Legionnaires’ disease timeline

2013

Michigan Department of Health and Human Services data show 56 people died in Genesee County from pneumonia or influenza in 2013. This same year, eight other people in Genesee County are confirmed as contracting Legionnaires’ disease, though it was not widely publicized.

2014

April 25: Flint begins using the Flint River as its primary source of drinking water.

June 6: The first recorded Legionnaires’ disease case in the Genesee County outbreak is discovered. It’s unclear whether that first case involved a patient at McLaren Regional Medical Center, but a hospital spokesperson later told the Detroit News that McLaren first noticed an uptick in Legionnaire’s cases in the spring of 2014, a year before Bertie Marble entered the hospital.

August 2014: McLaren said this is when it found “a low level of legionella” bacteria in its water system. The hospital said it “put immediate measures in place that were successful in controlling the situation.”

End 2014: Michigan Department of Health and Human Services data shows a 60 percent increase in deaths in Genesee County attributed to pneumonia and influenza in 2014, though the numbers, and the outbreak itself, were not publicized. There were 92 deaths in 2014, compared with 56 in 2013. (The state won’t reveal how many of those deaths were pneumonia versus the flu, saying the data remains under review).

2015

January 23: Jim Collins, head of Michigan's Communicable Disease Division at the Michigan Department of Health and Human Services, writes email to state and county health officials saying the volume of Legionnaires’ cases at that time "likely represents the tip of the iceberg relative to the actual number of cases of illness." (See page 9 of this link)

January 27: Shannon Johnson, a MDHHS epidemiologist, sent email to the Genesee County Health Department about the Legionnaires’ outbreak. “At this point, the priorities in the public health investigation are to determine the scope of the outbreak and to define as clearly as possible the characteristics of the cases of Legionnaire’s disease …,” she wrote. “A current map of the municipal water system needs to be obtained and cases’ residences mapped in relation to the water system.”

January 30: The same week Bridge Magazine and other media are reporting on public protests in Flint over discolored, smelly water, MDEQ Communications Director Brad Wurfel emails Gov. Rick Snyder’s Deputy Press Secretary Dave Murray and says, “I don’t want my director (MDEQ’s Dan Wyant) to say publicly that the water in Flint is safe until we get the results of some county health department epidemiological traceback work on 42 cases of Legionnaires disease in Genesee County since last May.”

March 2: Bertie Marble, 68, with an extensive medical history, goes to McLaren’s emergency room with chest pains and shortness of breath. Treatment includes dialysis and a chest x-ray. She is diagnosed with acute diastolic heart failure, hypertension, end-stage renal disease and acute coronary syndrome, according to the medical records. No fever or chills. Medical history includes chronic anemia, osteoarthritis, sleep apnea, diabetes (controlled with diet, not medicines) and a need for a kidney transplant.

March 6: Marble is “deemed stable” and discharged from McLaren.

March 9: Bertie Marble returns to the emergency room at McLaren with chest pains and shortness of breath. Test shows small amount of fluid in her left lung, which could be a symptom of pneumonia and/or Legionnaires’ disease.

March 10: Email from county health official James Henry to Flint and state officials complains that the state has been unresponsive to his inquiries about Legionnaire’s. “In 2014, Genesee County experienced a significant increase of confirmed Legionella illnesses relative to previous years. … McLaren Hospital identified and mitigated Legionella in their water. This is rather glaring information and it needs to be looked into now. … I want to make sure, in writing that there are no misunderstandings regarding this significant and urgent public health issues. The Trihalomethane issues (too much disinfectant byproduct in Flint’s water system) ‘pale in comparison’ to the potential public health risks of Legionella.”

March 11: Email from Richard Benzie (MDEQ) to colleagues about Henry’s email: “As I see it, we need a plan of action fast.”

March 11: Bertie Marble developed a fever on the third day of her second admission at McLaren. Symptoms of Legionnaire’s disease, which include a fever, typically show up anywhere from two days to two weeks after exposure to the bacteria. It had been nine days since Marble’s first admission to the hospital.

March 12: Marble is “lethargic but arousable,” and has no wheezing. Her mood is “fair,” but she is “acutely appearing ill.” Has “rigors,” or chills with fever.

March 13: Email from Brad Wurfel, MDEQ communications director, to Harvey Hollins, an aide to Governor Rick Snyder:

• “In December, our staff became peripherally aware that the hospitals in Genesee were seeing an uptick in Legionnaires cases.
• “Untreated, it can be deadly… More than 40 cases reported since last April. That’s a significant uptick – more than all the cases in the last five years or more combined.”
• “Essentially, Jim Henry with Genesee County Health is putting up the flare. He’s made the leap formally in his email that the uptick in cases is directly attributable to the river as a drinking water source – this is beyond irresponsible, given that it is his department that has failed to do the necessary traceback work to provide any conclusive evidence of where the outbreak is source(d), and it also flies in the face of the very thing a drinking water system is designed to do.”

March 13: Bertie Marble continues to have chills and fever, and blood work shows signs of infection and sepsis. McLaren doctor orders urine and blood tests as well as antibiotics.

March 14: Bertie Marble is alert, but too fatigued to speak to a doctor due to “increasing confusion.” Doctor anticipates her neurological condition will improve as medical conditions stabilize, according to her medical records.

March 15: Bertie Marble rallies a bit, starting the morning more alert but complaining of feeling weak. As the day progresses her condition worsens. “Healthcare associated pneumonia” is cited under notations in her medical chart. Fluid on her left lung, not her right. Around midnight, a “code blue” is called because Marble has no pulse. CPR is administered and her pulse returns within three minutes.

March 16: Again, Marble is unresponsive with no pulse. Medical staff performs CPR, restores her pulse. Doctors note that she has septic shock with left-sided pneumonia. Her condition is critical. She is transferred to intensive care unit. Cardiologist notes Marble “coded” twice and is now unresponsive. Writes, “I am not sure what is going on.” Chart shows she is prescribed antibiotics including levofloxacin, an antibiotic that can be used to fight bacterial infections including Legionnaires’ disease. Doctor’s notes instruct to obtain sputum and check urine for legionella. It appears to be the first time the bacteria is mentioned in her charts.

March 17: Bertie Marble has zero urine to test for legionella bacteria. Overall prognosis is “very grave.”

March 19: Email from Jim Henry (Genesee County) to Stephen Busch (MDEQ) regarding investigation into Legionnaires’ cases in Flint:

Says he is having trouble getting records from the City of Flint through the Freedom of Information Act. “The FOIA request is specific enough that we should have received a timely response from the City of Flint.”

“There have not been any conclusions regarding the source of the illnesses. Our team is gathering information and we suspect there may be several sources. It has been made clear that the Flint municipal water system is in compliance with the Safe Water Drinking Act. It seems reasonable that your office would be involved regardless if a potential health risk from municipal water is related to consumption, inhalation or dermal exposure. Perhaps the legislation should be revisited to better address risks.”

March 19: Family first says hospital should do what they can to save Marble, but later says the hospital should not use CPR if her heart stops a third time. Her chance of “functional favorable outcome is poor.”

March 20: Bertie Marble’s heart stops. No CPR is administered. She is pronounced dead at 8:47 p.m.

March 31: Email from Jennifer Crooks (EPA) to MDEQ about the Legionnaires’ outbreak: Key points:

(T)he State is currently figuring out a communication-with-the-public plan… laying a foundation now with the resources for when the State goes public with the issue of Legionella. Darren (Lytle of the EPA) said that the labs are set-up now ready for Legionella sampling and analysis.”

“Miguel said that we must look at the overall picture, i.e. is the system causing this increased incidence of Legionella disease? Darren said that first, we must find the source – is Legionella there? If Legionella is present, in the tanks/pipe, then disturbance of changing the water quality and flushing, could cause it to proliferate.”

April 27: In an email, Laurel Garrison of the U.S. Centers for Disease Control and Prevention expresses concern to Genesee County health officials about the handling of the Legionnaires’ outbreak, according to emails obtained by the Detroit Free Press. “We are very concerned about this Legionnaires’ disease outbreak,” she wrote. “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.” She indicates city and state officials were not supplying needed information for the county’s investigation.

May 29: A MDHHS summary of the Genesee County Legionnaires’ disease outbreak, that is not publicized, declares the outbreak is over.

June, 4: MDHHS sends a “Final Legionellosis outbreak report” to the Genesee County Health Department and discusses the report with the CDC. The report confirms 45 cases of the disease and says more than half had “healthcare facility exposure” shortly before developing the illness. Some were exposed to Flint water at their home – others were not.

June 8: Jim Collins of the MDHHS chastises Genesee health officials for communicating with the CDC about the Legionnaires’ outbreak without state approval, emails show. “Relative to communications around the investigation, I believe that CDC is in agreement that their involvement really should be at the request of the state, rather than the local health department.”

August 2015: Legionella bacteria is found at McLaren, again, according to MDHHS epidemiological reports. In some reports, the state refers to the health facility in question as Hospital A, but the profile it draws of Legionnaires’ patient volume at the hospital could only apply to McLaren. The state says the hospital found Legionella in environmental samples in August 2015 and continues to monitor for the bacteria (see page 4). MDHHS reports also say “Hospital A” is the hospital that hyperchlorinated its water system in 2014 and continues to monitor for it. McLaren officials have said they put measures in place to eradicate Legionella from its water after it was found in its water in 2014. August 2015 is also the month when McLaren started to deliver bottled water to all patient care, visitor and employee areas.

Summer 2015: McLaren upgrades its water system. The hospital installs a $300,000 secondary water disinfection system and replaced nine water fountains with filtered water stations.

December 5: A Genesee health official accuses the state of attempting to cover up mishandling of the investigation into Legionnaires’ disease, according to emails obtained by the Detroit Free Press. “The state is making clear they are not practicing ethical public health practice,” Tamara Brickey, the health department’s public health division director. “Now evidence is clearly pointing to a deliberate cover-up,” Brickey writes. “In my opinion, if we don’t act soon, we are going to become guilty by association.”

2016

January 13: Ten months after the MDEQ notified Snyder aide Harvey Hollins that the Legionnaires’ outbreak coincided with the switch to Flint River water, Snyder and the Michigan Department of Health and Human Services publicly announce the Legionnaires’ outbreak in Genesee County over the previous two years. Snyder says he just found out about the outbreak himself. State officials do not connect the disease outbreak or deaths to the Flint water system. Marc Edwards, the Virginia Tech professor, says there is a “very strong likelihood” the outbreak is connected to Flint’s water.

January 15: Michigan Attorney General Bill Schuette announces an investigation of the Flint water situation.

January 22: McLaren officials confirm that legionella bacteria was found in its water supply in 2014 . Of 45 people who came down with Legionnaires’ between June 2014 and March 2015, more than half – 23 people - had been patients or visitors at McLaren before they came down with symptoms of Legionnaires’ disease, a survey by MDHHS showed (page 7). McLaren says there is no confirmed tie between the hospital and the Legionnaires’ outbreak. "It is important to note that no tests have ever determined that McLaren is the source of exposure for any patients testing positive for the legionella antigen, and that there is no definitive data to support that McLaren Flint is the source of exposure for any patient testing positive for the legionella antigen.”

February 13: Jim Henry, of the Genesee County Health Department, tells CNN the Legionnaires’ outbreak was preventable, but the state blocked his office’s efforts to find the source of the disease.

March 11: Governor Snyder calls for a full investigation of how the Michigan Department of Health and Human Services handled lead poisoning and Legionnaires’ disease issues throughout the crisis. The governor tasks the state’s Auditor General and MDHHS Inspector General with the probe.

March 23: Flint’s water crisis is a case of “environmental injustice,” the Snyder-appointed Flint Water Task Force declares in its final report, laying the blame primarily on the Snyder Administration and its state agencies.

April 8: The updated MDHHS report on legionnaires’ disease says “healthcare-associated legionnaires’ disease was suspected for a subset of cases” that occurred May through October 2015. Over half of the case-patients (27/46) had at least one exposure to the same hospital facility - McLaren - within two weeks prior to getting ill, MDHHS data shows.

April 11: State health officials announce death toll from the Legionnaires’ outbreak has grown to 12. It is called one of the nation’s worst outbreaks.