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State's chief medical officer: Flint Legionnaires' probe followed "standard practice"

Feb 15, 2016

Dr. Eden Wells
Credit State of Michigan

Michigan’s top doctor says the state’s investigation into Flint’s deadly Legionnaires’ disease outbreak followed “standard public health practice.”

The state’s Chief Medical Officer, Dr. Eden Wells, says that investigation “was very consistent … with any outbreak investigation that’s been conducted.”

Wells’ comments come at a time when publicly released emails from state officials, including some with the Department of Health and Human Services, raise serious questions about state agencies’ response to an unfolding public health crisis.

Among those questions:

·        Why did MDHHS officials fail to follow up with the Centers for Disease Control, after federal experts expressed concern about an initial Flint-area Legionnaires’ outbreak in 2014?

·        Why did state health communicable diseases director Jim Collins declare the Legionnaires’ outbreak “over” in June 2015, the same week Genesee County health officials confirmed two more cases, followed by another disease spike?

·        Why wasn’t the public notified about the outbreak until January, 2016 — when Gov. Snyder disclosed it, along with a potential link to Flint’s larger water contamination crisis?

Wells, who started her job with the state in May 2015, said the state chose not to call on federal resources — even after the EPA, notified of the outbreak by county health officials in February 2015, alerted the CDC — because state agencies believed they had “all the resources needed” to investigate.

“It was my understanding … that the number of epidemiologists, the resources needed for the assistance to the local health department, were already provided at the state level,” Wells said.

Wells said it’s her “sense that the CDC was involved quite early on, in conjunction with the state” in the outbreak investigation. She said it’s standard for federal agencies to wait for a formal state-level request before getting involved.

“They [CDC] cannot come into the state unless actually invited by the state epidemiologist,” said Wells.

Nonetheless, after a federal disaster declaration, CDC teams are now on the ground in Flint. Wells said they're identifying “high-risk buildings,” and developing a model “prevention toolkit” that can be used to prevent future Legionnaires' outbreaks.

The CDC teams are also investigating the source of Flint’s outbreak. The legionella bacteria is usually found in water systems.

At least as early as Jan. 2015, county health officials suspected that Flint’s April 2014 switch to the Flint River for its water supply contributed to the outbreak, though that was just one of several hypotheses.

More recently, nationally recognized water and legionella experts have suggested the water switch as a likely source of the outbreak.

Wells admits there’s a strong “association” between the two. But not all the Legionnaires’ cases seemed to fit that hypothesis, and there were other confounding factors that made pinpointing the source difficult.

And because legionella bacteria from patients were never matched to an environmental source, Wells said there’s still no “clear evidence” that municipal water caused the outbreak — and there may never be.

“They couldn’t get the evidence to say to pull the trigger to say ‘We know it’s the water,’” said Wells.

“Because believe me, I think if anybody had that evidence — if we had environmental samples that showed there was legionella of the same strain as what was in the patients at that time — then absolutely, that would have rolled out very, very differently.”

As for the delayed public notification, that fell largely to the county health agency, according to Wells.

She said the state did recommend that a public health notice go out, but in terms of linking the outbreak to the public water supply, “I do not see that there was any evidence that led to that level, where people could comfortably make that type of public notification.”

And as for the state’s June 2015 conclusion that the Legionnaires’ outbreak was “over,” Wells said that was a hard call to make.

“You can either call this one outbreak with two waves, or two separate outbreaks,” said Wells, noting that 45 cases were reported in 2014, with a time gap before another 42 cases appeared in 2015. This is a typical pattern for Legionnaires’ cases, which usually spike in the summer months.

“To say the first wave or outbreak was over … is reasonable,” Wells said, adding that the state’s report on  the initial outbreak led to “enhanced surveillance” and recommendations that helped officials recognize and counter the second wave of cases.

Internal emails between county, state, and federal health officials tell a somewhat different story.

After the MDHHS’ Collins declared the outbreak “over,” Genesee County environmental health supervisor Jim Henry emailed colleagues that “The MDCH Legionella Executive Summary seems rather bold and premature, i.e. “The outbreak is over; the last reported case occurred in March, 2015.” In fact, the county had been notified of two possible cases that week, Henry said.

Henry also bemoaned a lack of state help in pinpointing the source of the outbreak: “I have concerns about MDCH’s [Michigan Department of Community Health] lack of ability to assist with the collection of environmental samples. CDC has offered their consultants and possibly to cover lab costs. I do not have the same assurance with MDCH.”

In November 2015, when Genesee County finally submitted a Legionnaires’ report to the CDC’s National Outbreak Reporting System (NORS), Henry sent an email praising colleagues' efforts, adding: “The state agencies restricted our actions to the point of interference and inhibition.”

Wells said she can only speak for her agency, but has seen “no evidence, at least in my mind, that there was any block between having essentially a federal, state, and local approach to this [investigation.]”

In emails, state and county officials point fingers at each other for lapses and alleged stonewalling that occurred throughout the investigation. Now, they continue to do so publicly.

But Janet Stout, a Legionnaires’ expert at the University of Pittsburgh, has said that in her opinion, “responsibility lies at the feet of the state.”

“Based on the outcome of all of this, people could have done much more, except the people at the Genesee County Health Department. They went down every potential avenue to raise concern about the uptick of Legionnaires’ disease,” Stout told the Detroit News.

Local officials have also raised concerns about the possibility of another outbreak this year, especially if Flint once again switches water suppliers — this time, from Detroit water to the Karegnondi Water Authority.

Wells said that with the help of the CDC, preventive measures should be in place at high-risk locations, and “enhanced surveillance for legionella will be ongoing.”