Suzanne Cupal

Sure! | will be happy te take a look! Stay tuned... tam looping back in the ather folks fram our team, as well as Jay. | think they fell off the exchange when | had to resend that initial email to you, Suzanne. My apologies! Suzanne, you mentioned that Manday we will be talking abaut next steps. Somewhere earlier in that email exchange there was something about the 2 hospitals that Marc Edwards tested. Were they positive for Legionella? Just to catch us up fo speed, could either of you give us a quick rundown af: « What's happened in the interim since aur call December 107 « What are the Legionella-specific activities taking place currently? e What kind of next steps are you hoping to define? Epi investigation? Environmental investigation? Remediation? Phope | arm not making things more complicated. We just want the conversation te be as productive as possible... the more we understand about the current situation and needs beforehand, the better prepared we can be. Again, thank you! Laura Laura Cooley, MB, MPHTM Legionellosis Surveillance & Qutbreak Response NCIREV/DBD/ Respiratory Diseases Branch Centers for Disease Control and Prevention 2600 Clifton Road, M5 C-25 Atlanta, GA 20329 Tek: 404.639.2096 Fax: 404,315 4686 E-mail: LCooleviGede coy

michizan.goy)" "Lytle, Darren" <[email protected]>, "Fiedler, Jay (CDC michigan.zay)" <[email protected]>, "LaRocco, Toni™ <[email protected]>, "Henry, James" <[email protected]>, "Johnson, Mark (ATSDR/DCHI/CB)" <[email protected]>, "'Valacak, Mark" <MYALACAK@echdus>, "Johnson, Shannon (DHHS)" "Miller, Corinne (CDC michizan.gov)" <[email protected]>

FYLics Suzanne Cupal, MPH. Public Health Supervisor Genesee County Health Department 630 S. Saginaw Street Suite 4 Flint, Mi 48502 (810) 758-7970 [email protected]

Sent from my iPad xxxEND_PAGE:dhhs02_b0430_1626_1628_2 001628 Begin forwarded message: Healthy Diet 504857 7. pdf www. Water-FightLead-Healthy Diet 504857 7.pdf attp/Avww mm 504857 7 pdf I thought we agreed - no unfiltered tap water for washing food or cooking. Where did this one minute flush before using tap water recommendations come from. See attached document linked to the Genesee county website- simple steps you can take ,bullet point 7. We cannot use this in Flint without editing. My plan was to use this in a Community Ed talk since the pictures and layout were so eye appealing .We will have to review all handouts. Believe me, I am not interested in playing gotcha. We need a consistent ,accurate message for Flint residents on all water materials, not general advice. xxxEND_PAGE:dhhs02_b0430_1626_1628_3

(CDC/ONDIEH/NCEH) <zse1. Gicele.gov>; Johnson, Mark (ATSDR/DCHI/CB) <[email protected]>; Valacak, Mark <MVALACAK @echd.us>; Henry, James <[email protected]>; LaRocco, Toni <[email protected]>; Fiedler, Jay (CDC michigan.gov) <fledieri@ michigan. goy> OK, fet’s go ahead and schedule for Thurs Bec, 10 at 9:00 AM Eastern. ode: i. Here is a proposed agenda... fed free to weigh iron other items we should discuss. Specific to Legionnaires’ disease: What type of assistance Uf any} is being requested? (State and County HD) -jAihat is the role of £PA and what assistance has bean provided so far? {EPA} What is the role of ATSDR and what assistance has been provided so far? (ATSDR) if additional federal assistance is needed, what can COC offer? (COC) Thanks everyone! Laurel xxxEND_PAGE:dhhs03_b0210_0805_0807_3

Julie Borowski just forwarded their summary report. It does not address all of our questions, but it is a good starting point. Please review and let’s discuss outstanding questions so we can address them with her. Suzanne Suzanne Cupal, M.P.H. Public Health Supervisor Genesee County Health Department 630 S. Saginaw Street Suite 4 Flint, Ml 48502 (810) 768-7970 1 xxxEND_PAGE:dhhs03_b0315_1164_1164_1

Mr. Prysby- GCHD is pulling together a meeting with local hospital infection control staff so they can connect with you and City of Flint water staff members so you can provide them an update on current water treatment procedures and concerns regarding lead in water. We would greatly appreciate your attendance on Friday, October 23" at 11:30am in the private dining room of the Masonic Temple in downtown Flint. Please let me know if you are available to attend. Thank you. Suzanne Cupal Suzanne Cupal, M.P.H. Public Health Supervisor Genesee County Health Department 630 S. Saginaw Street Suite 4 Flint, MI 48502 (810) 768-7970 xxxEND_PAGE:deq16_b5_0892_4900_0004

Susan Sased on our conversation with you yesterday, | am forwarding our plan for any future Leg) weather months agpreach, Once we have a Legionella case identified: ® €nter the case in MDSS within 24 h of notification if not already entered by provide » Email Regional Epidemiologist with MBSS aumber ¢ Call hosnital to verify that a respiratory specimen was collected fer culture within 24 h of notification s if Legionella lalate was found, verify that the hospital will send to BOL {see above for more details on this} *® Using the enhanced Legionella Disease Questionnaire, conduct interview as quickly as possible with case or proxy and upload to MOSS record when completed (We would like to review the current Legionelia questionnaire with input frorn our state and CDC colleagues as we examine the current questionnaire data from the investigation so far...so we can make appropriate adjustments ~ good idea} s Based on Information collected fram interview, evaluate with investigation team if enviranmental samples from the home should be collected. We think we have a salution for the environmental sampling. Gur on-site CDC EIS Officer may be willing te assist Jim Henry with the sampling. Logistically & would be difficult for a COC Epi aid team lo came in and sample # these cases continue to trickle in,. e Continued analysis of existing data ® Continue conversations with our state and CDC colleagues and other experts that may assist the investigation(s). 4s we shared in our canversation yesterday, Shuroog is reviewing the previous 5 years Legionelia cases to examine the number of cases that live in the City of Flint vs. other areas. We will also be reviewing syndromic surveillance data for the same time frame for respiratory, skin rash and gastrointestinal Hiness. Our concerns moving forward are: &; Collection of clinical sarnples- based on the comments from the CDC about collection of samples being an art as ' well as a science, we want to make sure we collect appropriate samples, The COC has aiready provided a change te the protocol with the request for frozen samples. [see above] ® Collection of environmental samples- GCHD staff members have not had experience collecting these types of environmental samples ~ see above. * Access te information. We have shared our concerns regarding obtaining information to assist our investigation As always, do not hesitate connecting with us if you need additional information, We want to ensure clear and continual communication as we move forward. Thank you. Suzanne xxxEND_PAGE:dhhs03_b0909_3200_3205_3 003203 xxxEND_PAGE:dhhs03_b0909_3200_3205_4 003204 ort Ge f u i eae 8 chy Rapartrran me Mi ERB BAG) 7EBI SPD scupai@iachd us xxxEND_PAGE:dhhs03_b0909_3200_3205_5 003205 ye ncanaewiearean tine xxxEND_PAGE:dhhs03_b0909_3200_3205_6

irritation and tap water quality UK Drinking Water.pdf; SF Water 2013 Chloramines and skin irritation.pdf; Weintraub 2006 Hetergeneous dermatitis complaints after change in DW treatment Env Hith.pdf Hi Suzanne Thank you for the information on Legionella. For the non-lagionaila water issues, here are same documerts that might assist with thinking about complaints related to drinking water. The 2007 investigation in Vermont has some questions designed to assess health effects such as darrnatitis that might be helpful. However that investigation was very difficult, partly because some members of the community and outside groups attempted to Influence the results of the investigation. If you want te discuss that investigation further, | can contact the staff whe participated for their feedback. Hf you want to pursue these other complaints, it would be good to gather standard inforrnation on each cornplaint and categorize by syndrome, time, location, etc. You might already being doing this. We previously discussed syndramic surveillance; lam glad to discuss that further if you are interested. We don’t have experience doing that type of analysis in this situation but there might be athers who da. Regards Jonathan

Attached is additional information Shurood prepared yesterday to supplement cur conversation Information, it includes the number of canfirmed Legionella cases in Genesee County by calendar year. To clarify, the number we quoted for 2013 yesterday reflects our fiscal year which is October 2012-3013 and included confirmed and suspect cases. 1 xxxEND_PAGE:dhhs03_b0323_1188_1196_1 001189 Suzanne Cupal, M.PLH. Public Health Superviser Genesee County Health Department 630 S. Saginaw Street Suite 4 Flint, Mi 48502 (819) 788-7970

Thank you Susari and everyone for your work on this and for sharing your findings thus far, i will forward this te the rest of the group here, and we'll talk to you tornorrow at 9. laurel

Hello, Attached please find the survey data of cases interviewed by MDHHS and Genesee Co HD so far (Epiinfo analysis} and updated info on the investigation (MDHHS Prelim Stats}. We've included an agenda to help guide tomarraw morning's cali. Call dgenda Summarizing the ® Prehminary Statistics MBHHS (Shannon & Susan} e interview Data MDHHS {Lily & Meghan} o EPI info Analysis @ £Pi Curve GCHD e © Biscussion of Current investigation Au Environmental investigation e Environmental Sampling Protocal cb xxxEND_PAGE:dhhs03_b0323_1188_1196_2 001190 e Piscussic All Additional Recommendations # Additional Recornmendatians COC/AH THi tomorrow then, Susan Bohm, M5 Manager, Enteric & Respiratory Hinesses Epidemiology Unit Surveillance and infectious Disease Epicerniology Division of Communicable Disease Michigan Department of Health and Hurnan Services 201 Townsend 3t, Sth Fir Lansing, Mi 48933 (sh and may iden sd fcs ithe senda! nf vephy e-rail ard

Thanks, Suzanne. in just looking at this quickly, Pr wondering Hf you can you break down the epi curve in the following ways: -~Colar code the cases with exposure to McLaren during their incubation periods --Color code by sorne kind of indicator of exposure to Flint water (maybe G.3?). You've probably already looked at this in several different ways, and | think there are other ways to took at it as well, but perhaps that might help us. Thanks!

| ust forwarded information. Please let us know if there is anything else we can share. Suzanne Cupal, MPH, Public Health Supervisor Genesee County Health Department 630 &. Saginaw Street Suite 4 xxxEND_PAGE:dhhs03_b0323_1188_1196_3 001191 Flint, Mi 48502 {810} 788-7970 soupal@achd us

Hi all, dust checking in to see whether you expect to send any ep! data to help guide the discussion tomorrow. ifwe could review it prior to the call] think that would help facilitate the call and ensure we make the must of our time. Thanks! Laurel

Hello, Yes, 9:00 or 9:30 on Thursday works for us. Let us know the final details when they're decided. O# the topics mentioned below, at this point in time it would be best to focus or: » the current investigation, e® CDC walk-through of the environmental sarnniing protecal, @ anda discussion of any additional recommendations. it's very likely that these topics wil fil our allotted time. There’s no need te discuss the clinical specimen collection and guidance that has already been provided to GCHD and sent te local providers. The syndramic surveillance data project 4 xxxEND_PAGE:dhhs03_b0323_1188_1196_4 001192 would be better handied at the focal/state level and should not take away from the ongoing epi investigation that we're currently assisting GCHD with. Thanks, and we look forward te hearing from you. --fay Jay Fiedler, MS Section Manager Surveillance and Infectious Disease Epidemiology Bureau of Disease Control, Prevention, and Epidemiology Michigan Department of Health and Hurnan Services 201 Townsend St - PO Box 301795 - Lansing, ME 48909 P) 517, 335.9516 - E: fledleriGimichigan.gov 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.

Thursday morning works for us. Suzarine Cupal, MPH. Public Healin Supervisor Genesee County Health Department 630 S. Saginaw Sireat Sule 4 Fini, Mi 48502 {810} 788-7970 scupal@achd us

xxxEND_PAGE:dhhs03_b0323_1188_1196_5 001193 Hi Suzanne, Yes, let’s try to schedule something for this week. Would Thursday morning work for everyone? Yes, it would be helpful to be able to review your epi curve, questionnaire results, ete. prior to the call, Thanks, Laurel

Hi Suzanne, lmet with colleagues and leadership at CDC, and we are very concerned about this Legionnaires’ disease outkreak. it’s very large, one of the largest we know of in the past decade, and community-wide, and in our opinion and experience it needs a comprehensive investigation. i know you all have been working on this for quite a while, but we are unclear 6 xxxEND_PAGE:dhhs03_b0323_1188_1196_6 001194 about which steps have been taken and what is currently known, and we feel a sense of urgency. is it possible to meet before May 8? it's difficult to give advice when we don’t have ali the information, but we are eager to help. You may have already taken several of these steps, but we recornmend a full investigation including the following steps: ~-Generate an epi curve, man the cases, interview ali cases with a hypothesis-generating questionnaire, analyze results

Hello Suzanna, Looking at our schedules, we have limited availability of our core staff here at DHHS an Friday May 8°. In order to help prioritize or to determine if we should iook fer an alternate meeting time, can we get an idea of what the agenda will be for this call? Thanks, -lay Jay Fiedler, MS Section Manager xxxEND_PAGE:dhhs03_b0323_1188_1196_7 001195 Surveillance arid Infectious Disease Epidemiciogy Bureau of Disease Contra, Prevention, and Epidernicioay Michigan Departraent of Health and Human Services 204 Townsend Sk - PO Box 30795 - Lansing, MF 48909 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.

Our team is available an Friday, May 8° at Llam if that would work for you and our state colleagues. Thank you for your assistance. Suzanne Suzanne Cupal, LPH. Public Health Supervisor Genesee County Health Department 830 S. Saginaw Street Suite 4 Flint, Mi 48502 (819) 768-7970 scupal@achd us

Hi Suzanne af al., Hf you are interested in discussing the Legionella action items in more detail, please let me know your availability for a conferance call involving the county, state, and RDB. Rest regards, Laurel Laurel Garrison, MPH Legionellosis Surveillance & Outbreak Resporse NCIRD/DBD/Respiratory Diseases Branch Centers for Disease Control and Prevention 1600 Cifton Rd, ME MS C-25 Atlanta, GA 30333 404.639.3434 fLaes@icde gov xxxEND_PAGE:dhhs03_b0323_1188_1196_8 001196

Hi Suzanne It was good to speak to you yesterday. | am copying Laurel on this email as the contact for the legionella program. She will coordinate with the state to make sure you have the protocols. We are glad to assist. Jonathan Sent from my iPhone Jonathan- Thank you and your team for the opportunity to speak yesterday. We appreciate your comments about a measured response. We recognize we do not have the data we need for further action. We were grateful for the opportunity to share with you and our state colleagues our concerns based on the information we do have. We are doing everything we can to mitigate risk to our residents. We look forward to receiving the sampling protocols and advice related to syndromic surveillance. Our concerns have now been communicated which opens the door to further communication as events unfold. We are dealing with complex and confounding information. We appreciate your assistance in gathering the facts. We want to be prepared to protect the health and safety of our residents and provide appropriate information. Thank you again. Your Genesee County Colleagues Suzanne Cupal, M.P.H. Public Health Supervisor Genesee County Health Department 630 S. Saginaw Street Suite 4 Flint, MI 48502 (810) 768-7970 xxxEND_PAGE:dhhs03_b0323_1188_1196_9