1. MSIPC Fundamentals: Interaction between IPs and Local and State Health Departments
Joyce Lai, MPH– Michigan Department of Health and Human Services
Noreen Mollon, MS CIC– Michigan Department of Health and Human Services
October 21, 2015

2. Outline MDHHS Organization Communicable Disease Surveillance
Reportable Diseases
Michigan Surveillance Data Systems
MDSS
MSSS
Sentinel Surveillance for ILI
SHARP
Outbreak Response
Surveillance and Reporting
Prevention Initiatives
Other MDHHS Entities that frequently interact with IPs

3. MDHHS Vision Statement
MDHHS will promote better health outcomes, reduce health risks and support stable and safe families while encouraging self-sufficiency

4. and Community Services
MDHHS Organization
DIRECTOR
Chief Operating
Officer
Office of Inspector General
Aging and Adult Services
Financial
Operations
External Relations
And Communications
Population Health
and Community Services
Behavioral Health &
Developmental
Disabilities
Administration
Medical Services
Administration

5. Bureau of Disease Control, Prevention, and Epidemiology
MDHHS Organization
Population Health and Community Services Administration
Bureau of Disease Control,
Prevention, and Epidemiology
Bureau of Local Health
& Administrative Services
Bureau of Laboratories
Bureau of Family, Maternal
And Child Health
Bureau of EMS, Trauma and
Preparedness (formerly OPHP)
Bureau of Community Services

6. MDHHS Organization Bureau of Disease Control,
Prevention, and Epidemiology
Division of Environmental Health
Division of Genomics, Perinatal
Health, and Chronic Disease
Division of Communicable Disease
Division of Immunization
Surveillance Section
Surveillance of Healthcare-Associated
and Resistant Pathogens (SHARP) Unit
Regional Epidemiology
Unit

7. Communicable Disease Surveillance
Communicable disease reporting is required by Michigan law:
Michigan Public Health Act No. 368 Communicable Disease Rules: R ,
Rule revision allows the State the right to periodically update the list of reportable diseases
This reporting is expressly allowed under HIPAA
Hepatitis C Virus
Neisseria meningitidis
Histoplasma capsulatum
Bordetella pertussis

8. Why Communicable Disease Surveillance is Important
To identify outbreaks
To assure treatment, preventive treatment and/or education
To evaluate prevention and control programs
To help target prevention resources
To facilitate epidemiologic research
To assist national and global surveillance efforts
Chlamydia trachomatis
Influenza Virus
Mycobacterium tuberculosis
Salmonella sp.

9. Public Health Depends on Collaboration
Healthcare
Providers
Clinical
Laboratories
Local Health
Department
Isolates and specimens
sent to State Lab for
additional testing
State Health
Department
Centers for Disease
Control and Prevention

10. Communicable Disease Reporting Entities
Physicians*
Laboratories*
Hospital ICP
Private citizens
School systems*
Pharmacists
Veterinarians
Medical Examiners
Hospitals*
Child care facilities
Long-term care facilities*
Pre-hospital emergency services
Police
Fire
EMS
*Required to report

11. Communicable Disease “Brick Book”
The current 2015 version provides a good summary of the communicable disease rules, requirements, and responsibilities

12. Michigan Reportable Diseases
~90 disease/conditions are reportable in Michigan
Also reportable are ‘unusual occurrences’, outbreaks and epidemics of any disease or condition (including healthcare-associated infections)
Specific reporting rules and definitions can be found at
List available by condition or by pathogen

13. Case Rules and Definitions
Example of Streptococcus pneumoniae reporting algorithm

14. Case Rules and Definitions
Acute / Chronic Hepatitis C Reporting Flowchart

15. Timeliness and Completeness of Communicable Disease Reports
In general, all reportable diseases are required to be reported within 24 hours of confirmation
Report contents
Demographic info – name, date of birth, sex, race
Contact info – address, phone number
Disease details – onset date, lab results
Surveillance is only as good as the data received
The timeliness and effectiveness of public health responses are dependent on prompt and accurate surveillance reporting

16. Authority of State and Local HDs
Michigan is a “home rule” state, meaning local HDs have autonomy within their jurisdiction
The MDHHS operates independently from the local HDs
The primary role of the MDHHS in communicable disease control is to provide:
expert consultation
reference level diagnostics laboratory services
childhood vaccines
support local HDs upon their request
Maintenance and administration of the MDSS
All communicable disease reports should be reported to your local HDs

17. Map of Michigan Local HDs

18. Public Health Investigative Authority
State and local HD personnel are authorized to investigate reported diseases, including:
Contacting health providers
Conducting additional case-finding
Conducting epidemiological studies
Conducting specimen collection
Gathering information on medical history, lab results, diagnostic procedures, treatment, and health outcomes
The MDHHS works collaboratively with the local HDs and participates in investigations when requested

19. Confidentiality, HIPAA, and PHI
Disclosure of protected health information (PHI) to health authorities without individual consent or authorization is permitted when disclosure is required by law or is authorized by law for a public health purpose (
All information provided to public health authorities is kept confidential

20. Helpful Links www.michigan.gov/mdhhs
Click on ‘Providers’ and then ‘Chronic and Communicable Diseases’
- HIV/STD/Viral Hepatitis
- Communicable Disease resources, forms, links, reports, and publications
- Michigan Disease Surveillance System (MDSS)
Healthcare-Associated Infection Surveillance & Prevention

21. Michigan Surveillance Systems
Michigan Disease Surveillance System (MDSS)
Michigan (Emergency Department) Syndromic Surveillance System (MSSS)
Sentinel Surveillance for Influenza-Like Illness

22. Disease Detection/Reporting Timeline
Symptom
Onset
Seeking of
Medical Care
Reported
to Local HD
Reported
to State HD
Exposure
Diagnosis
Time
ED Syndromic
Surveillance
Michigan Disease
Surveillance System

23. Michigan Disease Surveillance System
Web-based communicable disease surveillance system
Disease can be reported 24/7 from your computer
Used to facilitate coordination between local, State, and federal public health agencies
Streamlines disease reporting; more efficient and closer to real-time
Allows for more timely public health interventions
Reduces delays in public health follow-up by grouping disease based on county of patient residence

24. Michigan Disease Surveillance System
Data in the MDSS can be accessed and edited by multiple parties which facilitates the sharing of information without requiring multiple phone calls
Allows for instantaneous retrieval of summary reports
MDHHS Weekly Surveillance Report (
Data sent to CDC National Notifiable Disease Surveillance System (NNDSS – for Morbidity and Mortality Weekly Reports (MMWR –

25. MDSS Reporting Pathways
Community
Physicians
Infection
Preventionists
Hospital Labs
Local Health Department
MDSS
Case Follow-up
Local Surveillance
Electronic Reports
CDC
MDHHS
National Notifiable
Disease Surveillance
System (NNDSS)
Morbidity and Mortality
Weekly Report (MMWR)
Statewide Surveillance
Weekly Surveillance Reports (WSR)

26. Adding/Editing Cases in MDSS

27. Searching Records in MDSS

28. Pulling MDSS Data

29. Pulling MDSS Data

30. Individual Case Reports
MDSS Statistics
Year
Referrals
Individual Case Reports
Transactions
Unique User
Log Ins
2007
83,876
77,686
400,000
----
2008
136,057
104,616
429,848
783
2009
160,326
119,843
618,731
893
2010
158,225
113,765
697,258
906
2011
213,639
159,185
803,092
982
2012
211,150
146,069
1,018,304
1,126
2013
185,362
126,812
1,059,023
1,155
2014
174,237
134,896
1,245,493
1,218

31. MDSS System Use Statistics

32. More Info on the MDSS http://www.michigan.gov/mdss (517) 335-8165
Contact:
Your Local Health Department Communicable Disease Program
Your Regional Epidemiologist
Edward Hartwick, MS, MDSS Coordinator
(517)

33. Michigan (Emergency Department) Syndromic Surveillance (MSSS)
A surveillance system that detects and tracks the chief complaints of ED patients throughout the state
Chief complaints are classified into syndromic categories that could indicate a possible public health emergency
Web-based application displays the data in real-time
Alerts are automatically sent when rates of a given syndrome are detected to be higher than the predicted norm

34. MSSS # of facilities: 95 # of users: 173
# of referrals per day, Statewide: 12,343
# of referrals per day, per facility: 130

35. MSSS Data Each message sent to the MSSS consists of:
Demographics: date of birth, sex
Residence: home zip code
Visit Info: date, time, class (e.g. urgent care, ER)
Chief Complaint

36. MSSS Chief Complaints
Chief complaints are classified into the following syndromes:
Hemorrhagic
Botulinic
Neurological
Other
Default
Gastrointestinal
Constitutional
Respiratory
Rash

37. MSSS Classification Examples
Chief Complaint
Syndrome
“slurred speech”
Botulinic
“general weakness”
Constitutional
“stomach pain”
Gastrointestinal
“difficulty breathing”
Respiratory
“nose bleed”
Hemorrhagic
“headache”
Neurological
“hives and itching”
Rash
“right foot injury”
Other
“med refill”
Default

38. MSSS Alerts A detection algorithm monitors the data hourly
An alert is sent to State and regional epidemiologists if an aberration is detected
If the actual value of a syndrome exceeds the predicted value for a given syndrome in a geographic area
Users can view the data in charts, graphs, or maps

39. Use of MSS Data Early detection of outbreaks
Enhanced surveillance during high-profile events:
World Series
Super Bowl
MLB All-Star Game
Final Four
Detroit Auto Show
Seasonal influenza monitoring
Situational awareness

40. Sentinel Provider Surveillance for Influenza-Like Illness (ILI)
Michigan component of the CDC U.S. Outpatient Influenza-like Illness Surveillance Network
Influenza sentinel reports provide data on over 12,000 outpatient office visits per week and are an important part of influenza surveillance in Michigan
Contact Stefanie Cole at or for more information

41. Michigan Influenza Sentinel Hospital Network
MDHHS is working to establish a network of sentinel hospitals that report influenza-associated hospitalizations
Hospitals that agree to participate would be asked to provide:
Weekly report consisting of the number of influenza-associated hospitalizations in each of five age categories
Total number of admissions during that time frame
Contact:
Seth Eckel

42. Surveillance for Healthcare-Associated and Resistant Pathogens (SHARP) Unit
Objectives of the SHARP Unit:
Coordinate activities related to HAI surveillance and prevention in Michigan
Improve surveillance and detection of antimicrobial-resistant pathogens and HAIs
Identify and respond to disease outbreaks
Use collected data to monitor trends
Educate healthcare providers, state and local public health partners, and the public on HAIs

43. SHARP Activities Outbreak Response Surveillance and Reporting
SHARP Activities
Outbreak Response
Surveillance and Reporting
CRE Surveillance and Prevention Initiative
Consulting/Education
Staphylococcus aureus
Klebsiella pneumoniae
Clostridium difficile

44.
Outbreak Response
The MDHHS SHARP staff are available to offer our services and expertise in healthcare-associated outbreak investigations
MDHHS can help facilities coordinate molecular testing with the MDHHS Bureau of Laboratories to identify genetic-relatedness between patient isolates (at no cost)
Acinetobacter baumannii

45. Recent Outbreaks Investigated by SHARP
Recent Outbreaks Investigated by SHARP
Mycobacterium chelonae associated with tattoos
Community-onset, invasive MSSA infections
Ventilator-associated Stenotrophomonas maltophila
Clostridium difficile in a long-term care facility
Serratia marcescens SSIs post-cardiac surgery
Pseudomonas aeruginosa SSIs post-cardiac surgery
Pseudomonas aeruginosa respiratory infections associated with contaminated transesophageal echocardiogram (TEE) gel
Healthcare-associated Hepatitis C Virus (HCV) related to drug diversion
Multidrug-resistant Pseudomonas aeruginosa urinary tract infections associated with cystoscopy procedures in an outpatient urology clinic
First New Delhi Metallo-beta-lactamase-1 (NDM-1) detected in Escherichia coli (CRE)

46. Surveillance and Reporting
Surveillance and Reporting
Vancomycin-Intermediate Staphylococcus aureus (VISA) and Vancomycin-Resistant Staphylococcus aureus (VRSA) are required to be reported according to the communicable disease rules
Unusual occurrences and outbreaks of HAIs are also mandated by law to be reported
However, individual HAIs (like a CLABSI), are not required to be reported to state or local health departments

47. Surveillance and Reporting
Surveillance and Reporting
33 states have laws requiring HAIs to be reported to state health departments, the majority of which publically release hospital HAI rates (

48. Surveillance and Reporting
Surveillance and Reporting
In Michigan, hospitals can voluntarily report HAIs to MDHHS SHARP via the National Healthcare Safety Network (NHSN)
NHSN is a web-based surveillance program designed by CDC:
Uses standardized HAI surveillance definitions
Users can enter and analyze HAI data
The data sent to SHARP from Michigan hospitals are de-identified and the numbers aggregated for the purposes of producing state-wide HAI surveillance reports

49. Surveillance and Reporting
Surveillance and Reporting
HAIs tracked by MDHHS SHARP surveillance:
Central Line-Associated Blood Stream Infection (CLABSI)
Surgical Site Infection (SSI)
Catheter-Associated Urinary Tract Infection (CAUTI)
Ventilator-Associated Events (VAE)
Clostridium difficile LabID surveillance
MRSA LabID surveillance
Antimicrobial resistance in select pathogens

50. HAI Surveillance SSI CLABSI VAP CAUTI CDI LabID MRSA LabID
Surgical incision showing signs of infection
Subclavian central venous line
VAP
CAUTI
Foley catheter insertion kit
Mechanical ventilator
CDI LabID
MRSA LabID
Clostridium difficile
Staphylococcus aureus

51.
SHARP Surveillance
Currently there are 104 Michigan hospitals sharing HAI data with SHARP, with all 104 hospitals releasing their data to the Michigan Health and Hospital Association (MHA) Keystone Center, and 14 hospitals releasing their NICU data to the Vermont Oxford Network (10/7/15).

52. SHARP Surveillance
86 of 109 (79%) of Acute Care Hospitals in Michigan are sharing data
17 of 36 (47%) of Critical Access Hospitals in Michigan are sharing data
1 of 4 (25%) of Rehab Hospitals in Michigan are sharing data
Total: 104 of 168 (62%) of hospitals
“A Critical Access Hospital (CAH) is a hospital certified under a set of Medicare Conditions of Participation (CoP), which are structured differently than the acute care hospital CoP. Some of the requirements for CAH certification include having no more than 25 inpatient beds; maintaining an annual average length of stay of no more than 96 hours for acute inpatient care; offering 24-hour, 7-day-a-week emergency care; and being located in a rural area, at least 35 miles drive away from any other hospital or CAH (fewer in some circumstances). The limited size and short stay length allowed to CAHs encourage a focus on providing care for common conditions and outpatient care, while referring other conditions to larger hospitals.” (
LTAC: “A long term acute care facility is a specialty-care hospital designed for patients with serious medical problems that require intense, special treatment for an extended period of time—usually 20 to 30 days. Long term acute care facilities offer more individualized and resource-intensive care than a skilled nursing facility, nursing home or acute rehabilitation facility. Patients are typically transferred to a long term acute care hospital from the intensive care unit of a traditional hospital because they no longer require intensive diagnostic procedures offered by a traditional facility.” (

53.
SHARP Reports
SHARP releases state-wide HAI reports quarterly, semiannually, and annually which are posted at
All hospital data are de-identified and aggregated
Individual hospital data is not made public
SHARP also compiles hospital specific HAI reports which are only shared with those individual hospitals

54.
SIR
Standardized Infection Ratio (SIR) is a ratio comparing the number of observed infections to predicted infections. It controls for variables such as bed size, location type, medical affiliation, and procedure type (for SSIs only).
The number of expected or predicted infections comes from national baseline data.
SIR=Number of Observed Infections
Number of Expected Infections
*=Significantly different from 1
**=Significantly different from previous report

55. Cumulative Attributable Difference (CAD)
TAP reports use the cumulative attributable difference (CAD) to rank hospitals
CAD is generally calculated based on a target or goal SIR
Michigan reports use the HHS Target SIR
CAD = Observed – (Predicted * SIRtarget)
Interpretation:
CAD>0 = “more infections than predicted” OR “number of infections needed to be prevented to reach the HHS target SIR”
CAD<0 = “fewer infections than predicted” OR “number of infections prevented beyond the HHS target SIR”
Courtesy of Allie Murad

56. TAP Reports
Targeted Assessment Prevention (TAP) reports gives hospitals a way to target problem areas and see where they rank within a group
 The group is the SHARP-participating Michigan hospitals.
Courtesy of Allie Murad
Source:

57. Courtesy of Allie Murad

59.
SHARP HAI Data

60. 2014 Device-Associated SIRs
2014 Device-Associated SIRs

61.
2014 LabID SIRs

62. CRE Surveillance and Prevention Initiative
Staphylococcus aureus
SHARP also has started a prevention initiative aimed to reduce the incidence and prevalence of MDROs in healthcare facilities in Michigan:
Carbapenem-Resistant Enterobacteriaceae (CRE) surveillance and prevention initiative
Citrobacter freundii
Escherichia coli
Klebsiella pneumoniae
Enterobacter cloacae

63. CRE Surveillance and Prevention Initiative
CRE Surveillance and Prevention Initiative
2011
Awarded ELC funding
Hired CRE Coordinator
2012
Met with 8 healthcare systems across the state
Developed detection and infection prevention practices survey
Formed Collaborative group
Recruited 21 facilities
Surveillance began September 1, 2012
CRE Educational Conference Kick-off!
2013
Baseline surveillance ends February 28, 2013
CRE Prevention Plans implemented March 1, 2013
2014
Recruited 9 new facilities and maintained all current facilities for Phase 2
Phase 1 ends August 31, 2014
Phase 2 begins September 1, all CRE Prevention Plans implemented
2015
Surveillance continues
Prevention continues
Confirmatory testing, regional incidence, geography, and interest will drive recruitment for Phase 3 in early 2016…
In 2011, Michigan was funded through Epidemiology and Laboratory Capacity (ELC) for Infectious Diseases grant from CDC to begin a CRE Surveillance and Prevention Initiative. Coordinator hired in the fall of 2011 and through the spring 2012, we conducted surveys, formed collaborative group, recruited facilities and began surveillance in September 2012.
Planning Stage
Baseline Stage
Intervention Stage

64. CRE Incidence in Michigan- Phase 1
327 total cases – 284 inpatients
Baseline (Sept 2012 – Feb 2013)
102 cases (89 inpatients)
957,220 patient-days
0.93 cases per 10,000 p-d
Intervention (March 2013 – August 2014)
225 cases (195 inpatients)
2,791,350 patient-days
0.70 cases per 10,000 p-d
327 total cases… can only calculate incidence on 284 (other cases are outpatients/referrals)
Rate difference between baseline and intervention (p=0.03) is statistically significant!! Mid-P exact

65. Successes the first 2 years
Established a baseline incidence rate for CRE
September 2012 – February 2013
0.93 cases per 10,000 p-d
CRE incidence rate decreased during intervention period
March 2013 – August 2014
0.70 case per 10,000 p-d
Statistically significant (p=0.03)
Michigan prevented 86 infections of CRE
26 infections of CRE prevented in LTACs
Baseline 0.93 / Intervention 0.70 (p=0.03)

66. Past, Present, and Future
Phase 1
Phase 2
Phase 3
Time Period
September 2012 – August 2014
March 2014 – February 2016
September 2015–August 2017
# Acute Care Facilities 17 24
# Long-Term Acute Care Facilities 4 6
# CRE Prevention Plans 34 43
Baseline Incidence Rate
0.93
0.94
Post-Intervention Incidence Rate
0.70
0.73
# Infections Prevented 86
(26 in LTACs)
* 80
(10 in LTACs)
Won’t start recruiting until early 2016…
* Data as of 4/2015 (work in progress)

67. Education and Consulting
Education and Consulting
Another primary focus of the SHARP unit is increasing awareness of HAIs, answering FAQs, and disseminating best-practice and evidence-based recommendations and guidelines
Examples of entities/persons that ask for our guidance:
IPs
Gyms
Local HDs
Correctional Facilities
Healthcare workers
Students
Schools
Public

68. Special Collaboration
Special Collaboration
SHARP collaborates with the MDHHS Viral Hepatitis Unit:
Investigating potentially healthcare-related viral hepatitis infections (e.g. David Kwiatkowski)  
Works jointly on injection safety-related educational campaigns (e.g. One and Only campaign)
Contact information
(517)

69. SHARP Unit Contacts (517) 335-8165 www. michigan
SHARP Unit Contacts (517)
Jennie Finks, DVM, MVPH – HAI Coordinator and Unit Manager
Mike Balke, MPH- CSTE HAI fellow
Jennifer Beggs, MPH – Infectious Disease and Preparedness Epidemiologist
Brenda Brennan, MSPH – CRE Prevention Initiative Coordinator
Allison Murad, MPH – National Healthcare Safety Network (NHSN) Epidemiologist
Noreen Mollon, MS CIC – Infection Prevention Consultant

70. Other MDHHS Entities that Interact with IPs
Bureau of Labs (BOL)
Office of Public Health Preparedness (OPHP)
Licensing and Regulatory Affairs (LARA)
Michigan Occupational Safety and Health Administration (MIOSHA)
Healthcare Facility Engineering
Michigan Care Improvement Registry (MCIR)

71. MDHHS Bureau of Labs (BOL)
Main Phone: (517)
Tours available quarterly, to schedule call (517)

72. MDHHS BOL Testing www.michigan.gov/mdhhslab
List of Tests performed
By MDHHS BOL
Forms required to
Request testing

73. Regional Reference Labs
Report Suspected Bioterrorism:
Lansing: (517)
Kalamazoo: (269)
Grand Rapids: (616)
Saginaw: (989)
Oakland County: (248)

74. Bureau of EMS, Trauma & Preparedness
Formerly OPHP, BTEP combines the OPHP with EMS and Trauma. This bureau will better serve the citizens through administration and continuous improvement of emergency medical services, trauma system as well as all-hazards preparedness planning and response
Division of Emergency Preparedness and Response (DEPR)
Division of EMS and Trauma

75. Michigan Emergency Management System
President of US
Governor
Michigan State Police
State Director of Emergency Management
DHS / FEMA
Emergency Management
Division (EMD)
MDHHS
EMD District
Coordinators
Health Preparedness
Regions
Local Emergency
Management
Local Health
Departments
All emergencies and disasters are local

76. Emergency Preparedness Collaboration
Utilities
Transportation
Emergency
Management
Fire &
Rescue
Public
Health
Hospitals
EMS
Law
Enforcement
Public Works
Industry /
Private Sector

77. Emergency Preparedness Training MI-TRAIN (http://mi.train.org)

78. Emergency Preparedness Communication
Statewide communication capabilities:
Michigan Statewide Comprehensive Interoperable Communication Plan
Public Health Safety Communication System
(800Mhz radios)
Health Alert Network (HAN)

79. MI HAN (https://michiganhan.org)

80. Emergency Preparedness Regions
8 Michigan Emergency Preparedness Regions:
Modeled after State Police Regions
Encompass 45 Local HD Emergency Preparedness Centers
Each Region contains:
Medical Director
Hospital Bioterrorism Coordinator
Epidemiologist

82. Strategic National Stockpile
Able to distribute large quantities of pharmaceuticals and medical supplies during an emergency
Local HDs and hospitals are prepared to receive MISNS assets
MISNS is capable of delivering assets via ground or air transport

83. BTEP Contacts
Linda Scott – Division of Emergency Hospital Preparedness Coordinator
(517)
Mary Macqueen – Public Health Preparedness Coordinator

84. MIOSHA – Michigan Occupational Safety and Health Administration
MIOSHA operates under Licensing and Regulatory Affairs (LARA)
For healthcare inquiries contact MSIPC’s MIOSHA liaison Eric Zaban:
(517)
For general consultation and/or training contact:
(517)

85. LARA- Health Facilities Engineering
Provide enforcement and interpretation of the minimum healthcare facility design standards to reduce the risk of transmission
Kasra Zarbinian
(517)

86. Michigan Care Improvement Registry (MCIR) www.mcir.org
Web-based system created in 1998
to collect children’s immunization
information
Expanded in 2006 to include adults (lifespan registry)
Consolidates immunization information from multiple data sources and provides immediate, real-time, patient immunization history
Assists with all-hazard preparedness by tracking vaccines and medications during a public health emergency

87. MCIR Activity 9 million records Over 83 million shot records
29,000 registered users
5,500 active provider sites

88. The Benefits of MCIR High healthcare provider participation (90%)
Reports indicate ‘pockets of need’
Flexibility, allowing linkages with other public health systems
Types of information available in MCIR:
Patient Immunization status at time of visit
Reminders/recall letters
Coverage level reports
High risk influenza
Newborn screening
Lead results
Early hearing detection and intervention (EHDI)

89. Immunization Information
Annual Fall Conferences –
AIM Kits –
Influenza information “FluBytes”–
Quarterly Newsletters – send an with SUBSCRIBE in the subject line to
Beatrice Salada, State MCIR Coordinator

90. Thanks! Questions or comments? Joyce Lai Noreen Mollon (734) 727-7204
Noreen Mollon
(517)