothehealthcarecommunityandtoprovidelocalcontexttothatmessagebutarecertainlyavailable
toprovideassistancetoeitherfunctionifyoudprefer.
Again,wedolookforwardtohearingyourthoughtsonShannonspreviouspostandstandreadytoassistin
whatevercapacitymightbestservetheinvestigation.
AllMyBest,
Jim
JimCollinsMPH,RS
Director
CommunicableDiseaseDivision
201TownsendSt.
Lansing,MI48913
Desk:5173358586
Cell:5179306932

Sent: Tuesday, January 27, 2015 3:45 PM
To: gjohnson@gchd.us; bchilds@gchd.us; scupal@gchd.us; jhenry@gchd.us; shasan@gchd.us; mvalacak@gchd.us
Cc: Collins, Jim (DCH); Fiedler, Jay (DCH); Bohm, Susan (DCH)
Subject: Genesee Legionellosis Investigation
GreetingsGCHD,
Thankyoufortheopportunitytospeakwithyouthismorning.AfterbeingupdatedonwhereGCHDisinthe
investigationprocess,wehaveidentifiedsomeitemsthatneedadditionaldetailsand/ormayrequireadditionaldata
gatheringefforts.Inaddition,wevelistedareaswherewecanprovidepersonneltoassistwithdatacollection/analysis
oraidincommunicationbetweentheinvolvedgovernmentaldepartmentsduringtheoutbreakinvestigation.Atthis
point,theprioritiesinthepublichealthinvestigationaretodeterminethescopeoftheoutbreakandtodefineasclearly
aspossiblethecharacteristicsofthecasesofLegionnairesDiseaseandPontiacFever.Thesedatawillbecriticaltohelp
informandprovidedirectionfortheenvironmentalsideoftheinvestigation.
1)PleaseprovidethenameoftheprimarypointofcontactfortheoverallGCHDlegionellosisinvestigation.
2)ThecurrentcopyoftheGCHDLegionnairesDiseaseoutbreakdatacollectionlinelistisrequestedandupdatessentto
MDCHonaregularbasis.
3)Onsetdatesorestimatedonsetdatesneedtobedeterminedforallcases.
4)Acurrentmapofthemunicipalwatersystemneedstobeobtainedandcasesresidencesmappedinrelationtothe
watersystem.
5)TheinvestigationneedsaGeneseespecificsupplementalquestionnairebeyondtheMDCHsupplementalformand
the6questionsintheemailmessagedated10/17/14.
6)Allpreviouscases(since5/1/14)andnewcasesshouldbereinterviewedassoonaspossiblewiththenewoutbreak
specificquestionnaire.Ifcasesarenotavailable,thenaproxyshouldbeinterviewed,ideallysomeonefromthe
samehousehold.
7)TolookforcasesofmilderillnesssuchasPontiacFever,thequestionnaireshouldaskifthereareotherhousehold
memberswhohavehadasimilarrespiratoryillness.Anyhouseholdcontactswithlegionellosisconsistentillness
shouldalsobeinterviewedwiththeoutbreakspecificquestionnaire.
8)Clinicalculturespecimens,inadditiontourineantigentesting,shouldbecollectedfromallsuspectcaseswhere
individualsareseekingmedicalcare.
9)Hospitalsshouldbequeriedtodeterminewhetheranypreviouslydiagnosedcaseshadrespiratoryculturescollected
andwhetheranyoftheseculturespecimenswereretained.Ifso,itshouldberequestedthatthesesamplesbe
helduntiladeterminationonenvironmentaltestingcanbemade.
1)MDCHcanprovidelanguagetoGCHDfordistributiontothemedicalcommunityregardingtherequestforclinical
respiratoryculturecollectiononallsuspectcasesoflegionellosis(LegionnairesDiseaseandPontiacFever).
2)MDCHstaffisavailabletoconductmedicalrecordextraction,asneeded.
3)MDCHstaffcanassistwithdataentryintoMDSS,asneeded.
4)MDCHstaffcanhelpwiththedevelopmentofaGeneseespecificoutbreakquestionnaire.
5)MDCHiswillingtoassistwithsupplementalquestionnairedatacollectionbyconductingcaseinterviews(on
previouslyand/ornewlydiagnosedcases)andalsobyassistingwithdataanalysis,asneeded.
6)MDCHcanassistwiththecoordinationandcommunicationwithMDEQforspecificdatarequestsbyGCHD.
7)TheMDCHPIOcanworkwiththeGCHDPIOtodevelopacoordinatedpublichealthmessagetorespondtopublicand
mediainquiries.
5

Ifthereareotherissuesthatwehavenotaddressedwhereourassistancewouldbehelpful,pleasedonothesitateto
ask.Weappreciateyoureffortsandrecognizethedelicatesituationyouaredealingduringthisinvestigation.Welook
forwardtocontinuedcommunicationandcollaborationwithyou.
Regards,
ShannonJohnson
Lansing,MI48913
Phone:5173358165
Fax:5173358263
1)
PleaseprovidethenameoftheprimarypointofcontactfortheoverallGCHDlegionellosis
investigation.ShurooqHasanisleadontheCDinvestigation.JimHenryistheleadonthewater
systeminvestigation.OurentireCDIRTteamisinvolvedinbothinvestigations.
ShannonJohnsonwillserveastheprimarypointofcontactforMDCH.Shannonwillcoordinate
directlywithShurooqandJimatGCHD.
2)ThecurrentcopyoftheGCHDLegionnairesDiseaseoutbreakdatacollectionlinelistis
requestedandupdatessenttoMDCHonaregularbasis.Letusknowthetimetableyouare
proposing.Wewouldliketorequestaregularmeetingschedulesowecandiscussourmutual
findings.
TheGeneseelinelistwillserveasthemasterlinelistfortheoutbreakinvestigation.The
GeneseelinelistshouldbeprovidedtoMDCHweeklyandanydatagatheredbyMDCHwillbe
added.
3)Onsetdatesorestimatedonsetdatesneedtobedeterminedforallcases.Asdiscussedduring
ourcall,wecanprovideestimatedonsetdates.Wewouldlikeyourinputwouldyoupreferwe
reporttheonsetdatereportedbythepatient,theirprimarycarephysicianortheIDPhysician
consulting?Therearedifferences.Pleasekeepthisinmindwhenreviewingthedata.
Fornewcases,theonsetdatefromthepatientinterviewshouldbeused.Foroldercases,the
medicalrecordshouldbeusedtoassistindeterminingtheestimatedonsetdate.TheInfluenza
HospitalizationSurveillanceProjectusesthefollowingrecommendationsfordetermining
estimatedonsetdatesfrommedicalrecords:
InsomecasesyouwillneedtocalculatethedateofonsetbasedonnotesintheAdmission
H&PorDischargeSummarythatindicatethatfeverorcoughbegandaysearlier.
o Coupleofdays=2days
o Fewdays=3days
o Severaldays=5days
o Week=7days
o Forexampleifapatientisadmitted10/15(Day0)andtheAdmissionH&Pindicatesthe
patientcomplainedoffever/coughforafewdays,thentheearliestdateofonsetof
respiratorysymptomsis10/12:
Date:
10/12
10/13
10/14
10/15
DayNumber:
3
2
1
0
Onset
Admission
Ifdateofonsetisprovidedasarangeofdates,usetheearliestdateasdateofonsetof
respiratorysymptoms.
o Forexample,ifadateofonsetisgivenas3tofivedaysago,listthedate
correspondingto5daysago.
Date:
10/10
10/11
10/12
10/13
10/14
10/15
Day
5
4
3
2
1
0
Number:
Onset
Admission
4)Acurrentmapofthemunicipalwatersystemneedstobeobtainedandcasesresidences
mappedinrelationtothewatersystem.Asdiscussedinourcall,weareexperiencingdifficulty
inobtainingtheinformationwehaverequestedfromDWPandMDEQ.WehavesenttheFOIA
requestforthecurrentmapofthemunicipalwatersystem.Asdiscussedduringourcall,we
havemappedourcasestolookforcommonalitiesandtoidentifytheproximityofthecasesto
theboilwateradvisories.
MDCHwillcommunicatewithMDEQaboutobtainingthewatersystemmap.Ifyouhavethe
information,pleaseprovidetoMDCHacopyoftheboilwateradvisories(ordates)andtheareas
theycover.
5)TheinvestigationneedsaGeneseespecificsupplementalquestionnairebeyondtheMDCH
supplementalformandthe6questionsintheemailmessagedated10/17/14.Asdiscussedin
ourcall,GCHDhasbeenidentifyingandreachingouttoindividualswithexpertisewithtype1
watersupplies.Duringourcall,weaskedspecificallyofanyoneatMDCHhasthisexpertise.
Pleaseletusknowifyouhaveastaffmemberwecanconsultwith.Alsostatedduringourcall,
werequestedtheassistanceofMDCHincreatingourGeneseespecificquestionnaire.the
questionnairewearecurrentlyusing.Wearereachingouttowaterexpertstoassistinthe
updatingofourquestionnaire.Inthelimitedconversationswehavehadsofar,wehavelearned
agreatdealwhichwillinformthequestionsweneedtoask.Wealsolookforwardtoadditional
conversationswithourMDCHcolleages.
MDCHdoesnothavestaffwithexpertiseintype1watersupplies,thisfallsunderthepurviewof
MDEQandthelocalwaterauthority.MDCHisabletoadvisespecificallyonlegionellarelatedto
humanillness.Thecompileddataprovidedbythecasesonthequestionnairewillbevitalto
directingthefocusandscopeofpotentialfutureenvironmentaltesting.
AgeneralsupplementaldataformdevelopedbyMDCHwasprovidedtoGeneseeon10/17/14.
MDCHwillworkwithGCHDtodevelopaGeneseespecificquestionnairefortheoutbreak.
6)Allpreviouscases(since5/1/14)andnewcasesshouldbereinterviewedassoonaspossible
withthenewoutbreakspecificquestionnaire.Ifcasesarenotavailable,thenaproxyshouldbe
interviewed,ideallysomeonefromthesamehousehold.Seemenotesbelow
7)TolookforcasesofmilderillnesssuchasPontiacFever,thequestionnaireshouldaskifthere
areotherhouseholdmemberswhohavehadasimilarrespiratoryillness.Anyhousehold
contactswithlegionellosisconsistentillnessshouldalsobeinterviewedwiththeoutbreak
specificquestionnaire.Asdiscussedonthecallinthereviewofourinvesitgations,wehave
foundthisand,wehavebeenreportingthisandhavereportedtheminMDSS.Thisisthe
reasonwhyweaskedfortestingofclinicalsamplesnotonlyofthepatients,but,alsooftheir
closecontacts.
8)Clinicalculturespecimens,inadditiontourineantigentesting,shouldbecollectedfromall
suspectcaseswhereindividualsareseekingmedicalcare.Asdiscussedinourcall,thisiswhat
wehaverequestedfromMDCH.Inaddition,werequestedtestingofclosecontacts,
environmentaltestingofthepatienthomeenvironmentsandpotentiallytestingofkeylocations
inthecommunitywithhighheterotrophicplatecounts.Basedonthefeedbackfromour
consultations,thismaybeveryhelpful.
AsdetailedintheHANlanguageprovidedbyMDCHtoGCHD,hospitalsshouldcollectculture
specimensinadditiontotheurineantigentest.IfanisolateofLegionellaisfoundfromthe
culture,thehospitalwillsendtheisolatetotheMDCHBureauofLaboratoriesforfurther
testing.
9)Hospitalsshouldbequeriedtodeterminewhetheranypreviouslydiagnosedcaseshad
respiratoryculturescollectedandwhetheranyoftheseculturespecimenswereretained.Ifso,
itshouldberequestedthatthesesamplesbehelduntiladeterminationonenvironmental
testingcanbemade.ThiswasdiscussedatourBugFuzzmeetingon1/22/15.Wewillalsobe
requestingmoreinformationregardingpreviousyearslegionellatesting.Wesuspecta
significantincreaseinthenumbersoftestsconducted,particularlyduringAugust/September
thaninpreviousyears.Remember,thehyperclorinationdoneatourhospitalofinterestwas
completed10/4/15.Thatmayalsoinfluencethenumberoftestsconducted.
1)
MDCHcanprovidelanguagetoGCHDfordistributiontothemedicalcommunityregardingthe
requestforclinicalrespiratoryculturecollectiononallsuspectcasesoflegionellosis
(LegionnairesDiseaseandPontiacFever).Whatwespecificallyrequestedwasthespecific
testingprotocolsforsamplecollection,storageandtransportationofclinicalsamples.Wealso
requestedtestingofenvironmentalsamplesfrompatienthomesandkeycommunitysites.We
wouldlikethesameprotocolinformationforthistypeoftestingaswell.Jimsemailcovered
someofthis,but,westillhavesomequestions.
Hospitalsshouldbefamiliarwithtestingprotocolsforlegionellaculturespecimens.Ifa
legionellaisolateisfoundbythehospital,thehandlingandshipmenttoBoLforadditional
testingisdiscussedinthelanguageoftheHAN.
2)MDCHstaffisavailabletoconductmedicalrecordextraction,asneeded.Medicalrecordsare
attachedinMDSSandwedonotneedassistancewiththisatthistime.
3)MDCHstaffcanassistwithdataentryintoMDSS,asneeded.Atthistime,wedonotneed
assistancewiththis.Pleaseseethenotebelow
4)MDCHstaffcanhelpwiththedevelopmentofaGeneseespecificoutbreakquestionnaire.We
welcomeyourparticipationintherevisionofourGeneseespecificquestionnaire.Wehave
alreadyreceivedsomehelpfulfeedbackfromourexpertconsultations.
Wewouldliketohaveanoutbreakspecificquestionnairefinalizedbytheendofnextweek,
FridayFeb13th.PerShurooq,GeneseeiscollaboratingwithJoanRosefromMSUonwater
systemspecificquestions.MDCHwillbegincreatingaquestionnairetemplatetobecombined
withGeneseesquestionsandafinalversionwillbereviewedbybothagencies.
5)MDCHiswillingtoassistwithsupplementalquestionnairedatacollectionbyconductingcase
interviews(onpreviouslyand/ornewlydiagnosedcases)andalsobyassistingwithdataanalysis,
asneeded.OurCDnursescanaddressnewlydiagnosedcases.WewouldliketodiscussMDCHs
assistanceforconductinginterviewswithpreviouslydiagonosed/interviewedcases.
MDCHstaffmembersareavailabletoassistwithinterviewingoldercases.Wecandiscussthis
issuefurtherafterthequestionnaireiscompleted.
6)MDCHcanassistwiththecoordinationandcommunicationwithMDEQforspecificdata
requestsbyGCHD.Asdiscussedinourcall,wearerequestingMDCHassistancewithobtaining
informationfromMDEQ.GCHDhassentaFOIAletterrequestingtheinformationwehavenot
beenabletoobtainregardingthewatersystem.Ifwedonotreceivetheinformationorhave
otherchallengeswewouldrequestMDCHassistanceinobtainingtheinformation.
MDCHwillcommunicatewithMDEQaboutobtainingthewatersystemmap.
7)TheMDCHPIOcanworkwiththeGCHDPIOtodevelopacoordinatedpublichealthmessageto
respondtopublicandmediainquiries.Asdiscussedinourcall,thewatersystemisanextremely
sensitivetopic.Weareverycarefulincraftingmessages.ShouldweneedMDCHPIOassistance,
wewillrequestit.
MDHHS #8
This is one of the first times the Genesee County Health Department reaches out
to the CDC, and the CDC directs them back to MDCH. CDC Subject Matter Expert
Laurel Garrison is someone MDCH/MDHHS has worked extensively with and MDCH/
MDHHS has ensured that CDC remains present on communications and conference
calls throughout the investigation.
Sent:Wednesday,February11,20159:21AM
To:Collins,Jim(DHHS)<CollinsJ12@michigan.gov>;Fiedler,Jay(DHHS)<FiedlerJ@michigan.gov>;Bohm,Susan(DHHS)
<bohms@michigan.gov>
Subject:RE:LegionellaInvestigationGuidance
IspokewithLaurelatCDCandgaveherthebackgroundonthiswholesituationandourmultipleattemptsoverthelast
7monthstoprovideassistanceandhelptoGCHDwiththisoutbreak.Shesgoingtoreiterateinherresponsethat
GeneseeshouldbeworkingdirectlywithusandthatcontactwithCDCisnormallyfromthestatetoCDC.Shesgoingto
CCmeonanyresponsetoShurooqandsendalongthequestionnaireonceshegetsit.ItoldLaurelshesmorethan
welcometoprovidefeedbackontheirquestionnaire,butthatwehadntevenseenityetandthatitwasour
understandingtheywereworkingonwatersystemquestionswithalocalwaterborneillnessacademicianwhilewe
developedthehypothesisgeneratingtemplate.
Funwaytostarttheday.
Thanks,
Shannon
Lansing,MI48913
Phone:5173358165
Fax:5173358263
From: Collins, Jim (DCH)

Sent: Wednesday, February 11, 2015 8:38 AM
To: Johnson, Shannon (DCH); Fiedler, Jay (DCH)
Subject: RE: Legionella Investigation Guidance
Shannon,
1

PleasethanktheCDCpersonforloopingusin.AtthesametimepleaseprovideasummarytodateofGenesees
effortsonthisinvestigationrecommendationswevegiven,whereweofferedtoassistandhowthathasbeen
received.
PleasetakethisdocumentandrequestacopyofthetooltheysharedwiththeCDC.
Thanks
Jim
JimCollinsMPH,RS
Desk:5173358586
Cell:5179306932

To: Fiedler, Jay (DCH); Collins, Jim (DCH)
Subject: Re: Legionella Investigation Guidance
This is getting old real fast.

Shannon Andrews Johnson, MPH
Infectious Disease Epidemiologist
Michigan Department of Community Health
Communicable Disease Division
Phone: 517-335-8165
Fax: 517-335-8263
johnsons61@michigan.gov
From:Fiedler,Jay(DCH)
Sent:Wednesday,February11,20158:31:32AM
To:Johnson,Shannon(DCH);Collins,Jim(DCH)
Subject:RE:LegionellaInvestigationGuidance
Wow

To: Collins, Jim (DCH); Fiedler, Jay (DCH)
Subject: Re: Legionella Investigation Guidance
No, not their part of the questionnaire. They were supposedly working on questions about water systems with
Joan Rose. We have a template almost finished on our end and the plan was to combine their questions with it.
Shannon Andrews Johnson, MPH
Infectious Disease Epidemiologist
Communicable Disease Division
Phone: 517-335-8165
Fax: 517-335-8263
johnsons61@michigan.gov
From:Collins,Jim(DCH)
Sent:Wednesday,February11,20158:24:26AM
To:Johnson,Shannon(DCH);Fiedler,Jay(DCH)
Subject:FW:LegionellaInvestigationGuidance
Haveweseenthesurvey?
JimCollinsMPH,RS
Desk:5173358586
Cell:5179306932
From: Garrison, Laurel (CDC/OID/NCIRD) [mailto:lee5@cdc.gov]

To: shasan@gchd.us
Cc: Collins, Jim (DCH); Johnson, Shannon (DCH)
Subject: RE: Legionella Investigation Guidance
HiShurooq,
Lauriisntworkingonlegionellosisanymoreandsheforwardedyouremail.Imhappytohelpbrainstormand/orreview
yourquestionnaire.Imalsoccingmycontactsatthestatesotheyareintheloop.Ididntgettheattachmentcanyou
sendagain?
Bestregards,
Laurel
__________________________________________________
LaurelGarrison,MPH
LegionellosisSurveillance&OutbreakResponse
NCIRD/DBD/RespiratoryDiseasesBranch
CentersforDiseaseControlandPrevention
1600CliftonRd.MSC25
Atlanta,GA30333
Tel:404.639.3424
Fax:404.315.4680
Email:lee5@cdc.gov
From: Hicks, Lauri (CDC/OID/NCIRD)

Sent: Tuesday, February 10, 2015 5:05 PM
To: Garrison, Laurel (CDC/OID/NCIRD)
Subject: Fw: Legionella Investigation Guidance
HiLaurel,
Anychanceyoucouldfollowup?
Thanks,
L
Sent: Tuesday, February 10, 2015 02:25 PM Eastern Standard Time
To: Hicks, Lauri (CDC/OID/NCIRD)
Subject: Legionella Investigation Guidance
HelloLauri,
Dr.JanetStoutreferredmetoyou.Wearecurrentlyexperiencingalegionellaoutbreakinourcountyandare
investigatingmultiplesourcesaspotentialcausesforourincrease.SinceJune2014,wehavehad47casesofLegionella,
almostfourtimesthenumberofcaseswehadduring2013,andthehighestnumberofcasespercountyinthestatefor
2014.Wehaveinvestigatedahospitalasapotentialsourceforthedisease,buthaveexpandedourinvestigationto
includethecitywatersupply.Ofour47cases,25caseshaveoccurredwithinthecitywatersupplydistributionsystem.
Nocommonlinksorassociationshavebeendeterminedbetweenthecases.Themajorityofourcasesarehomebound
immunecomprisedindividualswhohavenottraveledandarenotreadilymobile.Theyarealsounabletoanswerour
questionswhenweinvestigateduetotheseverityoftheirconditionsoncehospitalized.Weareintheprocessof
developingasurveytoimplementforallnewincomingcasesaswellasgoingbacktoallourpreviouscases.Dr.Stout
mentionedyourexperienceandknowledgewithlegionellaandsuggestedweseekyourinputonthesurveywehave
developed.Wewouldreallyappreciateanyfeedback,ortheopportunitytotalkanytimeyouarefree.Weareworking
onatightdeadlineandweneedtohaveoursurveydonebyFriday.IhaveattachedthesurveyandIamlookingforward
tohearingfromyousoon.
ThankYou,
Shurooq

Epidemiologist
Flint, MI 48502
(810) 257-3815
shasan@gchd.us
MDHHS #9
MDCH epidemiologist sends the outbreak specific questionnaire that MDCH

developed for the Genesee County Health Department. It is necessary to go back
and interview every case that occurred in 2014, many of whom had never been
contacted for an interview by the Genesee County Health Department.
Sent:Friday,February13,20159:00AM
To:'shasan@gchd.us'<shasan@gchd.us>;jhenry@gchd.us
Cc:'bchilds@gchd.us'<bchilds@gchd.us>;'scupal@gchd.us'<scupal@gchd.us>;'mvalacak@gchd.us'
<mvalacak@gchd.us>;'gjohnson@gchd.us'<gjohnson@gchd.us>;Bolen,Timothy(DHHS)<BolenT1@michigan.gov>;
Bohm,Susan(DHHS)<bohms@michigan.gov>;Fiedler,Jay(DHHS)<FiedlerJ@michigan.gov>;Collins,Jim(DHHS)
<CollinsJ12@michigan.gov>
Subject:GeneseeCountyDraftOutbreakQuestionnaire
Importance:High
HiShurooqandJim,
Iveattachedthedraftoutbreakspecificquestionnaireweputtogether.Wellneedtousethistooltointerviewallthe
casesgoingbacktoJune,2014.PleaserespondtomewithanycommentsoreditsbyWednesday,Feb.18th.
Wecandiscussthedivisionoflaborforconductinginterviewsonournextgroupcall.DoesThursday,2/19at9amwork
foreveryone?
Thanks,
Shannon
Lansing,MI48913
Phone:5173358165
Fax:5173358263
MDSSID
_____
LegionellosisQuestionnaire
GeneseeCounty,20142015
InterviewerIdentification
DateofInterview:InterviewersName:
HealthDepartment:PhoneNumber:Email:
Whatwasthepatientsoutcome?RECOVERED STILLILLDIED
PatientContactInformation
Age:Sex:MF
Name:
________
City:
State:Zip:County:
DaytimePhone:EveningPhone:
SurrogateContactInformation<Listsurrogatecontactinformationifpatientistoounwellorhasdied>
Name:
________
DaytimePhone:EveningPhone:__________________________
RelationshiptoPatient:
Hello,mynameis andImcallingfrom(healthdepartment).
WeareinvestigatingaclusterofrespiratoryillnessesinGeneseeCounty.Atthispoint,thesourceof
theseillnessesisstillunderinvestigation.Wearehopingthisinterviewwillprovidefurther
informationandanswersabouttheillnesses.Idliketoaskyouafewquestionsaboutyourhomeand
yourexposuresduringthe2weeksbeforeyougotsick. Youdonothavetoansweranyofthequestions,
butanyassistanceyoucanprovideisappreciated.Doyouhaveabout20minutestotalk? Ifnotnow,
whenwouldbeagoodtimeformetocallback?______________________________________
<Ifthecaseisfrommorethan1monthprior,thefollowingtextmaybeused:>
Itmightbehelpfulforyoutocollectdocumentssuchasacalendar,receipts,creditcardorbank
statementstojogyourmemoryaboutyouractivities2weekspriortogettingsick.Wouldyoulikemeto
callyoubackafteryouhavetimetocollectthesematerials?Whenwouldbeaconvenientdayandtime
formetocallyouback?___________________________________
Ihavethatyourfirstsymptomstartedon<insertonsetdate> . Isthiscorrect?
Yes NoNotsure
Ifno,whatwasthefirstdateyoustartedfeelingsick?___________________
Listdatesofexposureperiod:from_//to_//<Theexposureperiodincludes
the2weeksbeforethedateofillnessonset>
Page1 of 6
MDSSID
IllnessInformation
1.) Duringyourillness,didyouhaveanyofthefollowingsymptoms?
Checkone:
Ifyes,whendid
YES
NO
UNK
thissymptom
start?
Diagnosisofpneumonia
______
Areyoustillill
withthis
symptom?
Fever
Ifyes,highesttemp:_____
Chills
Cough
Nausea
Lossofappetite
Vomiting
Diarrhea
Achesormusclepains
Chestpain
Chestburning
Shortnessofbreath
Sorethroat
Headaches
Othersymptoms(specify)
ExposureInformation
2.) Howlonghaveyoulivedatyourcurrentresidence?__________
<Iftheyhavemovedsincethelistedexposureperiod,indicatethatyouareaskingaboutthehouse
theylivedinpriortobecomingsick>
a.) Ifyoumovedaftertheexposureperiod/illness,whatwasyourpreviousresidence
address?____________________________________________________________
3.) Priortoyourillness,didyoumakeanyrecentplumbingchangesorrepairsatyourresidence?
YesNoNotsure
a.) Ifyes,pleasedescribethechanges/repairsandgivethedatestheworkwasdone.
____________________________________________________________________
____________________________________________________________________
4.) Priortoyourillness,werethereanywatermainbreaksorotherwaterlineissuesthataffectedthe
wateratyourresidence?
YesNoNotsure
a.) Ifyes,pleasedescribethewatermain/lineissuesandgivethedatestheyoccurred.
____________________________________________________________________
____________________________________________________________________
Page2 of 6
______
MDSSID
5.) Wheredidyougetyourtap(drinkingandotherhouseholduse)waterfrombetween_____________
and ?
1.CityofFlintWater
2.CityofFlintTownshipWater
3.Othermunicipalwatersystem
4.Privatewell
5.Unknown
6.Other______________________
Idliketoaskyousomequestionsaboutwhatyoudidduringthe2weeksbeforeyougotsick.
ThetimeperiodImaskingaboutisbetween and . Duringthis2
weekperiod,didyou:
6.)Workorvolunteerfullorparttime?YesNoNotsure
a.)Ifyes,completethefollowingtable:
Jobdescription
Company
Location
Anyexposure to misty water?
7.)Spendanytimeinahospital,doctorsoffice,clinic,ordentistofficeasapatient,visitor,employee,or
volunteer?YesNoNotsure
a.) Ifyes,checkallthatapply:
Date(s)
Inpatient
Name&CityofHospital/
Office/Clinic
ReasonforVisit
NameofDoctor
Admission
Discharge
Outpatient
Visitor
Employee
Volunteer
8.) Visit,reside,orworkinalongtermcarefacility,nursinghome,assistedlivingfacility,orseniorliving
facility?YesNoNotsure
Exposure
Date(s)
Name& Cityof Facility
Resident
Visitor
Employee
Page3 of 6
MDSSID
______
9.) Inthe2weeksbeforeyoubeforeyougotsick(_ _to _)didyouspendanynights

awayfromhome(excludinghealthcaresettings)?YesNoNotsure
a.)Ifyes,completethefollowingtable:<prompts:hotel,campground,cabin,cruise,second
home,withfamily,etc.>
Accommodation
Address
Floor/Room
Dates of Stay
Street,City,State
Type/Name
No.
Arrival
Departure
10.) Inthe2weeksbeforeyoubeforeyougotsick(_ _to _),didyouvisitanyofthe

followingcommunityvenues?
Checkone:
YES
NO
UNK
Date(s)
Name of Venue
Address
Venue
Hotel(without
stayingovernight
e.g.dinner,wedding)
Auditorium
BarbershoporHair
salon
CarWash
Casino
ChurchorPlaceof
worship
GymorWorkout
facility
Grocerystore
Homeimprovement
store
SpaorNailsalon
MallorDepartment
store
Movietheater
Other(specify)
Page4 of 6
______
MDSSID
11.) Inthe2weeksbeforeyoubeforeyougotsick(_ _to _),didyouhave

exposuretoanyofthefollowingwatersources,eitherathomeorwhileawayfromhome?
Checkone:
Exposuresathome
YES NO UNK
Dates(s)
Name(orType)/Location
Shower
Useadetachableshowerheador
hose
Hottub,whirlpoolspa,Jacuzzi
tub
SatNEARaworkinghottubor
whirlpoolspabutdidnotgetin
Steamroomorwetsauna
Humidifier(wholehouseor
portable)
Respiratorytherapymachine
(e.g.nebulizer,CPAP,BiPAP,etc.)
Other(specify)
YES NO UNK
Exposuresawayfromhome
Showeratgym,work,other
location
hose
tub
portable)
Pool/splashpad/waterpark
Ifyes,whattypeofwaterisusedindevice?
BottledTapOther:____________
Dates(s)
Name(orType)/Location
Recreationalorcoolingmisters
Steamroomorwetsauna
Decorativefountain
Outdoorwateringhoseor
sprinkler
Beach,lake,pond,river,creek,
etc.
Other(specify)
Page5 of 6
MDSSID
______
MedicalHistory
NowImgoingtoaskafewquestionsaboutyourmedicalhistoryandhealthbehaviors.
12.) Haveyoueverbeentoldbyahealthcareproviderthatyouhadanyofthefollowingconditions:
Check one:
Condition
YES
NO
UNK
Comments
Chronickidneydisease
Weakenedimmunesystem (Cancer,
Chemotherapy,Radiationtherapy,Immuno
suppressivemeds,HIV,organtransplant)
Diabetes
Chroniclungdisease(COPD,emphysema)
Asthmaorchronicbronchitis
Heartdiseaseorcongestiveheartfailure
Liverdisease
Otherconditions(specify)
13.) Healthbehaviors:
Checkone:
YES
NO
Quantity per day

(packs or drinks)
Duration(years)
Areyoucurrentlyasmoker?
Areyouaformersmoker?
Doyoudrinkalcohol?
14.) Doyouknowanyoneelsewithsimilarsymptoms? YesNoNotsure
State of
Name
Phone
DetailsofSharedExposure
Residence
AdditionalComments_________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Thankyousomuchfortakingthetimetoanswerthesequestions.DoyouhaveanyquestionsthatI
canhelpanswer? Ifyouhaveanyquestionsorrememberanyfurtherdetailslater,pleasecontactthe
_____________________(healthdepartment)atphone:_____________________.
Page6 of 6
MDHHS #10
This is the first notification the Genesee County Health Department sends to
the healthcare community. MDCH epidemiologists recommended in October 2014
that information be sent to local providers and that a Health Alert Network
(HAN) notice be sent to the greater healthcare community in Genesee County.
Instead the Genesee County Health Department sent it to select personnel in the
3 area hospitals.
Sent:Friday,February13,20152:50PM
To:Collins,Jim(DHHS)<CollinsJ12@michigan.gov>;Fiedler,Jay(DHHS)<FiedlerJ@michigan.gov>;Bohm,Susan(DHHS)
<bohms@michigan.gov>;TyndallSnow,Leigh(DHHS)<TyndallSnowL@michigan.gov>;Weinberg,Meghan(DHHS)
<WeinbergM1@michigan.gov>
Subject:FW:ClinicalGuidanceforLegionellosis
FYIcopyofthemessageGeneseesentabouttesting.ItwasntsentasaHANbecausethepersonwhohasaccessto
sendingcapabilitieswasntintoday,butasanemailtotheICPsatthe3hospitals.Itwentouttoapproximately15
people.

Sent: Friday, February 13, 2015 1:57 PM
To: Cupal, Suzanne; Thornton, Venita; Miller, Colleen; Childs, Bonnie; Bolen, Timothy (DCH); anewell1@hurleymc.com;
danielle.donovan@mclaren.org; dcharle2@hurleymc.com; Johnson, M.D., Gary; ehabte1@hurleymc.com;
yrafee1@hurleymc.com; July, Jori; kari.wanless@mclaren.org; kimberly.tylenda@mclaren.org;
kwarden@hamiltonchn.org; romara@genesys.org; sharlow@genesys.org; aarmor1@hurleymc.com;
tsperry1@hurleymc.com; Wiskur, Lori; Henry, James; Hallwood, Dawn; Johnson, Shannon (DCH)
Subject: Clinical Guidance for Legionellosis
Hello,
Genesee County has reported over 45 cases of legionellosis since June 2014. This represents the highest
number of legionellosis cases for this time frame over the past 5 years and new cases continue to be identified.
Most patients were or are currently hospitalized (some in the ICU) and symptoms reported include fever,
vomiting, abdominal pain, nausea and diarrhea.
Investigations are ongoing to determine common sources of exposure. We are asking that the clinical
community assist in this investigation through accurate identification, testing and reporting of all suspect cases
of legionellosis.
The guidance attached has been prepared to assist clinicians in case evaluation and facilitate specimen
collection/testing. Also included are the Michigan Department of Community Health Bureau of Laboratories
testing protocol and requisition form to be used when sending Legionella isolates for testing.
Please share this information with the appropriate contacts and departments within your hospital systems.
1
For additional information, please contact the Genesee County Health Department at 810-257-3815 or 810257-1017
Thank You,
Shurooq
Epidemiologist
Flint, MI 48502
(810) 257-3815
shasan@gchd.us
LegionellosisGuidanceforClinicians
Legionellabacteriacanbefoundinnatural,freshwaterenvironments,buttheyaregenerallypresent
ininsufficientnumberstocausedisease.Watersystemssuchaspotable(drinking)watersystems,
whirlpoolspas,andcoolingtowersprovidetheconditionsneededforLegionellagrowthand
transmissionheat,stasis,andaerosolization;therefore,thesearecommonsourcesofoutbreaks.
EpidemiologicRiskFactorsforLegionellosis
Recenttravelwithanovernightstayoutsideofthehome(upto14dayspriortosymptom
onset)
Exposuretowhirlpoolspas
Recentrepairsormaintenanceworkondomesticplumbing
Renalorhepaticfailure
Diabetes
Systemicmalignancy
Smoking
Immunesystemdisorders
Age>50years
DiagnosingLegionellosis
Legionnaires' disease Pontiac fever
Pneumonia, cough,
fever
Flu-like illness (fever, chills, malaise) without

pneumonia
Yes
No
Incubation period
2-14 days after

exposure
24-72 hours after exposure
Etiologic agent
Legionella species
Legionella species
Attack rate
< 5%
> 90%
Clinical features
Radiographic
pneumonia
Isolation of organism Possible
Outcome
Never
Hospitalization common
Hospitalization uncommon
Case-fatality rate: 5Case-fatality rate: 0%
30%
Source:http://www.cdc.gov/legionella/clinicians.html
WhotoTestforLegionnaires'Disease
PatientswithpneumoniainthesettingofaLegionellosisoutbreak
Patientswhohavefailedoutpatientantibiotictherapy
Patientswithseverepneumonia,inparticularthoserequiringintensivecare
Immunocompromisedhostwithpneumonia
Patientswithatravelhistory[Patientsthathavetraveledawayfromtheirhomewithintwo
weeksbeforetheonsetofillness.]
Patientssuspectedofhealthcareassociatedpneumonia

TestingforLegionnaires'Disease
UrinaryantigenassayANDcultureofrespiratorysecretionsonselectivemediaaretherequested
diagnostictestsforLegionnaires'disease
Sensitivityvariesdependingonthequalityandtimingofspecimencollectionaswellastechnical
skillofthelaboratoryperformingthetest
AdvantagesandDisadvantagesofDiagnosticTests
Test
Advantages
Culture
Clinical&
environmental
isolatescanbe
compared
Detectsallspecies&
serogroups
100%specific
100%specific...
Rapid(sameday)
Serology
Lessaffectedby
antibiotictreatment
8090%sensitive;
99%specific
Canbeperformedon
pathologicspecimens
>95%specific
Rapid
Urine
Antigen
DFA
PCR
Disadvantages
Technicallydifficult
Slow(>5daystogrow)
Sensitivityhighlydependentontechnicalskill
Maybeaffectedbyantibiotictreatment
...butonlyforL.pneumophilaserogroup1(Lp1)
[whichmayaccountforupto80%ofcases]
Doesnotallowformolecularcomparisontoenvironmental
isolates
Musthavepairedsera
510%ofpopulationhastiter1:256.Singleacutephase
antibodytitersof1:256donotdiscriminatebetweencases
ofLegionnaires'diseaseandothercausesofcommunity
acquiredpneumonia.
2575%sensitive
AssaysvarybylaboratoryandarenotFDAapproved
ClinicalIsolatesandShipping
IsolationofLegionellafromrespiratorysecretions,lungtissue,pleuralfluid,oranormallysterilesiteis
stillanimportantmethodfordiagnosis,despitetheconvenienceandspecificityofurinaryantigentesting.
InvestigationsofoutbreaksofLegionnaires'diseaserelyonbothclinicalandenvironmentalisolates.
Clinicalandenvironmentalisolatescanbecomparedusingmonoclonalantibodyandmolecular
techniques.BecauseLegionellaarecommonlyfoundintheenvironment,clinicalisolatesarenecessary
tointerpretthefindingsofanenvironmentalinvestigation.
TheMichiganDepartmentofCommunityHealthstatelaboratorywilltestclinicalisolatesoflegionella
shippedtothefacilityfreeofcharge.Pleaseavoidfreezingandthawingofisolates.Forlabsshippinga
clinicalisolate,aBYCEplateisacceptable.NOTE:Platesdonotgenerallytravelwellsoacouriershould
beusedifpossible.
Treatment
RecommendedtreatmentforLegionellapneumoniainmostpatientsincludeseitherafluoroquinolone
(e.g.levofloxacin750mgoncedaily)oramacrolide(e.g.azithromycin1gramondayone,followedby
500mgoncedaily)foratotaltreatmentdurationof1014days.Antibioticregimenandtreatment
durationmayvarydependingonspecificpatientriskfactorsorcomorbidities.
Reporting
LegionellosisisareportablediseaseinMichigan.Weareaskinghealthcareprofessionalstoreportboth
LegionnairesdiseaseandPontiacfevercasesviatheMichiganDiseaseSurveillanceSystem(MDSS)or
directlytotheLocalHealthDepartment.Physiciansarerequestedtocollectandrecordillnessonset
datesaspartofthepatientrecord.Anaccurateillnessonsetdateisextremelyimportanttodetermine
thepatientspotentialenvironmentalexposuresandisvitaltotheinvestigationofanoutbreak.In
patientswithchronicrespiratoryconditions,thefirstappearanceoffevermaybeausefulindicatorof
legionellosisonsetdate.
Foradditionalinformation,pleasecontact:
GeneseeCountyHealthDepartment:8102571017or8102573815
MICHIGAN DEPARTMENT OF COMMUNITY HEALTH

BUREAU OF LABORATORIES
Legionella spp. Isolation and Identification, Page 1 of 2
Rev. 3/6/12
Legionella spp. Isolation and Identification

ANALYTES TESTED:
Suspected bacterial isolate or a clinical specimen. Environmental or water samples are
accepted only after prior approval from epidemiology.
USE OF TEST:
For the isolation and identification of Legionella spp. from clinical specimens
obtained from patients with illnesses compatible with legionellosis.
SPECIMEN COLLECTION AND SUBMISSION GUIDELINES:
Test Request Form DCH-0583
Specimen Submission Guidelines
Transport Temperature: Ambient
SPECIMEN TYPE:
Specimen Required:
Bronchoscopy; transtracheal aspirate; bronchial biopsy, bronchial washing,
sputum, and brushing specimens.
For serological testing see Bacterial and Parasitic Serology.
Minimum Acceptable Volume:
Minimum of 1.0 ml or 1g tissue (prevent from desiccation using sterile water).
Container:
Shipping Unit: Unit 12
SPECIMEN REJECTION CRITERIA:
Critical Data Needed For Testing:
Patient Name
Patient Date of Birth
Specimen Source
Date Collected
Submitting Agency
TEST PERFORMED:
Methodology:
MICHIGAN DEPARTMENT OF COMMUNITY HEALTH

BUREAU OF LABORATORIES
Legionella spp. Isolation and Identification, Page 2 of 2
Rev. 3/6/12
Turn Around Time: Up to 14 days.

When Performed: Monday through Friday.
RESULT INTERPRETATION:
The presence of Legionella spp. in a clinical specimen obtained from a patient
with clinical symptomatology suggestive of legionellosis constitutes laboratory
diagnosis of the illness.
Reference Range: N/A
FEES: N/A
NOTES:
1. A direct fluorescent antigen test should be requested simultaneously on
specimens submitted for culture for Legionella spp.
2. There is a much greater likelihood that Legionella spp. will be recovered from
tissues, washings, or brushings obtained from deep within the respiratory tree than
from sputum or tracheal aspirates. Growth of this bacterium may be inhibited by
the normal flora of the upper respiratory tract.
3. Saline and salt-containing fluids are inhibitory to the Legionella spp.; therefore,
exposure to these compounds should be limited as much as possible.
4. Specimens to be cultured for Legionella spp. should be held at refrigerator
temperatures during transport to preserve viability.
5. Sputum specimens are not accepted for Legionella DFA.
ALIASES:
None
MICHIGAN DEPARTMENT OF COMMUNITY HEALTH BUREAU OF LABORATORIES
MICROBIOLOGY/VIROLOGY TEST REQUISITION
P.O. Box 30035 3350 North Martin Luther King Jr. Blvd. Lansing, Michigan 48909
Laboratory Records: (517) 335-8059 Fax: (517) 335-9871 Technical Information: (517) 335-8067 Web: http://www.michigan.gov/mdchlab
DATE RECEIVED AT MDCH MDCH SAMPLE #
AGENCY - SUBMITTER INFORMATION
ENTER STARLIMS AGENCY CODE
RETURN RESULTS TO
PHONE
(24/7)
FAX
PHYSICIAN OF RECORD/LEGALLY AUTHORIZED PERSON ORDERING TEST
NATIONAL
PROVIDER
IDENTIFIER
PATIENT INFORMATION - NAME (Last, First, Middle Initial or Unique Identifier) Must Match Specimen Label Exactly
SUBMITTERS PATIENT NUMBER (If Applicable)

PATIENTS CITY OF RESIDENCE
ZIP CODE
GENDER

h M hF
RACE
h Black/AA h White h Native American or Alaskan h Asian h Hawaiian/PI h Unknown h Other (Specify)
ETHNICITY DATE OF BIRTH (MM/DD/YYYY)
SUBSCRIBER INFORMATION
h Hispanic h Arab Descent h UNKNOWN

h Medicaid hADAP
hDOCh Other:
SUBSCRIBER NUMBER
SUBMITTERS SPECIMEN NUMBER (If Applicable)
DATE COLLECTED (MM/DD/YYYY)
TIME COLLECTED

hAMhPM
INDICATE TEST REQUESTED
INDICATE SPECIMEN SOURCE

h BRONCHIAL
h CERVIX
h CSF
h GASTRIC
h NASOPHARYNGEAL
h ORAL MUCOSAL TRANSUDATE
h PLASMA
h SERUM
h STOOL
h SPUTUM
h THROAT
h URETHRA
h URINE
h WHOLE BLOOD
h FOOD-Specify:
h OTHER-Specify:
HIV TESTING
h HIV Ag/Ab - Serum
h HIV AB - Oral Mucosal
Transudate
h CD4/CD8
(EDTA whole blood)
h HIV-1 VIRAL LOAD
(EDTA plasma)
h HIV-1 GENOTYPING
(EDTA plasma)
SEROLOGY
SERUM STATUS - If Applicable
h ACUTE
h

h CONVALESCENT
ARBOVIRUS ENCEP PANEL (IgM)

May-October Includes Eastern Equine,
California, St. Louis and West Nile,
CSF Only
h BRUCELLA SEROLOGY
h FUNGAL SEROLOGY

COMPLEMENT FIXATION
MICROBIOLOGY
h AEROBIC ISOLATE ID
Complete #5 (reverse)
TESTS THAT REQUIRE

MDCH APPROVAL
h BACTERIAL TYPING-PFGE
h AFB SLIDE/CULTURE-CLINICAL
SPECIMEN
h AFB IDENTIFICATION-ISOLATE ID
h MUMPS - PCR
h E. COLI (SLT) TOXIN & SEROLOGY
h MEASLES IgM
h ENTERIC BACTERIAL CULTURE
h MUMPS IgM
h FOODBORNE ILLNESS-Stool or Food
h NOROVIRUS PCR
h BOTULISM TOXIN
h FUNGAL IMMUNODIFFUSION
h FUNGAL IDENTIFICATION Isolate ID
h FRANCISELLA SEROLOGY
h LEGIONELLA CULTURE
h LEGIONELLA - HA
h RUBELLA IgM
h NEISSERIA GONORRHOEAE-Isolation
h LYME DISEASE - EIA
h NEISSERIA - REFERRED CULTURE
h SALMONELLA SEROTYPING
NON-HUMAN
h MEASLES IgG
h MUMPS IgG
h RABIES AB SEROLOGY
h RUBELLA IgG
h TETANUS TOXIN EIA
h PARASITOLOGY - BLOOD
h TOXIC SHOCK TESTING
h PARASITOLOGY - STOOL
h AFB NUCLEIC ACID AMPLIFICATION
h PARASITOLOGY - WORM
h OTHER
h PERTUSSIS PCR
h SALMONELLA/SHIGELLA
SEROTYPING-HUMAN
h VARICELLA ZOSTER IgG
VIROLOGY
SYPHILIS TESTING
h ENTEROVIRUS PCR
h SYPHILIS (USR Test)

h SYPHILIS VDRL - CSF Only
h SYPHILIS DFA
OTHER
h SYPHILIS FTA - ABS DS*
h AUTOCLAVE TEST STRIPS
h SYPHILIS TP-PA*
h LEGIONELLA - DFA
h SYPHILIS IgM WESTERN BLOT*
h LYME DISEASE-IFA (Tick)
*Prior Approval Required
h PERTUSSIS CULTURE
h RESPIRATORY PCR PANEL
HEPATITIS TESTING
h HEPATITIS C ANTIBODY
h HEPATITIS B SURFACE ANTIGEN (HBsAg)
h HEPATITIS B ANTIBODY (Anti-HBsAg)

h HEPATITIS A ANTIBODY (IgM)
h INFLUENZA (PCR/CULTURE)
h VIRAL CULTURE
INSTRUCTIONS FOR COMPLETION: Completely fill in the appropriate box. For example, upon completion the box should appear as m, rather than x.
DCH-0583 (1/9/2015)
By Authority of Act 368, P.A. 1978
INDICATE TEST REASON
h Diagnosis h Surveillance h Outbreak (complete Section 6) h Other (Specify)
FOR:HEPATITIS B REQUESTCOMPLETE THIS SECTION
h Pregnancy (HBsAg)
h Exposure to someone
with Hepatitis B?
FOR: SYPHILIS - DFA REQUEST COMPLETE THIS SECTION
Duration of Lesion
h Days h Months h Years Specify Site:
FOR: RABIES ANTIBODY SEROLOGY REQUEST COMPLETE THIS SECTION
Date of Last Rabies Vaccination
FOR:LYME BORRELIOSIS REQUESTCOMPLETE THIS SECTION
Onset Date
State/County/Country
of Exposure
EARLY DISEASE LATE DISEASE
h Erythema Migrans (5 cm at least in diameter) h Symptoms (Example- Rash, Fever, Headache, Joint Pain) h Neurologic h Cardiologic h Rheumatologic
FOR:AEROBIC CULTURE REQUESTCOMPLETE THIS SECTION
h Aerobe h Microaerophile
Gram h Positive h Negative h Variable h Rod h Coccus h Diplococcus
Bacterial Growth Char.: MacConkey h Pos h Neg Oxidase h Pos h Neg Catalase h Pos h Neg Dextrose h Oxidation h Fermentation
OTHER:
FOR:OUTBREAK INVESTIGATIONCOMPLETE THIS SECTION
Onset Date
Outbreak Identifier
Organism Suspected (If Applicable)
MDCH Prior Approval: Name, Date or Code
FOR: INFLUENZA TESTING REQUEST (PCR/CULTURE) COMPLETE THIS SECTION
Date/Type of Last Influenza Vaccination
TYPE
h Flu Mist h Trivalent (Shot)
h Other
ADDITIONAL INFORMATION
DCH-0583 (1/9/2015)
By Authority of Act 368, P.A. 1978
MDHHS #11
MDCH documents the division of labor and the start of the interviewing process.
MDCH is also conducting medical record reviews on all cases to determine onset
dates of illness as many of these were not completed by the Genesee County
Health Department and are necessary for establishing timelines, clustering and
identifying any association with healthcare facilities.
Sent:Friday,February20,201511:31AM
To:'shasan@gchd.us'<shasan@gchd.us>;jhenry@gchd.us
Cc:'scupal@gchd.us'<scupal@gchd.us>;Bolen,Timothy(DHHS)<BolenT1@michigan.gov>;Bohm,Susan(DHHS)
<bohms@michigan.gov>;Fiedler,Jay(DHHS)<FiedlerJ@michigan.gov>;Collins,Jim(DHHS)<CollinsJ12@michigan.gov>
Subject:Finalquestionnaireandenvironmentalsamplingresource
HiShurooqandJim,
Iveattachedthefinalversionofthesupplementalquestionnaire.Wellbestartingourinterviewsnextweekonthe
caseswith6/1/1412/31/14MDSSreferraldates.
Fromourdiscussionyesterday,herestheCDCwebsitethathasenvironmentalsamplinginformationandprotocols:
http://www.cdc.gov/legionella/specimencollectmgmt/index.html
PleaseletmeknowifthereareanyquestionsortheresanythingelseIcanhelpwith.
Thanks,
Shannon
Lansing,MI48913
Phone:5173358165
Fax:5173358263
MDSSID
_____
LegionellosisQuestionnaire
GeneseeCounty,20142015
InterviewerIdentification
DateofInterview:InterviewersName:
HealthDept.:PhoneNumber:__Email:
Whatwasthepatientsoutcome?RECOVERED STILLILLDIED UNK
PatientContactInformation
Age:Sex:MF
Name:
________
Streetaddress:City:
State:Zip:County:________________
DaytimePhone:EveningPhone:
SurrogateContactInformation<Listsurrogatecontactinformationifpatientistoounwellorhasdied>
Name:
________
DaytimePhone:EveningPhone:_________________________________
RelationshiptoPatient:
Hello,mynameis andImcallingfrom(healthdepartment).
WeareinvestigatingaclusterofrespiratoryillnessesinGeneseeCounty.Atthispoint,thesourceof
theseillnessesisstillunderinvestigation.Wearehopingthisinterviewwillprovidefurther
informationandanswersabouttheillnesses.Idliketoaskyouafewquestionsaboutyourhomeand
yourexposuresduringthe2weeksbeforeyougotsick. Youdonothavetoansweranyofthequestions,
butanyassistanceyoucanprovideisappreciated.Doyouhaveabout20minutestotalk? Ifnotnow,
whenwouldbeagoodtimeformetocallback?______________________________________
<Ifthecaseisfrommorethan1monthprior,thefollowingtextmaybeused:>
Itmightbehelpfulforyoutocollectdocumentssuchasacalendar,receipts,creditcardorbank
statementstojogyourmemoryaboutyouractivitiesandwhereyouwereinthe2weekspriortogetting
sick.Wouldyoulikemetocallyoubackafteryouhavetimetocollectthesematerials?Whenwouldbea
convenientdayandtimeformetocallyouback?____________________________________________
Ihavethatyourfirstsymptomstartedon<insertonsetdate> . Isthiscorrect?
Yes NoNotsure
Ifno,whatwasthefirstdateyoustartedfeelingsick?____/_____/______
Listdatesofexposureperiod:from_//to_//<Theexposureperiodincludesthe
2weeksbeforethedateofillnessonset>
Page1 of 6
MDSSID
IllnessInformation
1.) Duringyourillness,didyouhaveanyofthefollowingsymptoms?
Checkone:
Ifyes,whendid
YES
NO
UNK
thissymptom
start?
Diagnosisofpneumonia
Fever
Ifyes,highesttemp:_____
Chills
Cough
___
Areyoustillill
withthis
symptom?
Nausea
Lossofappetite
Vomiting
Diarrhea
Achesormusclepains
Chestpain
Chestburning
Shortnessofbreath
Sorethroat
Headaches
Othersymptoms(specify):
ExposureInformation
2.) Howlonghaveyoulivedatyourcurrentresidence?__________________
<Iftheyhavemovedsincethelistedexposureperiod,indicatethatyouareaskingaboutthehouse
theylivedinpriortobecomingsick>
a.) Ifyoumovedaftertheexposureperiod/illness,whatwasyourpreviousresidence
address?____________________________________________________________
3.)Wheredidyougetyourtap(drinkingandotherhouseholduse)waterfrombetween_//___
and_//?<Exposureperiodfromabove>
1.CityofFlintWater
2.CityofFlintTownshipWater
3.Othermunicipalwatersystem
4.Privatewell
5.Unknown
6.Other______________________
3.)
Page2 of 6
MDSSID
___
4.)Duringthelastyear,hasthewaterpressureatyourresidencechanged?YesNoNotSure
a.)Ifyes,didthewaterpressure:Increase Decrease
b).Ifyes,whendidthewaterpressurechangeoccur?________________________________
5.)Duringthelastyear,hasthewaterquality(appearance,taste,smell)atyourresidencechanged?
YesNoNotSure
a.)Ifyes,pleasedescribethechangeinthewaterquality:_____________________________
____________________________________________________________________________
b).Ifyes,whendidthewaterqualitychangeoccur?__________________________________
6.)Priortoyourillness,didyoumakeanyrecentplumbingchangesorrepairsatyourresidence?
Yes NoNotsure
a.) Ifyes,pleasedescribethechanges/repairsandgivethedatestheworkwasdone.
____________________________________________________________________
____________________________________________________________________
7.)Priortoyourillness,werethereanywatermainbreaksorotherwaterlineissuesthataffectedthe
wateratyourresidence?YesNoNotsure
a.) Ifyes,pleasedescribethewatermain/lineissuesandgivethedatestheyoccurred.
____________________________________________________________________
____________________________________________________________________
Idliketoaskyousomequestionsaboutwhatyoudidduringthe2weeksbeforeyougotsick.
ThetimeperiodImaskingaboutisbetween_//_and_//.<Exposureperiod>
Duringthis2weekperiod,didyou:
8.)Workorvolunteer,eitherfullorparttime?YesNoNotsure
Jobdescription
Company
Location
Anyexposure to misty
water?
9.)Spendanytimeinahospital,doctorsoffice,clinic,ordentistofficeasapatient,visitor,employee,or
volunteer?YesNoNotsure
a.) Ifyes,checkallthatapply:
Exposure
Inpatient
Date(s)
ReasonforVisit
Name& Cityof Hospital/

Office/Clinic
NameofDoctor
Admission_______
Discharge_______
Outpatient
Visitor
Employee
Volunteer
Page3 of 6
MDSSID
___
10.) Visit,reside,orworkinalongtermcarefacility,nursinghome,assistedlivingfacility,orseniorliving
facility?YesNoNotsure
Exposure
Date(s)
Name& Cityof Facility
Resident
Visitor
Employee
11.) Inthe2weeksbeforeyoubeforeyougotsick(_//_to_//),didyouspendany
nightsawayfromhome(excludinghealthcaresettings)?YesNoNotsure
a.)Ifyes,completethefollowingtable:<prompts:hotel,campground,cabin,cruise,second
home,withfamily,etc.>
Accommodation
Address
Floor/Room
Dates of Stay
Street,City,State
Type/Name
No.
Arrival
Departure
12.) Inthe2weeksbeforeyoubeforeyougotsick(_//_to_//),didyouvisitanyof
thefollowingcommunityvenues?
Checkone:
YES NO UNK
Date(s)
Name of Venue
Address
Venue
Hotel(without
stayingovernight
e.g.dinner,wedding)
Auditorium
BarbershoporHair
salon
Carwash
Casino
ChurchorPlaceof
worship
GymorWorkout
facility
Grocerystore
Homeimprovement
store
SpaorNailsalon
MallorDepartment
store
Movietheater
Other(specify)
Page4 of 6
MDSSID
___
13.) Inthe2weeksbeforeyoubeforeyougotsick(_//_to//),didyouhave
exposuretoanyofthefollowingwatersources,eitherathomeorwhileawayfromhome?
Checkone:
Exposuresathome
YES NO UNK
Dates(s)
Description:Name(orType)/Location
Shower
hose
tub
Steamroomorwetsauna
portable)
Ifyes,specifytype:
Ifyes,specifytype:
Respiratorytherapymachine
(e.g.nebulizer,CPAP,BiPAP,etc.)
Other(specify)
YES NO UNK
Exposuresawayfromhome
Showeratgym,work,other
location
hose
tub
portable)
Dates(s)
Description:Name(orType)/Location
Ifyes,specifytype:
Pool/splashpad/waterpark
Recreationalorcoolingmisters
Steamroomorwetsauna
Decorativefountain
Outdoorwateringhoseor
sprinkler
Beach,lake,pond,river,creek,
etc.
Other(specify)
Page5 of 6
MDSSID
___
MedicalHistory
NowImgoingtoaskafewquestionsaboutyourmedicalhistoryandhealthbehaviors.
14.) Haveyoueverbeentoldbyahealthcareproviderthatyouhadanyofthefollowingconditions:
Check one:
Condition
YES
NO
UNK
Comments
Chronickidneydisease
Weakenedimmunesystem (Cancer,
Chemotherapy,Radiationtherapy,Immuno
suppressivemeds,HIV,organtransplant)
Diabetes
Chroniclungdisease(COPD,emphysema)
Asthmaorchronicbronchitis
Heartdiseaseorcongestiveheartfailure
Liverdisease
Otherconditions(specify)
15.) Healthbehaviors:
Checkone:
YES
NO
Quantity per day

(packs or drinks)
Duration(years)
Areyoucurrentlyasmoker?
Areyouaformersmoker?
Doyoudrinkalcohol?
16.) Doyouknowanyoneelsewithsimilarsymptoms? YesNoNotsure
State of
Name
Phone
DetailsofSharedExposure
Residence
AdditionalComments_________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Thankyousomuchfortakingthetimetoanswerthesequestions.DoyouhaveanyquestionsthatI
canhelpanswer? Ifyouhaveanyquestionsorrememberanyfurtherdetailslater,pleasecontactthe
_____________________(healthdepartment)atphone:_____________________.
Page6 of 6
MDHHS #12
CDC again asks MDCH to reinforce the Local to State to Federal line of
communication with the Genesee County Health Department.
Sent:Thursday,April02,20154:26PM
To:Garrison,Laurel(CDC/OID/NCIRD)<lee5@cdc.gov>
Cc:Collins,Jim(DHHS)<CollinsJ12@michigan.gov>;Miller,Corinne(DHHS)<MillerC39@michigan.gov>;Fiedler,Jay
(DHHS)<FiedlerJ@michigan.gov>
Subject:RE:CommunitywideLegionnaires'diseaseoutbreakFlint,MI
HiLaurel,
Thankssomuchforlettingmeknow.Iactuallywasintheprocessofwritingyou.Iapologizefornotrespondingtoyour
lastemailsooner.MysupervisorhasunexpectedlybeenoutoftheofficeallweekandIwashopingtodiscussyouremail
withherandwithGeneseebeforeIresponded.Shesgoingtobeoutuntilnextweekandwehaveaconferencecallset
upwithGeneseeforearlynextweek.SincetechnicallythisisGeneseesoutbreakandtheyhavejurisdiction,its
probablynotappropriateforMDCHtomakedecisionsaboutinvolvingCDCwithoutconsultingGeneseefirst.I
appreciateyourofferofassistanceandIthinkthewayyouframeditisprobablythebestapproachfornow.Well
consultwithGeneseeandifthereareareaswherewewouldliketorequestCDCsassistance,wellgetintouchwith
you.Eitherway,Immorethanhappytotouchbasewithyouoccasionallytoletyouknowwherewereatinthe
investigation.
Bestwishes,
Shannon
Lansing,MI48913
Phone:5173358165
Fax:5173358263
From: Garrison, Laurel (CDC/OID/NCIRD) [mailto:lee5@cdc.gov]

Sent: Thursday, April 02, 2015 2:49 PM
To: Johnson, Shannon (DCH)
Cc: Collins, Jim (DCH); Miller, Corinne (DCH)
Subject: Community-wide Legionnaires' disease outbreak--Flint, MI
HiShannon,
1
Sorrytobotheryouagain,butIwantedtoletyouknowthatthelocalhealthdepartmentreachedouttoCDCregarding
assistancewitharesearchstudy.JuliaGargano,epidemiologistintheWaterborneDiseasePreventionBranchatCDC,
mentionedtodaythatshewasinMIforaconferenceandsomeonefromFlintapproachedheraboutthis.Idontknowif
youareinvolved,butmysuggestiontoJuliawastotellthelocalHDtodiscusswiththestateHDandstatewaterquality
folksfirst.Afterdiscussinginternally,ifyoufeelthatCDCcouldassistinanyway,pleaseletusknow.Wewouldbehappy
todiscussfurther,butwantedtomakesureyouwereawareandinvolvedgiventhehistoryandsensitivities.
Bestregards,
Laurel
__________________________________________________
LaurelGarrison,MPH
LegionellosisSurveillance&OutbreakResponse
NCIRD/DBD/RespiratoryDiseasesBranch
CentersforDiseaseControlandPrevention
1600CliftonRd.MSC25
Atlanta,GA30333
Tel:404.639.3424
Fax:404.315.4680
Email:lee5@cdc.gov
MDHHS #13
From:Fiedler,Jay(DCH)
Sent:Thursday,April09,201511:45AM
To:scupal@gchd.us;GJOHNSON@gchd.us;jhenry@gchd.us;shasan@gchd.us;Valacak,Mark<MVALACAK@gchd.us>
Cc:Miller,Corinne(DCH)<MillerC39@michigan.gov>;Collins,Jim(DCH)<CollinsJ12@michigan.gov>;Bohm,Susan(DCH)
<bohms@michigan.gov>;Johnson,Shannon(JohnsonS61@michigan.gov)<JohnsonS61@michigan.gov>;Bolen,Timothy
(DCH)<BolenT1@michigan.gov>
Subject:GeneseeCountyInquiries4/7/2015
Hello,
Onourupdatecallon4/7/15wecoveredthecurrentstatusoftheLegionnairesDiseaseoutbreakinvestigation.
MDCHprovidedasummaryofinformationonthecasesthatwassharedwiththegroup.
Currentstatusofinterviews,contacts,andcompletionwasreviewed.
ShannonandShurooqdiscussedtheremaining7casesthatneedtobecontactedandagreedtotalkafterthe
calltodeterminewhichcaseswouldbecontactedbywhichagency.
Aninitialplanwasdiscussedregardingthenumberofcontactattemptsthatwouldbemadeandsendingletters
tocasesthatdidnotrespondorwereunreachableasafinalattemptbeforedeclaringthemLTF.
Aletterwillbeformalizedaspartofthisprocess.
AdditionalrequestsweremadebyGeneseeCountyforMDCHtofacilitate:
GeneseeCountywouldliketospeakwithMDCHEH,EPA,andCDCregardingadditionaldrinkingwaterconcerns.
Regardingtheserequests,IhavespokenwithCorinneMillertheStateEpidemiologistastohowMDCHwould
coordinate/facilitate.TherecommendationisthatGCHDcontactDEQastheleadstateagencyregardingdrinkingwater
concerns.MDCHEHwillonoccasionconsultwithDEQ,butisbroughtinattherequestofDEQ.DEQwouldalsobethe
firststepinreachingouttoEPAifadditionalexpertiseisneeded.Second,itisourunderstandingthatGCHDhasalready
reachedouttoJonathanYoderatCDCregardingdrinkingwaterconcerns.HewouldbethebestcontactatCDCfor
additionalquestions.
WewillcontinuetobeintouchregardingourassistancewiththeLegionnairesDiseaseoutbreakinvestigation.
Thanks.Jay
Jay Fiedler, MS
Section Manager
Surveillance and Infectious Disease Epidemiology
Bureau of Disease Control, Prevention, and Epidemiology
201 Townsend St - PO Box 30195 - Lansing, MI 48909
P: 517.335.9516 - E: fiedlerj@michigan.gov
1
Confidentiality Notice: This message, including any attachments, is intended solely for the use of the named recipient(s) and may contain confidential
and/or privileged information. Any unauthorized review, use, disclosure or distribution of this communication(s) is expressly prohibited. If you are not
the intended recipient, please contact the sender by reply e-mail and destroy any and all copies of the original message.

MDHHS Legionnaires Emails

Enviado por

Dados do documento

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

MDHHS Legionnaires Emails

Enviado por

Direitos autorais:

Formatos disponíveis

MDHHS #1

From: Johnson, Shannon (DCH)

MDCH epidemiologist begins the process of facilitating questionnaire

From: Johnson, Shannon (DCH)

From: Hasan, Shurooq [mailto:shasan@gchd.us]

Cc: Cupal, Suzanne

Shurooq Hasan, M.P.H

MDCH Supplemental Legionellosis Questionnaire

Dates to consider for exposure (2 weeks prior to onset): ___/___ - ___/___

From: Cupal, Suzanne [mailto:scupal@gchd.us]

Suzanne Cupal, M.P.H.

From: Collins, Jim (DCH) [mailto:CollinsJ12@michigan.gov]

Text from SE Legionellosis increase HAN in 2013:

From: Johnson, Shannon (DCH)

From: Collins, Jim (DCH)

From: Johnson, Shannon (DCH)

This is getting old real fast.

From: Johnson, Shannon (DCH)

From: Garrison, Laurel (CDC/OID/NCIRD) [mailto:lee5@cdc.gov]

From: Hicks, Lauri (CDC/OID/NCIRD)

Shurooq Hasan, M.P.H

MDCH epidemiologist sends the outbreak specific questionnaire that MDCH

Anyexposure to misty water?

9.) Inthe2weeksbeforeyoubeforeyougotsick(_ _to _)didyouspendanynights

10.) Inthe2weeksbeforeyoubeforeyougotsick(_ _to _),didyouvisitanyofthe

11.) Inthe2weeksbeforeyoubeforeyougotsick(_ _to _),didyouhave

Quantity per day

From: Hasan, Shurooq [mailto:shasan@gchd.us]

Legionnaires' disease Pontiac fever

Flu-like illness (fever, chills, malaise) without

2-14 days after

24-72 hours after exposure

Isolation of organism Possible

MICHIGAN DEPARTMENT OF COMMUNITY HEALTH

Legionella spp. Isolation and Identification

MICHIGAN DEPARTMENT OF COMMUNITY HEALTH

Turn Around Time: Up to 14 days.

MICHIGAN DEPARTMENT OF COMMUNITY HEALTH BUREAU OF LABORATORIES

MICROBIOLOGY/VIROLOGY TEST REQUISITION

AGENCY - SUBMITTER INFORMATION

ENTER STARLIMS AGENCY CODE

SUBMITTERS PATIENT NUMBER (If Applicable)

ETHNICITY DATE OF BIRTH (MM/DD/YYYY)

h Hispanic h Arab Descent h UNKNOWN

INDICATE SPECIMEN SOURCE

ARBOVIRUS ENCEP PANEL (IgM)

TESTS THAT REQUIRE

h E. COLI (SLT) TOXIN & SEROLOGY

h ENTERIC BACTERIAL CULTURE

h FOODBORNE ILLNESS-Stool or Food

h FUNGAL IDENTIFICATION Isolate ID

h LYME DISEASE - EIA

h NEISSERIA - REFERRED CULTURE

h TOXIC SHOCK TESTING

h AFB NUCLEIC ACID AMPLIFICATION

h VARICELLA ZOSTER IgG

h SYPHILIS (USR Test)

h SYPHILIS FTA - ABS DS*

h AUTOCLAVE TEST STRIPS

h SYPHILIS IgM WESTERN BLOT*

h LYME DISEASE-IFA (Tick)

*Prior Approval Required

h HEPATITIS B ANTIBODY (Anti-HBsAg)

Dates to consider for exposure (2 weeks prior to onset): _/_ - _/_