MDHHS Legionnaires emails

7/25/2019 MDHHS Legionnaires emails

1/53

1

From:Johnson,Shannon(DCH)

Sent:Monday,October13,201412:02PM

To:Bohm,Susan(DHHS);Fiedler,Jay(DHHS);Collins,Jim(DHHS)

Cc:Bolen,Timothy(DHHS);TyndallSnow,Leigh(DHHS);

Rudrik,James

T.

(DHHS)

Subject:GeneseeCo.Legionnaire'soutbreak

Hello,

IspokewithTimlatelastweekabouttheongoingLegionnairesincreaseinGeneseeCounty.Theyvehad30casesof

LegionnairesDiseasereportedintotheMDSSfromJunepresentthisyear,whereinpreviousyears(20092013)theyve

hadarangefrom29casesreportedduringthissametimeframe.Geneseeinitiallythoughttheincreasewasassociated

withMcLarenFlintHospitalasasource,butafterTimandIbothreviewedthepreliminarydataitwasprettyclearthat

manyofthecasesdidnotfitwiththishypothesis.Inaddition,thepicturehasbeencloudedbythefactthatmostcases

beingreporteddidnothaveonsetdatesrecorded.Thecurrenthypothesisisthatthesourceoftheoutbreakmaybethe

Flintmunicipalwater.TiminformedmethatFlintswitchedfromtheDetroitmunicipalwatersystemtogettingwater

fromthe

Flint

River

last

year.

Iran

5year

epi

curves

for

the

6counties

(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

environmentaltesting

is

done

and

Legionella

is

recovered,

there

is

aclinical

sample

to

compare

it

to.

She

let

me

know

thatMcLarenconductedenvironmentaltestingontheirsystemandfoundlowlevelsoflegionellabacteriaandhave

sincehyperchlorinatedtheirwatertodisinfectthesystem.McLarenreceivesitswaterfromtheFlintmunicipalsystem.

TimandIhavebothtriedtoofferourservicestoGeneseeandthusfarhavegottenverylittleinformationand/or

willingnesstoreceiveassistance.AsthisverymuchappearstobeconfinedtoGeneseeandnotamulticountyissue,Im

notsurehowmuchtopushasitssolelytheirjurisdiction.Weknowitsonlyamatteroftimeuntilthishitsthemedia

though

Tim PleasefeelfreetocorrectanydetailsIhavewrong,oraddanyothersyoumighthave.

This is the first email MDHHS has that documents then-MDCH staff knowledge

involvement. At the time of all these emails, the department is the Michig

Department of Community Health (MDCH) as the merger to create the Michigan

Department of Health and Human Services (MDHHS) does not take place until

April, 2015.

MDHHS 1


2/53

2

Thanks,

ShannonAndrewsJohnson,MPH

InfectiousDiseaseEpidemiologist

MichiganDept.ofCommunityHealth

201TownsendSt.,CVB5thFloor

Lansing,MI48913

Phone:5173358165

Fax:517

335

8263


3/53

1

From:Bohm,Susan(DCH)

Sent:Friday,October17,20144:31PM

To:Johnson,Shannon(DHHS)

Cc:Fiedler,Jay(DHHS);Collins,Jim(DHHS)

Subject:QueryfromDEQreGeneseeCountyLegionnaire'sDiseaseCluster

Ireceived

acall

just

now

from

the

DEQ

Chief

of

the

Office

of

Drinking

Water

and

Municipal

Assistance,

Liane

Shekter

Smith,aboutacallthatcameintoherOfficefromtheGeneseeCountyHealthDepartmentreLegionnairesDiseasein

GeneseeCounty.FortunatelyIhadShannonsgreatsummarytoworkwith.Lianewasconcernedthiswasasituationjust

breakingsoIwasabletotellherithadbeenunderinvestigationbytheGeneseeCountyHealthDepartmentforseveral

weeks.Shewasconcernedthatweweregoingtobemakingsomeannouncementsoonaboutthewaterbeingthe

sourceofinfection,soItoldhertheFlintwaterwasatthispointjustahypothesis.SheaskedwhetherGeneseehadthe

capabilitytotestwaterandIrepliedthatwewouldbeworkingwithGeneseetocoordinateanywatertesting.Whatshe

didsharewithmewasinterestingthattherehavebeennumerouscomplaintsabouttheFlintwater,thatthe

GovernorsOfficehadbeeninvolved,andthatanyannouncementbypublichealthaboutthequalityofthewater

wouldcertainlyinflamethesituation.

ShegavemethenameofSteveBusch,theFieldOperationsActingChief,DistrictSupervisorforthePublicWaterSupply

Programfor

the

district

that

includes

Genesee.

Communications

with

DEQ

about

this

investigation

can

go

to

Steve.

His

telnumberis5176432314.Andshewaspleasedthatwewereawareofwhatwasgoingon.

Susan

From:Johnson, Shannon (DCH)Sent:Monday, October 13, 2014 12:02 PMTo: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,

Shortly after a MDCH epidemiologist elevated this internally, MDCH was

contacted by DEQ regarding Legionnaire's Disease in Genesee County.

MDHHS 2


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Lapeer,andTuscola)surroundingGeneseeandnoneofthosecountiesareexperiencinganincreasesimilartowhat

Geneseeisseeing.TheothercountiesareatnormalorbelownormallevelsofcasecountsforJunepresent.Ispokewith

theGeneseeEpi,Shurooq,againtodayandshetoldmetheyhavemappedtheircasesandfoundthatnearlyallofthem

arewithinthecityofFlintandonthemunicipalwater.Theyalsofoundthatthemajorityofcasesarenotoccurringclose

tothetreatmentplant,butfurtherdowntheline.Thiswouldnotbesurprisingsincechlorinationanddisinfectionlevels

dropthefurtherawayyougetfromthetreatmentsource.TheLHDmetwiththecityswatertreatmentdepartmentand

confirmedtheydonotconductanyLegionellatestingatthefacility.IletShurooqknowthatwecouldassistwithand

facilitateenvironmentaltesting,whetheritbethroughourlaborDEQ.TheLHDismeetingwiththewaterdept.this

weekso

she

said

she

would

let

me

know

what

their

plan

is.

Ialso

requested,

again,

that

she

let

the

area

hospitals

know

iftheyseeanynewcasesofillnesstocollectarespiratorycultureinadditiontotheurineantigentestsothatif

environmentaltestingisdoneandLegionellaisrecovered,thereisaclinicalsampletocompareitto.Sheletmeknow

thatMcLarenconductedenvironmentaltestingontheirsystemandfoundlowlevelsoflegionellabacteriaandhave

sincehyperchlorinatedtheirwatertodisinfectthesystem.McLarenreceivesitswaterfromtheFlintmunicipalsystem.

TimandIhavebothtriedtoofferourservicestoGeneseeandthusfarhavegottenverylittleinformationand/or

willingnesstoreceiveassistance.AsthisverymuchappearstobeconfinedtoGeneseeandnotamulticountyissue,Im

notsurehowmuchtopushasitssolelytheirjurisdiction.Weknowitsonlyamatteroftimeuntilthishitsthemedia

though

Tim PleasefeelfreetocorrectanydetailsIhavewrong,oraddanyothersyoumighthave.

Thanks,





Lansing,MI48913

Phone:5173358165

Fax:5173358263


5/53

1

From:Bohm,Susan(DCH)

Sent:Tuesday,October21,20149:47AM

To:Valacak,

Mark

;

Johnson,

Garry

Cc:Fiedler,Jay(DHHS);Johnson,Shannon(DHHS);Bolen,

Timothy(DHHS)

Subject:Legionnaire'sDiseaseClusterinFlintarea

Goodmorning,

WehavebeencontactedacoupleoftimesnowbytheDEQChiefoftheOfficeofDrinkingWaterandMunicipal

Assistance,LianeShekterSmith,abouttheLegionnairesDiseaseclusterintheFlintarea.Weletherknowthatthe

clusterhasbeenunderinvestigationbytheGeneseeCountyHealthDepartmentforseveralweeks.Shewasconcerned

thatanannouncementwasgoingtobemadesoonaboutthewaterasthesourceofinfection;ItoldhertheFlintwater

wasat

this

point

just

ahypothesis.

Iwould

like

to

give

Liane

contact

information

of

someone

at

the

Genesee

County

HealthDepartmenttospeakwithdirectlyabouttheinvestigation.Pleaseletmeknowwhothatmightbe.

Asalways,shouldGCHDneedanyassistancewiththeinvestigation,wewouldbemorethanwillingtoassist.Thanks.

SusanBohm,MS

Manager,Enteric&RespiratoryIllnessesEpidemiologyUnit

SurveillanceandInfectiousDiseaseEpidemiology

DivisionofCommunicableDisease

MichiganDepartmentofCommunityHealth

201TownsendSt,5thFlr

Lansing,MI

48933

5173358165or5173735508(Cell:5179303100) 5173358263

[email protected] www.michigan.gov/mdch

ConfidentialityNotice:Thismessage,includinganyattachments,isintendedsolelyfortheuseofthenamedrecipient(s)andmaycontain

confidentialand/orprivilegedinformation.Anyunauthorizedreview,use,disclosureordistributionofanyconfidentialand/orprivileged

informationcontainedinthisemailisexpresslyprohibited.Ifyouarenottheintendedrecipient,pleasecontactthesenderbyreplyemailand

destroyanyandallcopiesoftheoriginalmessage.

MDCH epidemiologist reaches out directly to the Genesee County Health

Department Health officer and Medical Director. No record they ever respon

MDHHS 3


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Sent:Friday,January23,201510:38AM

To:Collins,Jim(DHHS);Fiedler,Jay(DHHS)

Subject:FW:LegionellaQuestions

From:Johnson, Shannon (DCH)Sent:Friday, October 17, 2014 1:52 PMTo:'Hasan, Shurooq'; Bolen, Timothy (DCH)Cc:Cupal, SuzanneSubject:RE: Legionella Questions

HiShurooq,

Great,thanksforsendingthatalong.Attachedistheextendedquestionnairethatweputtogetheranumberofyears

agotouseinconjunctionwiththeMDSSforminordertocollectadditionalexposureinformationwhenwereseeinga

highnumberofcases.PerhapsonceyoulookitoverwecanfigureoutaGeneseespecificversionbycombiningsomeof

thequestions

and

adding

any

others

that

might

be

needed.

Thanks,

Shannon





Lansing,MI48913

Phone:517

335

8165

Fax:5173358263

From:Hasan, Shurooq [mailto:[email protected]]Sent:Friday, October 17, 2014 1:44 PM

To:Johnson, Shannon (DCH); Bolen, Timothy (DCH)

MDCH epidemiologist begins the process of facilitating questionnaire

development with the Genesee County Health Department epidemiologist.

MDHHS 4


7/53

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Cc:Cupal, SuzanneSubject:Legionella Questions

Hi,

ThequestionsbelowarewhatwedeterminedshouldbeaskedtothosewhoarediagnosedwithLegionella.Pleaseshare

withusanysuggestionsorconcernsyoumighthave.Thanks!

1) What

kind

of

water

do

you

drink?

(Well

vs.

City)

a. Ifcitywater,fromwhatlocation?

2) Haveyourecentlytraveled/stayedinanyhotels?

3) Doyouuseanairconditionerathome?Ahumidifier?

4) Doyouhaveapool,saunaorspayouuseregularlyuseathome?

5) Hastherebeenanyrecentremodelinginyourhouse?

6) Doyouhaveproperventilationinyourbathroomathome?

Shurooq

Shurooq Hasan, M.P.HEpidemiologistGenesee County Health Department

630 S. Saginaw Street

Flint, MI 48502(810) [email protected]


8/53

Version 2.0

MDCH Supplemental Legionellosis QuestionnaireTo be used in addition to the MDSS Legionellosis form

Health Status Risk Factors (please check all that apply):

Smoking- packs per day:_________ Emphysema Asthma Chronic lung disease (e.g. COPD) Cancer Diabetes

Compromised immune system Liver disease Kidney problems Heart disease Oral steroid use Organ transplant Previous dx of pneumonia- when?:___________________ Other- detail:___________________

Onset Date: 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?_________________________________________________________________________


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From:Collins,Jim(DCH)

Sent:Friday,January23,201511:40AM

To:[email protected];[email protected];[email protected];[email protected];[email protected];[email protected]

Cc:TyndallSnow,Leigh(DHHS);Bohm,Susan(DHHS);Johnson,

Shannon(DHHS);Fiedler,Jay(DHHS);Miller,Corinne(DHHS)

;McFadden,

Jevon

(DHHS)

Subject:LegionellaInvestigations

HelloColleagues,

Imcertainlyawareofthepressuresonyouragencyoflatefromthepublicandmediaalikearoundthewaterquality

questionsinFlint.Honestly,Ireallydonotwanttoinconvenienceyouwiththisrequest,butitisonethatwefeelneeds

tobeaddressed.

Asyouknow,therehasbeenamarkedincreaseinconfirmedcasesofLegionellainfectioninGeneseecounty(which

likelyrepresentsthetipoftheicebergrelativetotheactualnumberofcasesofillness).Webelievethatthisincrease

warrantsadditionalevaluationonthepartofpublichealth.CommunicableDiseaseDivisionstaffarecertainlyavailable

tosupport

that

effort

at

your

request.

Ive

gotten

some

mixed

messages

around

the

level

of

follow

up

that

has

been

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

As epidemiologists continue to elevate this internally, the MDCH Communica

Disease Division Director makes another offer of assistance to the leaders

of the Genesee County Health Department. We then identify a consistent po

of contact within the local health department.

MDHHS 5


10/53

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Cell:5179306932


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Sent:Tuesday,January27,20153:45PM

To:[email protected];[email protected];[email protected];[email protected];[email protected];[email protected]

Cc:Collins,Jim(DHHS);Fiedler,Jay(DHHS);Bohm,Susan(DHHS)

Subject:Genesee

Legionellosis

Investigation

GreetingsGCHD,

Thankyoufortheopportunitytospeakwithyouthismorning.AfterbeingupdatedonwhereGCHDisinthe

investigationprocess,wehaveidentifiedsomeitemsthatneedadditionaldetailsand/ormayrequireadditionaldata

gatheringefforts.Inaddition,wevelistedareaswherewecanprovidepersonneltoassistwithdatacollection/analysis

oraidincommunicationbetweentheinvolvedgovernmentaldepartmentsduringtheoutbreakinvestigation.Atthis

point,theprioritiesinthepublichealthinvestigationaretodeterminethescopeoftheoutbreakandtodefineasclearly

aspossiblethecharacteristicsofthecasesofLegionnairesDiseaseandPontiacFever.Thesedatawillbecriticaltohelp

informandprovidedirectionfortheenvironmentalsideoftheinvestigation.

Databeing

requested

by

MDCH

and/or

suggested

data

collection

needs

to

be

addressed:

1)PleaseprovidethenameoftheprimarypointofcontactfortheoverallGCHDlegionellosisinvestigation.

2)ThecurrentcopyoftheGCHDLegionnairesDiseaseoutbreakdatacollectionlinelistisrequestedandupdatessentto

MDCHonaregularbasis.

3)Onsetdatesorestimatedonsetdatesneedtobedeterminedforallcases.

4)Acurrentmapofthemunicipalwatersystemneedstobeobtainedandcasesresidencesmappedinrelationtothe

watersystem.

5)TheinvestigationneedsaGeneseespecificsupplementalquestionnairebeyondtheMDCHsupplementalformand

the6questionsintheemailmessagedated10/17/14.

6)Allpreviouscases(since5/1/14)andnewcasesshouldbereinterviewedassoonaspossiblewiththenewoutbreak

specificquestionnaire.

If

cases

are

not

available,

then

aproxy

should

be

interviewed,

ideally

someone

from

the

samehousehold.

7)TolookforcasesofmilderillnesssuchasPontiacFever,thequestionnaireshouldaskifthereareotherhousehold

memberswhohavehadasimilarrespiratoryillness.Anyhouseholdcontactswithlegionellosisconsistentillness

shouldalsobeinterviewedwiththeoutbreakspecificquestionnaire.

8)Clinicalculturespecimens,inadditiontourineantigentesting,shouldbecollectedfromallsuspectcaseswhere

individualsareseekingmedicalcare.

9)Hospitalsshouldbequeriedtodeterminewhetheranypreviouslydiagnosedcaseshadrespiratoryculturescollected

andwhetheranyoftheseculturespecimenswereretained.Ifso,itshouldberequestedthatthesesamplesbe

helduntiladeterminationonenvironmentaltestingcanbemade.

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 m

a comprehensive investigation forward.

MDHHS 6


12/53

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AssistancethatMDCHcanprovidetoGeneseetoaidintheoutbreakinvestigation:

1)MDCHcanprovidelanguagetoGCHDfordistributiontothemedicalcommunityregardingtherequestforclinical

respiratoryculturecollectiononallsuspectcasesoflegionellosis(LegionnairesDiseaseandPontiacFever).

2)MDCHstaffisavailabletoconductmedicalrecordextraction,asneeded.

3)MDCHstaffcanassistwithdataentryintoMDSS,asneeded.

4)MDCHstaffcanhelpwiththedevelopmentofaGeneseespecificoutbreakquestionnaire.

5)MDCH

is

willing

to

assist

with

supplemental

questionnaire

data

collection

by

conducting

case

interviews

(on

previouslyand/ornewlydiagnosedcases)andalsobyassistingwithdataanalysis,asneeded.

6)MDCHcanassistwiththecoordinationandcommunicationwithMDEQforspecificdatarequestsbyGCHD.

7)TheMDCHPIOcanworkwiththeGCHDPIOtodevelopacoordinatedpublichealthmessagetorespondtopublicand

mediainquiries.

Ifthereareotherissuesthatwehavenotaddressedwhereourassistancewouldbehelpful,pleasedonothesitateto

ask.Weappreciateyoureffortsandrecognizethedelicatesituationyouaredealingduringthisinvestigation.Welook

forwardtocontinuedcommunicationandcollaborationwithyou.

Regards,

ShannonJohnson





Lansing,MI48913

Phone:5173358165

Fax:5173358263


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Sent:Wednesday,February04,20152:39PM

To:Hasan,Shurooq;Henry,James

Cc:Cupal,Suzanne;Childs,Bonnie;Johnson,M.D.,Gary

;Valacak,

Mark

;

Fiedler,

Jay

(DHHS)

;

Bohm,

Susan(DHHS);Collins,Jim(DHHS);Miller,Corinne(DHHS)

Subject:RE:GeneseeLegionellosisInvestigation

DearGCHD,

Thankyouallforyourresponse.IhaveattachedtheWorddocumentwithadditionalMDCHanswerstoyourquestions

(inblue).Movingforward,weveidentifiedsomenextstepsinourcollaborationontheinvestigation.Ispokewith

Shurooqtodayandwemadedecisionsonthedivisionoflaborforthesepoints.

1) GeneseewillsendMDCHacopyoftheircurrentlinelistbythisFriday,Feb6th.Wewillusethisasthemasterline

listfor

the

investigation.

2) PleaseprovideanestimateddateofwhentheHANdiscussingclinicaltestingwillbesenttoprovidersinthe

community.WewouldappreciateseeingacopyofthefinalHANpriortoitbeingsentout.Idiscussedsome

pointsofclarificationabouttheHANlanguagewithShurooqonthephonetoday.Thehospitalswillbefollowing

theirownprotocolsforrespiratoryculturetestingtoattempttoisolatelegionella.Geneseemaywanttoinclude

languageintheHANsuggestingbronchialwashesbeusedastheyaremorelikelytocontainsufficientbacteria

forculturegrowthcomparedtoasputumspecimen.Ifthelegionellabacteriaisidentifiedatthehospitallab,

thoseisolateswillbesentalongtotheMDCHlabforadditionaltesting.

3) Wewouldliketohaveanoutbreakspecificquestionnairefinalizedbytheendofnextweek,FridayFeb13th.Per

Shurooq,Genesee

is

collaborating

with

Joan

Rose

from

MSU

on

water

system

specific

questions.

MDCH

will

begincreatingaquestionnairetemplatetobecombinedwithGeneseesquestionsandafinalversionwillbe

reviewedbybothagencies.

4) MDCHhasrequestedmedicalrecordaccessforthelegionellosisinvestigationfromGenesys,Hurley,and

McLarenhospitals.AfterdiscussingwithShurooq,MDCHwillbegintocollectinformationonprevious

hospitalizations(dates,admissioncomplaint,etc.)forcases.

MDCH is forced to lay out exact steps to be taken with dates that we expect

Genesee County Health Department to complete tasks by in order to accompli

the work needed to be done by the locals.

MDHHS #7


14/53

2

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.

In

the

future,

we

may

be

able

to

refine

the

definition

as

additional

data

is

obtained.

If

Genesee

prefers,theymaymarkallcasesinMDSSmeetingthecurrentdefinitionasoutbreakassociatedandassignan

outbreakID.ThisisgenerallymoreusefulwhenneedingtosearchtheMDSSforasubsetofcasesinthesystem.

SincetheoutbreakcurrentlyincludesallGeneseelegionellosiscasessince6/1/14,itisnotasurgent.

Ifthereareotherinitialstepsyouwouldliketoincludepleasefeelfreetoaddthemtothelist.

Bestwishes,

Shannon



MichiganDept.

of

Community

Health


Lansing,MI48913

Phone:5173358165

Fax:5173358263

From:Cupal, Suzanne [mailto:[email protected]]

Sent:Friday, January 30, 2015 3:22 PMTo: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.WearealsoappreciativeoftheopportunitytorequestMDCHsassistanceinmovingourinvestigationforward.Welookforwardtocontinuedandimprovedcommunicationandcollaborationand

appreciateyouroffersofassistance.

Weappreciateyouracknowledgmentofthesensitivenatureofourworkinanenvironmentofanxietyandsuspicion.

Wedonotwanttojumptoconclusionsbaseduponverylimitedandinconclusiveevidenceandyourassistanceinfilling

someoftheinformationgapswehaveidentifiedwouldbeofgreathelp.Wespecificallyaskedforyourassistancein

identifyingsomeoneatMDCHwithexpertiseintype1watersuppliesandcommunicabledisease.Thatwasnotreflected

inyourresponse.PleaseletusknowifthereisanidentifiedresourceforthisatMDCH.Inaddition,werequestedyour

supportinidentifyingsomeoneonyourstaffwhocouldfunctionasaliaisonwithyourfellowstatecolleaguesatMDEQ


15/53

3

sinceanumberofquestionshavecomeupregardingthetype1watersupplywherethestatehasregulatoryauthority

andaccesstoimportantdata.

Asweindicatedinourcall,wecontinuetoidentifyandreachouttothosethatcaninformourinvestigationandprovide

moreinformationregardingwaterandlegionellosis.Thefeedbackthatwearereceivinghasbeenveryhelpfulin

evolvingourinvestigation.However,additionalexpertiseisbeingsoughtastheinvestigationunfolds.

Wehavemetinternallyandcollaboratedonourresponsestoyourquestions.Inyourresponse,youmakereferenceto

thescope

of

the

outbreak.

We

encourage

you

to

review

the

case

notes

in

MDSS.

If

we

are

referring

to

this

as

an

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

Genesee County Health Department630 S. Saginaw StreetSuite 4Flint, MI 48502

(810) 768-7970

[email protected]

From:Collins, Jim (DCH) [mailto:[email protected]]Sent:Friday, January 30, 2015 1:21 PM

To:Johnson, M.D., Gary; Childs, Bonnie; Cupal, Suzanne; Henry, James; Hasan, Shurooq; Valacak, MarkCc:Fiedler, Jay (DCH); Bohm, Susan (DCH); Bolen, Timothy (DCH); Miller, Corinne (DCH); Johnson, Shannon (DCH)Subject:RE: Genesee Legionellosis InvestigationImportance:High

GoodAfternoonAll,

WhileyouallattheGeneseeCountyHealthDepartmentarereviewingShannonspostfromacoupleofdays

ago(Copiedbelow.Welookforwardtohearingyourthoughtsonthisaswell),IthoughtIdgoaheadand

providesomeadditionalinformationthatwevecompiledaftertheconferencecall.


16/53

4

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. Thisrepresents the highest number of Legionellosis cases for the month of June over the past decade andnew 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 theNortheast (NY, DE, CT & PA).

Investigations are ongoing in Southeast Michigan to determine common sources of exposure. We areasking that the clinical community assist in this investigation through accurate identification, testing andreporting of all suspect cases of Legionellosis.

Attached, please find guidance that has been prepared to assist clinicians in case evaluation andfacilitate specimen collection/testing as well as an updated "Supplemental Interview Form" for localhealth department use in evaluating reported cases.

Pleasenotethatintheattachment,thereisintroductoryroomtoofferalocalassessmentofthesituationand

therationale

behind

distributing

the

MIHAN

message.

We

feel

that

GCHD

is

best

positioned

distribute

a

messagetothehealthcarecommunityandtoprovidelocalcontexttothatmessagebutarecertainlyavailable

toprovideassistancetoeitherfunctionifyoudprefer.

Again,wedolookforwardtohearingyourthoughtsonShannonspreviouspostandstandreadytoassistin

whatevercapacitymightbestservetheinvestigation.

AllMyBest,

Jim

JimCollinsMPH,RS

Director

CommunicableDiseaseDivision


201TownsendSt.

Lansing,MI48913

Desk:5173358586

Cell:5179306932


17/53

5

From:Johnson, Shannon (DCH)

Sent:Tuesday, January 27, 2015 3:45 PMTo:[email protected]; [email protected]; [email protected];[email protected]; [email protected]; [email protected]: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.

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)MDCHcanprovidelanguagetoGCHDfordistributiontothemedicalcommunityregardingtherequestforclinicalrespiratoryculturecollectiononallsuspectcasesoflegionellosis(LegionnairesDiseaseandPontiacFever).

2)MDCHstaffisavailabletoconductmedicalrecordextraction,asneeded.

3)MDCHstaffcanassistwithdataentryintoMDSS,asneeded.

4)MDCHstaffcanhelpwiththedevelopmentofaGeneseespecificoutbreakquestionnaire.

5)MDCHiswillingtoassistwithsupplementalquestionnairedatacollectionbyconductingcaseinterviews(on

previouslyand/ornewlydiagnosedcases)andalsobyassistingwithdataanalysis,asneeded.

6)MDCHcanassistwiththecoordinationandcommunicationwithMDEQforspecificdatarequestsbyGCHD.

7)TheMDCHPIOcanworkwiththeGCHDPIOtodevelopacoordinatedpublichealthmessagetorespondtopublicand

mediainquiries.


18/53

6

Ifthereareotherissuesthatwehavenotaddressedwhereourassistancewouldbehelpful,pleasedonothesitateto

ask.Weappreciateyoureffortsandrecognizethedelicatesituationyouaredealingduringthisinvestigation.Welook

forwardtocontinuedcommunicationandcollaborationwithyou.

Regards,

ShannonJohnson





Lansing,MI48913

Phone:5173358165

Fax:5173358263


19/53

DatabeingrequestedbyMDCHand/orsuggesteddatacollectionneedstobeaddressed:

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,

we

can

provide

estimated

onset

dates.

We

would

like

your

inputwould

you

prefer

we

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


20/53

Ifdateofonsetisprovidedasarangeofdates,usetheearliestdateasdateofonsetof

respiratorysymptoms.

o Forexample,ifadateofonsetisgivenas3tofivedaysago,listthedate

correspondingto5daysago.

Date: 10/10 10/11 10/12 10/13 10/14 10/15

Day

Number:5 4 3 2 1 0

Onset Admission

4) Acurrentmapofthemunicipalwatersystemneedstobeobtainedandcasesresidences

mappedinrelationtothewatersystem. Asdiscussedinourcall,weareexperiencingdifficulty

inobtainingtheinformationwehaverequestedfromDWPandMDEQ.WehavesenttheFOIA

requestforthecurrentmapofthemunicipalwatersystem.Asdiscussedduringourcall,we

havemappedourcasestolookforcommonalitiesandtoidentifytheproximityofthecasesto

theboilwateradvisories.

MDCHwillcommunicatewithMDEQaboutobtainingthewatersystemmap.Ifyouhavetheinformation,pleaseprovidetoMDCHacopyoftheboilwateradvisories(ordates)andtheareas

theycover.

5) TheinvestigationneedsaGeneseespecificsupplementalquestionnairebeyondtheMDCH

supplementalformandthe6questionsintheemailmessagedated10/17/14.Asdiscussedin

ourcall,GCHDhasbeenidentifyingandreachingouttoindividualswithexpertisewithtype1

watersupplies.Duringourcall,weaskedspecificallyofanyoneatMDCHhasthisexpertise.

Pleaseletusknowifyouhaveastaffmemberwecanconsultwith.Alsostatedduringourcall,

werequestedtheassistanceofMDCHincreatingourGeneseespecificquestionnaire.the

questionnairewearecurrentlyusing.Wearereachingouttowaterexpertstoassistinthe

updatingof

our

questionnaire.

In

the

limited

conversations

we

have

had

so

far,

we

have

learned

agreatdealwhichwillinformthequestionsweneedtoask.Wealsolookforwardtoadditional

conversationswithourMDCHcolleages.

MDCHdoesnothavestaffwithexpertiseintype1watersupplies,thisfallsunderthepurviewof

MDEQandthelocalwaterauthority.MDCHisabletoadvisespecificallyonlegionellarelatedto

humanillness.Thecompileddataprovidedbythecasesonthequestionnairewillbevitalto

directingthefocusandscopeofpotentialfutureenvironmentaltesting.

AgeneralsupplementaldataformdevelopedbyMDCHwasprovidedtoGeneseeon10/17/14.

MDCHwillworkwithGCHDtodevelopaGeneseespecificquestionnairefortheoutbreak.

6) Allpreviouscases(since5/1/14)andnewcasesshouldbereinterviewedassoonaspossible

with

the

new

outbreak

specific

questionnaire.

If

cases

are

not

available,

then

a

proxy

should

be

interviewed,ideallysomeonefromthesamehousehold. Seemenotesbelow

7) TolookforcasesofmilderillnesssuchasPontiacFever,thequestionnaireshouldaskifthere

areotherhouseholdmemberswhohavehadasimilarrespiratoryillness.Anyhousehold

contactswithlegionellosisconsistentillnessshouldalsobeinterviewedwiththeoutbreak

specificquestionnaire.Asdiscussedonthecallinthereviewofourinvesitgations,wehave

foundthisand,wehavebeenreportingthisandhavereportedtheminMDSS.Thisisthe


21/53

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

testingcan

be

made.

This

was

discussed

at

our

Bug

Fuzz

meeting

on

1/22/15.

We

will

also

be

requestingmoreinformationregardingpreviousyearslegionellatesting.Wesuspecta

significantincreaseinthenumbersoftestsconducted,particularlyduringAugust/September

thaninpreviousyears.Remember,thehyperclorinationdoneatourhospitalofinterestwas

completed10/4/15.Thatmayalsoinfluencethenumberoftestsconducted.


1) MDCHcanprovidelanguagetoGCHDfordistributiontothemedicalcommunityregardingthe

requestforclinicalrespiratoryculturecollectiononallsuspectcasesoflegionellosis

(LegionnairesDiseaseandPontiacFever).Whatwespecificallyrequestedwasthespecific

testing

protocols

for

sample

collection,

storage

and

transportation

of

clinical

samples.

We

also

requestedtestingofenvironmentalsamplesfrompatienthomesandkeycommunitysites.We

wouldlikethesameprotocolinformationforthistypeoftestingaswell.Jimsemailcovered

someofthis,but,westillhavesomequestions.

Hospitalsshouldbefamiliarwithtestingprotocolsforlegionellaculturespecimens.Ifa

legionellaisolateisfoundbythehospital,thehandlingandshipmenttoBoLforadditional

testingisdiscussedinthelanguageoftheHAN.

2) MDCHstaffisavailabletoconductmedicalrecordextraction,asneeded.Medicalrecordsare

attachedinMDSSandwedonotneedassistancewiththisatthistime.

3) MDCHstaffcanassistwithdataentryintoMDSS,asneeded. Atthistime,wedonotneed

assistancewith

this.

Please

see

the

note

below

4) MDCHstaffcanhelpwiththedevelopmentofaGeneseespecificoutbreakquestionnaire.We

welcomeyourparticipationintherevisionofourGeneseespecificquestionnaire.Wehave

alreadyreceivedsomehelpfulfeedbackfromourexpertconsultations.

Wewouldliketohaveanoutbreakspecificquestionnairefinalizedbytheendofnextweek,

FridayFeb13th.PerShurooq,GeneseeiscollaboratingwithJoanRosefromMSUonwater


22/53

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)

TheMDCH

PIO

can

work

with

the

GCHD

PIO

to

develop

acoordinated

public

health

message

to

respondtopublicandmediainquiries.Asdiscussedinourcall,thewatersystemisanextremely

sensitivetopic.Weareverycarefulincraftingmessages.ShouldweneedMDCHPIOassistance,

wewillrequestit.


23/53

1


Sent:Wednesday,February11,20159:21AM

To:Collins,Jim(DHHS);Fiedler,Jay(DHHS);Bohm,Susan(DHHS)

Subject:RE:LegionellaInvestigationGuidance

IspokewithLaurelatCDCandgaveherthebackgroundonthiswholesituationandourmultipleattemptsoverthelast

7monthstoprovideassistanceandhelptoGCHDwiththisoutbreak.Shesgoingtoreiterateinherresponsethat

GeneseeshouldbeworkingdirectlywithusandthatcontactwithCDCisnormallyfromthestatetoCDC.Shesgoingto

CCmeonanyresponsetoShurooqandsendalongthequestionnaireonceshegetsit.ItoldLaurelshesmorethan

welcometoprovidefeedbackontheirquestionnaire,butthatwehadntevenseenityetandthatitwasour

understandingtheywereworkingonwatersystemquestionswithalocalwaterborneillnessacademicianwhilewe

developedthehypothesisgeneratingtemplate.

Funwaytostarttheday.

Thanks,

Shannon





Lansing,MI48913

Phone:5173358165

Fax:517

335

8263

From:Collins, Jim (DCH)Sent:Wednesday, February 11, 2015 8:38 AMTo:Johnson, Shannon (DCH); Fiedler, Jay (DCH)

Subject:RE: Legionella Investigation Guidance

Shannon,

This is one of the first times the Genesee County Health Department reaches

to the CDC, and the CDC directs them back to MDCH. CDC Subject Matter Exp

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.

MDHHS #8


24/53

2

PleasethanktheCDCpersonforloopingusin.AtthesametimepleaseprovideasummarytodateofGenesees

effortsonthisinvestigationrecommendationswevegiven,whereweofferedtoassistandhowthathasbeen

received.

PleasetakethisdocumentandrequestacopyofthetooltheysharedwiththeCDC.

Thanks

JimJimCollinsMPH,RS

Desk:5173358586

Cell:5179306932

From:Johnson, Shannon (DCH)Sent:Wednesday, February 11, 2015 8:34 AMTo:Fiedler, Jay (DCH); Collins, Jim (DCH)

Subject:Re: Legionella Investigation Guidance

This is getting old real fast.

Shannon Andrews Johnson, MPHInfectious Disease Epidemiologist

Michigan Department of Community Health

Communicable Disease DivisionPhone: 517-335-8165

Fax: 517-335-8263

[email protected]

From:Fiedler,Jay(DCH)

Sent:Wednesday,February11,20158:31:32AM

To:Johnson,Shannon(DCH);Collins,Jim(DCH)

Subject:RE:

Legionella

Investigation

Guidance

Wow

From:Johnson, Shannon (DCH)Sent:Wednesday, February 11, 2015 8:31 AMTo: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 EpidemiologistMichigan Department of Community Health

Communicable Disease Division

Phone: 517-335-8165Fax: 517-335-8263

[email protected]


25/53


26/53

4

Dr.JanetStoutreferredmetoyou.Wearecurrentlyexperiencingalegionellaoutbreakinourcountyandare

investigatingmultiplesourcesaspotentialcausesforourincrease.SinceJune2014,wehavehad47casesofLegionella,

almostfourtimesthenumberofcaseswehadduring2013,andthehighestnumberofcasespercountyinthestatefor

2014.Wehaveinvestigatedahospitalasapotentialsourceforthedisease,buthaveexpandedourinvestigationto

includethecitywatersupply.Ofour47cases,25caseshaveoccurredwithinthecitywatersupplydistributionsystem.

Nocommonlinksorassociationshavebeendeterminedbetweenthecases.Themajorityofourcasesarehomebound

immunecomprisedindividualswhohavenottraveledandarenotreadilymobile.Theyarealsounabletoanswerour

questionswhenweinvestigateduetotheseverityoftheirconditionsoncehospitalized.Weareintheprocessof

developingasurvey

to

implement

for

all

new

incoming

cases

as

well

as

going

back

to

all

our

previous

cases.

Dr.

Stout

mentionedyourexperienceandknowledgewithlegionellaandsuggestedweseekyourinputonthesurveywehave

developed.Wewouldreallyappreciateanyfeedback,ortheopportunitytotalkanytimeyouarefree.Weareworking

onatightdeadlineandweneedtohaveoursurveydonebyFriday.IhaveattachedthesurveyandIamlookingforward

tohearingfromyousoon.

ThankYou,

Shurooq

Shurooq Hasan, M.P.HEpidemiologistGenesee County Health Department630 S. Saginaw StreetFlint, MI 48502(810) [email protected]


27/53

1


Sent:Friday,February13,20159:00AM

To:'[email protected]';[email protected]

Cc:'[email protected]';'[email protected]';'[email protected]'

;'[email protected]'

;

Bolen,

Timothy

(DHHS)

;

Bohm,Susan(DHHS);Fiedler,Jay(DHHS);Collins,Jim(DHHS)

Subject:GeneseeCountyDraftOutbreakQuestionnaire

Importance:High

HiShurooqandJim,

Iveattachedthedraftoutbreakspecificquestionnaireweputtogether.Wellneedtousethistooltointerviewallthe

casesgoingbacktoJune,2014.PleaserespondtomewithanycommentsoreditsbyWednesday,Feb.18th.

Wecandiscussthedivisionoflaborforconductinginterviewsonournextgroupcall.DoesThursday,2/19at9amwork

foreveryone?

Thanks,

Shannon





Lansing,MI

48913

Phone:5173358165

Fax:5173358263

MDCH epidemiologist sends the outbreak specific questionnaire that MDCH

developed for the Genesee County Health Department. It is necessary to go

and interview every case that occurred in 2014, many of whom had never been

contacted for an interview by the Genesee County Health Department.

MDHHS #9


28/53

MDSSID _____

Page1of6

LegionellosisQuestionnaire

GeneseeCounty,20142015

InterviewerIdentification

DateofInterview: InterviewersName:

HealthDepartment: PhoneNumber: Email:

Whatwasthepatientsoutcome? RECOVERED STILLILL DIED

PatientContactInformation

Name: ________ Age: Sex: M F

City: State: Zip: County:

DaytimePhone: EveningPhone:

SurrogateContactInformation

Name:

________

DaytimePhone: EveningPhone:__________________________

RelationshiptoPatient:

Hello,mynameis andImcallingfrom (healthdepartment).

WeareinvestigatingaclusterofrespiratoryillnessesinGeneseeCounty.Atthispoint,thesourceof

theseillnessesisstillunderinvestigation.Wearehopingthisinterviewwillprovidefurther

informationandanswersabouttheillnesses.Idliketoaskyouafewquestionsaboutyourhomeand

yourexposuresduringthe2weeksbeforeyougotsick. Youdonothavetoansweranyofthequestions,

butany

assistance

you

can

provide

is

appreciated.

Do

you

have

about

20

minutes

to

talk?

If

not

now,

whenwouldbeagoodtimeformetocallback?______________________________________

Itmightbehelpfulforyoutocollectdocumentssuchasacalendar,receipts, creditcardorbank

statementstojogyourmemoryaboutyouractivities2weekspriortogettingsick.Wouldyoulikemeto

callyoubackafteryouhavetimetocollectthesematerials?Whenwouldbeaconvenientdayandtime

formetocallyouback?___________________________________

Ihavethatyourfirstsymptomstartedon . Isthiscorrect?

Yes No Notsure

Ifno,whatwasthefirstdateyoustartedfeelingsick?___________________

Listdatesofexposureperiod:from _ / / to _ / /


29/53

MDSSID

Page2of 6

______

IllnessInformation

1.)Duringyourillness,didyouhaveanyofthefollowingsymptoms?

Checkone:

YES NO UNK

Ifyes,whendid

thissymptom

start?

Areyoustillill

withthis

symptom?Diagnosisofpneumonia

Fever

Ifyes,highesttemp:_____

Chills

Cough

Nausea

Lossofappetite

Vomiting

Diarrhea

Achesormusclepains

Chestpain

Chestburning

Shortnessofbreath

Sorethroat

Headaches

Othersymptoms(specify)

ExposureInformation

2.)Howlonghaveyoulivedatyourcurrentresidence?__________

a.) Ifyoumovedaftertheexposureperiod/illness,whatwasyourpreviousresidence

address?____________________________________________________________

3.)Priortoyourillness,didyoumakeanyrecentplumbingchangesorrepairsatyourresidence?

Yes No Notsure

a.) Ifyes,pleasedescribethechanges/repairsandgivethedatestheworkwasdone.

____________________________________________________________________

____________________________________________________________________

4.)Priortoyourillness,werethereanywatermainbreaksorotherwaterlineissuesthataffectedthe

wateratyourresidence?

Yes No Notsure

a.) Ifyes,pleasedescribethewatermain/lineissuesandgivethedatestheyoccurred.

____________________________________________________________________

____________________________________________________________________


30/53

MDSSID

Page3of 6

______

Exposure Date(s) Name& Cityof Facility

Resident

Visitor

Employee

Date(s)Name&CityofHospital/

Office/ClinicReasonforVisit NameofDoctor

Inpatient Admission

Discharge

Outpatient

Visitor

Employee

Volunteer

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? Yes No Notsure

a.)Ifyes,completethefollowingtable:

Jobdescription Company Location Anyexposure to misty water?

7.)Spendanytimeinahospital,doctorsoffice,clinic,ordentistofficeasapatient,visitor,employee,or

volunteer? Yes No Notsure

a.) Ifyes,checkallthatapply:

8.) Visit,reside,orworkinalongtermcarefacility,nursinghome,assistedlivingfacility,orseniorliving

facility? Yes No Notsure



31/53

MDSSID

Page4of 6

______

9.) Inthe2weeksbeforeyoubeforeyougotsick(_ _to _)didyouspendanynights

awayfromhome(excludinghealthcaresettings)? Yes No Notsure


Accommodation

Type/Name

Address

Street,City,State

Floor/Room

No.

Dates of Stay

Arrival Departur

10.) Inthe2weeksbeforeyoubeforeyougotsick(_ _to _),didyouvisitanyofthe

followingcommunityvenues?

Checkone:

Venue YES NO UNK Date(s) Name of Venue Address

Hotel(without

stayingovernight

e.g.dinner,wedding)

Auditorium

BarbershoporHair

salon

CarWash

Casino

Churchor

Place

of

worship

GymorWorkout

facility

Grocerystore

Homeimprovement

store

SpaorNailsalon

MallorDepartment

store

Movietheater

Other(specify)


32/53

MDSSID

Page5of 6

______

11.) Inthe2weeksbeforeyoubeforeyougotsick(_ _to _),didyouhave

exposuretoanyofthefollowingwatersources,eitherathomeorwhileawayfromhome?

Checkone:

Exposuresathome YES NO UNK Dates(s) Name(orType)/Location

Shower

Useadetachable

shower

head

or

hose

Hottub,whirlpoolspa,Jacuzzi

tubSatNEARaworkinghottubor

whirlpoolspabutdidnotgetin

Steamroomorwetsauna

Humidifier(wholehouseor

portable)

Ifyes,whattypeofwaterisusedindevice?

Bottled Tap Other:____________

Respiratorytherapymachine

(e.g.

nebulizer,

CPAP,

BiPAP,

etc.)



Other(specify)

Exposuresawayfromhome YES NO UNK Dates(s) Name(orType)/Location

Showeratgym,work,other

location

Useadetachableshowerheador

hose

Hottub,whirlpoolspa,Jacuzzi

tub

SatNEARaworkinghottubor

whirlpoolspabutdidnotgetin

Humidifier(wholehouseor

portable)



Pool/splashpad/waterpark

Recreationalorcoolingmisters

Steamroomorwetsauna

Decorativefountain

Outdoorwateringhoseor

sprinklerBeach,lake,pond,river,creek,

etc.

Other(specify)


33/53

MDSSID

Page6of 6

______

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 NOQuantity per day

(packs or drinks) Duration(years)

Areyoucurrentlyasmoker?

Areyouaformersmoker?

Doyoudrinkalcohol?

14.) Doyouknowanyoneelsewithsimilarsymptoms? Yes No Notsure


Name PhoneState of

Residence DetailsofSharedExposure

AdditionalComments

_________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Thankyousomuchfortakingthetimetoanswerthesequestions. DoyouhaveanyquestionsthatI

canhelpanswer? Ifyouhaveanyquestionsorrememberanyfurtherdetailslater,pleasecontactthe

_____________________(healthdepartment)atphone:_____________________.


34/53

1


Sent:Friday,February13,20152:50PM

To:Collins,Jim(DHHS);Fiedler,Jay(DHHS);Bohm,Susan(DHHS)

;Tyndall

Snow,

Leigh

(DHHS)

;

Weinberg,

Meghan

(DHHS)

Subject:FW:ClinicalGuidanceforLegionellosis

FYI copyofthemessageGeneseesentabouttesting.ItwasntsentasaHANbecausethepersonwhohasaccessto

sendingcapabilitieswasntintoday,butasanemailtotheICPsatthe3hospitals.Itwentouttoapproximately15

people.

From:Hasan, Shurooq [mailto:[email protected]]Sent:Friday, February 13, 2015 1:57 PMTo:Cupal, Suzanne; Thornton, Venita; Miller, Colleen; Childs, Bonnie; Bolen, Timothy (DCH); [email protected];[email protected]; [email protected]; Johnson, M.D., Gary; [email protected];

[email protected]; July, Jori; [email protected]; [email protected];[email protected]; [email protected]; [email protected]; [email protected];[email protected]; 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 highestnumber 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 clinicalcommunity assist in this investigation through accurate identification, testing and reporting of all suspect casesof legionellosis.

The guidance attached has been prepared to assist clinicians in case evaluation and facilitate specimencollection/testing. Also included are the Michigan Department of Community Health Bureau of Laboratoriestesting protocol and requisition form to be used when sending Legionellaisolates for testing.

Please share this information with the appropriate contacts and departments within your hospital systems.

This is the first notification the Genesee County Health Department sends t

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 in3 area hospitals.

MDHHS #10


35/53

2

For additional information, please contact the Genesee County Health Department at 810-257-3815 or 810-257-1017

Thank You,Shurooq

Shurooq Hasan, M.P.H

Epidemiologist

Genesee County Health Department

630 S. Saginaw StreetFlint, MI 48502(810) [email protected]


36/53

1

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

Clinical featuresPneumonia, cough,fever

Flu-like illness (fever, chills, malaise) withoutpneumonia

Radiographicpneumonia

Yes No

Incubation period2-14 days afterexposure 24-72 hours after exposure

Etiologic agent Legionella species Legionella species

Attack rate < 5% > 90%

Isolation of organism Possible Never

OutcomeHospitalization commonCase-fatality rate: 5-30%

Hospitalization uncommonCase-fatality rate: 0%

Source:http://www.cdc.gov/legionella/clinicians.html

WhotoTestforLegionnaires'Disease

PatientswithpneumoniainthesettingofaLegionellosisoutbreak

Patientswhohavefailedoutpatientantibiotictherapy

Patientswithseverepneumonia,inparticularthoserequiringintensivecare

Immunocompromisedhostwithpneumonia

Patientswithatravelhistory[Patientsthathavetraveledawayfromtheirhomewithintwo

weeksbeforetheonsetofillness.]

Patientssuspectedofhealthcareassociatedpneumonia


37/53

2

TestingforLegionnaires'Disease

UrinaryantigenassayANDcultureofrespiratorysecretionsonselectivemediaaretherequested

diagnostictestsforLegionnaires'disease

Sensitivityvariesdependingonthequalityandtimingofspecimencollectionaswellastechnical

skillofthelaboratoryperformingthetest

AdvantagesandDisadvantagesofDiagnosticTests

Test Advantages Disadvantages

Culture

Clinical&

environmental

isolatescanbe

compared

Detectsallspecies&

serogroups

100%specific

Technicallydifficult

Slow(>5daystogrow)

Sensitivityhighlydependentontechnicalskill

Maybeaffectedbyantibiotictreatment

Urine

Antigen

100%specific...

Rapid(sameday)

...butonlyforL.pneumophilaserogroup1(Lp1)

[whichmayaccountforupto80%ofcases]

Doesnotallowformolecularcomparisontoenvironmental

isolates

Serology

Lessaffectedby

antibiotictreatment

8090%sensitive;

99%specific

Musthavepairedsera

510%ofpopulationhastiter1:256.Singleacutephase

antibodytitersof1: 256donotdiscriminatebetweencases

ofLegionnaires'diseaseandothercausesofcommunityacquiredpneumonia.

DFA

Canbeperformedon

pathologicspecimens

>95%specific

2575%sensitive

PCR Rapid AssaysvarybylaboratoryandarenotFDAapproved


38/53

3

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.Antibioticregimenandtreatmentdurationmayvarydependingonspecificpatientriskfactorsorcomorbidities.

Reporting

LegionellosisisareportablediseaseinMichigan.Weareaskinghealthcareprofessionalstoreportboth

LegionnairesdiseaseandPontiacfevercasesviatheMichiganDiseaseSurveillanceSystem(MDSS)or

directlytotheLocalHealthDepartment.Physiciansarerequestedtocollectandrecordillnessonset

datesaspartofthepatientrecord.Anaccurateillnessonsetdateisextremelyimportanttodetermine

thepatientspotentialenvironmentalexposuresandisvitaltotheinvestigationofanoutbreak.In

patientswithchronicrespiratoryconditions,thefirstappearanceoffevermaybeausefulindicatorof

legionellosisonsetdate.

Foradditionalinformation,pleasecontact:

GeneseeCountyHealthDepartment:8102571017or8102573815


39/53

MICHIGAN DEPARTMENT OF COMMUNITY HEALTHBUREAU OF LABORATORIES

Legionellaspp. Isolation and Identification, Page 1 of 2Rev. 3/6/12

LL eeggiioonneellllaasspppp..IIssoollaattiioonnaannddIIddeennttiiffiiccaattiioonn

AANNAALLYYTTEESSTTEESSTTEEDD::

Suspected bacterial isolate or a clinical specimen. Environmental or water samples are

accepted only after prior approval from epidemiology.

UUSSEEOOFFTTEESSTT::For the isolation and identification of Legionellaspp. from clinical specimensobtained from patients with illnesses compatible with legionellosis.

SSPPEECCIIMMEENNCCOOLLLLEECCTTIIOONNAANNDDSSUUBBMMIISSSSIIOONNGGUUIIDDEELLIINNEESS::Test Request FormDCH-0583Specimen Submission Guidelines

Transport Temperature: Ambient

SSPPEECCIIMMEENNTTYYPPEE::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

SSPPEECCIIMMEENNRREEJJEECCTTIIOONNCCRRIITTEERRIIAA::Critical Data Needed For Testing:

Patient Name

Patient Date of BirthSpecimen SourceDate Collected

Submitting Agency

TTEESSTTPPEERRFFOORRMMEEDD::Methodology:
http://www.michigan.gov/documents/DCH-0583TEST_REQUEST_7587_7.pdfhttp://www.michigan.gov/mdch/0,1607,7-132-2945_5103_5278-14793--,00.htmlhttp://www.michigan.gov/mdch/0,1607,7-132-2945_5103_5278-14793--,00.htmlhttp://www.michigan.gov/mdch/0,1607,7-132-2945_5103_5278-14793--,00.htmlhttp://www.michigan.gov/documents/DCH-0583TEST_REQUEST_7587_7.pdf


40/53

MICHIGAN DEPARTMENT OF COMMUNITY HEALTHBUREAU OF LABORATORIES

Legionellaspp. Isolation and Identification, Page 2 of 2Rev. 3/6/12

Turn Around Time: Up to 14 days.

When Performed: Monday through Friday.

RREESSUULLTTIINNTTEERRPPRREETTAATTIIOONN::

The presence of Legionellaspp. in a clinical specimen obtained from a patient

with clinical symptomatology suggestive of legionellosis constitutes laboratorydiagnosis of the illness.

Reference Range: N/A

FFEEEESS::N/A

NNOOTTEESS::

1. A direct fluorescent antigen test should be requested simultaneously on

specimens submitted for culture for Legionellaspp.

2. There is a much greater likelihood that Legionellaspp. 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 bythe normal flora of the upper respiratory tract.

3. Saline and salt-containing fluids are inhibitory to the Legionellaspp.; therefore,

exposure to these compounds should be limited as much as possible.

4. Specimens to be cultured for Legionellaspp. should be held at refrigerator

temperatures during transport to preserve viability.

5. Sputum specimens are not accepted for Legionella DFA.

AALLIIAASSEESS::None


41/53

MICHIGAN DEPARTMENT OF COMMUNITY HEALTH BUREAU OF LABORATORIES

MICROBIOLOGY/VIROLOGY TEST REQUISITIONP.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 INFORMATIONENTER STARLIMS AGENCY CODERETURN RESULTS TO

PHONE

(24/7)

FAX

NATIONAL

PROVIDER

IDENTIFIER

PHYSICIAN OF RECORD/LEGALLY AUTHORIZED PERSON ORDERING TEST

PATIENT INFORMATION - NAME (Last, First, Middle Initial or Unique Identier) Must Match Specimen Label Exactly

SUBMITTERS PATIENT NUMBER (If Applicable)

PATIENTS CITY OF RESIDENCE ZIP CODE GEND

M

RACE

Black/AA White Native American or Alaskan Asian Hawaiian/PI Unknown Other (Specify)

ETHNICITY DATE OF BIRTH (MM/DD/YYYY) SUBSCRIBER INFORMATION Hispanic Arab Descent UNKNOWN Medicaid ADAP DOC Other:

SUBSCRIBER NUMBER

SUBMITTERS SPECIMEN NUMBER (If Applicable)

DATE COLLECTED (MM/DD/YYYY) TIME COLLECTED

AM PM

INDICATE TEST REQUESTED

SEROLOGY

SERUM STATUS - If Applicable

ACUTE CONVALESCENT

ARBOVIRUS ENCEP PANEL (IgM) May-October Includes Eastern Equine, California, St. Louis and West Nile, CSF Only

BRUCELLASEROLOGY

FUNGAL SEROLOGY

COMPLEMENT FIXATION

FUNGAL IMMUNODIFFUSION

FRANCISELLASEROLOGY

LEGIONELLA- HA

LYME DISEASE - EIA

Complete #4 (reverse)

MEASLES IgG

MUMPS IgG

RABIES AB SEROLOGY


RUBELLA IgG

TETANUS TOXIN EIA

VARICELLA ZOSTER IgG

SYPHILIS TESTING

SYPHILIS (USR Test)

SYPHILIS VDRL - CSF Only

SYPHILIS DFA


SYPHILIS FTA - ABS DS*

SYPHILIS TP-PA*

SYPHILIS IgM WESTERN BLOT*

*Prior Approval Required

HIV TESTING

HIV Ag/Ab - Serum HIV AB - Oral Mucosal

Transudate

CD4/CD8

(EDTA whole blood)

HIV-1 VIRAL LOAD

(EDTA plasma)

HIV-1 GENOTYPING

(EDTA plasma)

INDICATE SPECIMEN SOURCE

BRONCHIAL

CERVIX

CSF

GASTRIC

NASOPHARYNGEAL

ORAL MUCOSAL TRANSUDATE

PLASMA

SERUM

STOOL

SPUTUM

THROAT

URETHRA

URINE

WHOLE BLOOD

FOOD-Specify:

OTHER-Specify:

TESTS THAT REQUIREMDCH APPROVAL

BACTERIAL TYPING-PFGE


BOTULISM TOXIN

MUMPS - PCR

MEASLES IgM

MUMPS IgM

NOROVIRUS PCR


PERTUSSISCULTURE

RUBELLA IgM

SALMONELLASEROTYPING

NON-HUMAN

TOXIC SHOCK TESTING

AFB NUCLEIC ACID AMPLIFICATIO

OTHER

HEPATITIS TESTING HEPATITIS C ANTIBODY

HEPATITIS B SURFACE ANTIGEN (H


HEPATITIS B ANTIBODY (Anti-HBsA

HEPATITIS A ANTIBODY (IgM)

NSTRUCTIONS FOR COMPLETION: Completely ll in the appropriate box. For example, upon completion the box should appear as, rather thanx.CH-0583 (1/9/2015) By Authority of Act 368, P.A

MICROBIOLOGY

AEROBIC ISOLATE ID


AFB SLIDE/CULTURE-CLINICAL

SPECIMEN

AFB IDENTIFICATION-ISOLATE ID

E. COLI (SLT) TOXIN & SEROLOGY

ENTERIC BACTERIAL CULTURE

FOODBORNE ILLNESS-Stool or Food


FUNGAL IDENTIFICATION Isolate ID

LEGIONELLACULTURE

NEISSERIA GONORRHOEAE-Isolation

NEISSERIA- REFERRED CULTURE

PARASITOLOGY - BLOOD

PARASITOLOGY - STOOL

PARASITOLOGY - WORM

PERTUSSISPCR

SALMONELLA/SHIGELLA SEROTYPING-HUMAN

VIROLOGY

ENTEROVIRUS PCR


RESPIRATORY PCR PANEL

INFLUENZA (PCR/CULTURE)


VIRAL CULTUREOTHER

AUTOCLAVE TEST STRIPS

LEGIONELLA- DFA

LYME DISEASE-IFA (Tick)


42/53

NDICATE TEST REASON

Diagnosis Surveillance Outbreak (complete Section 6) Other (Specify)

1 FOR: HEPATITIS B REQUEST COMPLETE THIS SECTION

Pregnancy (HBsAg) Exposure to someone with Hepatitis B?

2 FOR: SYPHILIS - DFA REQUEST COMPLETE THIS SECTION

Duration of Lesion Days Months Years Specify Site:

3 FOR: RABIES ANTIBODY SEROLOGY REQUEST COMPLETE THIS SECTION

Date of Last Rabies VaccinationM M D D Y Y Y Y

4 FOR: LYME BORRELIOSIS REQUEST COMPLETE THIS SECTION

Onset DateM M D D Y Y Y Y

State/County/Country of Exposure

EARLY DISEASE LATE DISEASE

Erythema Migrans (5 cm at least in diameter) Symptoms (Example- Rash, Fever, Headache, Joint Pain) Neurologic Cardiologic Rheumato

5 FOR: AEROBIC CULTURE REQUEST COMPLETE THIS SECTION

Aerobe Microaerophile Gram Positive Negative Variable Rod Coccus Diplococcus

Bacterial Growth Char.: MacConkey Pos Neg Oxidase Pos Neg Catalase Pos Neg Dextrose Oxidation Ferment

OTHER:

6 FOR: OUTBREAK INVESTIGATION COMPLETE THIS SECTION

Onset DateM M D D Y Y Y Y

Outbreak Identier

Organism Suspected (If Applicable)

MDCH Prior Approval: Name, Date or Code

7 FOR: INFLUENZA TESTING REQUEST (PCR/CULTURE) COMPLETE THIS SECTION

Date/Type of Last Inuenza VaccinationM M D D Y Y Y Y TYPE

Flu Mist Trivalent (Shot)

Other

CH-0583 (1/9/2015) By Authority of Act 368, P.A

8 ADDITIONAL INFORMATION


43/53

1


Sent:Friday,February20,201511:31AM

To:'[email protected]';[email protected]

Cc:'[email protected]'

;

Bolen,

Timothy

(DHHS)

;

Bohm,

Susan

(DHHS)

;Fiedler,Jay(DHHS);Collins,Jim(DHHS)

Subject:Finalquestionnaireandenvironmentalsamplingresource

HiShurooqandJim,

Iveattachedthefinalversionofthesupplementalquestionnaire.Wellbestartingourinterviewsnextweekonthe

caseswith6/1/1412/31/14MDSSreferraldates.

Fromourdiscussionyesterday,herestheCDCwebsitethathasenvironmentalsamplinginformationandprotocols:

http://www.cdc.gov/legionella/specimencollectmgmt/index.html

Pleaselet

me

know

ifthere

are

any

questions

or

theres

anything

else

Ican

help

with.

Thanks,

Shannon





Lansing,MI48913

Phone:517

335

8165

Fax:5173358263

MDCH documents the division of labor and the start of the interviewing pro

MDCH is also conducting medical record reviews on all cases to determine o

dates of illness as many of these were not completed by the Genesee County

Health Department and are necessary for establishing timelines, clustering

identifying any association with healthcare facilities.

MDHHS #11


44/53

MDSSID _____

Page1of6

LegionellosisQuestionnaire

GeneseeCounty,20142015

InterviewerIdentification

DateofInterview: InterviewersName:

HealthDept.: PhoneNumber: __ Email:

Whatwasthepatientsoutcome? RECOVERED STILLILL DIED UNK

PatientContactInformation

Name: ________ Age: Sex: M F

Streetaddress: City:

State: Zip: County:________________

DaytimePhone: EveningPhone:

SurrogateContact

Information

Name: ________

DaytimePhone: EveningPhone:_________________________________

RelationshiptoPatient:

Hello,mynameis andImcallingfrom (healthdepartment).

WeareinvestigatingaclusterofrespiratoryillnessesinGeneseeCounty.Atthispoint,thesourceof

theseillnessesisstillunderinvestigation.Wearehopingthisinterviewwillprovidefurther

informationandanswersabouttheillnesses.Idliketoaskyouafewquestionsaboutyourhomeand

yourexposures

during

the

2weeks

before

you

got

sick.

You

do

not

have

to

answer

any

of

the

questions,

butanyassistanceyoucanprovideisappreciated. Doyouhaveabout20minutestotalk? Ifnotnow,

whenwouldbeagoodtimeformetocallback?______________________________________

Itmightbehelpfulforyoutocollectdocumentssuchasacalendar,receipts,creditcardorbank

statementstojogyourmemoryaboutyouractivitiesandwhereyouwereinthe2weekspriortogetting

sick.Wouldyoulikemetocallyoubackafteryouhavetimetocollectthesematerials?Whenwouldbea

convenientdayandtimeformetocallyouback?____________________________________________

Ihavethatyourfirstsymptomstartedon . Isthiscorrect?

Yes No Notsure

Ifno,whatwasthefirstdateyoustartedfeelingsick?____/_____/______

List

dates

of

exposure

period:

from

_

/

/

to

_

/

/


45/53

MDSSID ___

Page2of

IllnessInformation

1.)Duringyourillness,didyouhaveanyofthefollowingsymptoms?

Checkone:

YES NO UNK

Ifyes,whendid

thissymptom

start?

Areyoustillill

withthis

symptom?

Diagnosisof

pneumonia

Fever

Ifyes,highesttemp:_____

Chills

Cough

Nausea

Lossofappetite

Vomiting

Diarrhea

Achesor

muscle

pains

Chestpain

Chestburning

Shortnessofbreath

Sorethroat

Headaches

Othersymptoms(specify):

ExposureInformation

2.)Howlonghaveyoulivedatyourcurrentresidence?__________________

a.) Ifyoumovedaftertheexposureperiod/illness,whatwasyourpreviousresidence

address?____________________________________________________________

3.)Wheredidyougetyourtap(drinkingandotherhouseholduse)waterfrombetween _ / /___

and _ / / ? 3.)

1.CityofFlintWater

2.City

of

Flint

Township

Water

3.Othermunicipalwatersystem

4.Privatewell

5.Unknown

6.Other______________________


46/53

MDSSID ___

Page3of

Exposure Date(s) ReasonforVisitName& Cityof Hospital/

Office/ClinicNameofDoctor

Inpatient Admission_______Discharge_______

Outpatient

Visitor

Employee

Volunteer

4.)Duringthelastyear,hasthewaterpressureatyourresidencechanged? Yes No NotSure

a.)Ifyes,didthewaterpressure: Increase Decrease

b).Ifyes,whendidthewaterpressurechangeoccur?________________________________

5.)Duringthelastyear,hasthewaterquality(appearance,taste,smell)atyourresidencechanged?

Yes No NotSure

a.)

If

yes,

please

describe

the

change

in

the

water

quality:_____________________________

____________________________________________________________________________

b).Ifyes,whendidthewaterqualitychangeoccur?__________________________________

6.)Priortoyourillness,didyoumakeanyrecentplumbingchangesorrepairsatyourresidence?

Yes No Notsure

a.) Ifyes,pleasedescribethechanges/repairsandgivethedatestheworkwasdone.

____________________________________________________________________

____________________________________________________________________

7.)Priortoyourillness,werethereanywatermainbreaksorotherwaterlineissuesthataffectedthe

waterat

your

residence?

Yes

No

Not

sure

a.) Ifyes,pleasedescribethewatermain/lineissuesandgivethedatestheyoccurred.

____________________________________________________________________

____________________________________________________________________

Idliketoaskyousomequestionsaboutwhatyoudidduringthe2weeksbeforeyougotsick.

ThetimeperiodImaskingaboutisbetween _ / /_ and _ / / .

Duringthis2weekperiod,didyou:

8.)

Work

or

volunteer,

either

full

or

part

time?

Yes

No

Not

sure


Jobdescription Company LocationAnyexposure to misty

water?

9.)Spendanytimeinahospital,doctorsoffice,clinic,ordentistofficeasapatient,visitor,employee,or

voluntee

Documents

MDHHS Legionnaires emails