FLINT, Mich. >> It was the Fourth of July, a warm summer night in 2014, but Tim Monahan was shivering in a thick blanket as he watched fireworks from his front yard here. By the next afternoon his temperature had shot to 104.6, and doctors at the hospital he had checked into puzzled over what was wrong.

Two days later, they had an answer: Legionnaires’ disease, a virulent form of pneumonia caused by a type of bacteria that can multiply in water systems. Monahan, now 58, was given antibiotics and eventually recovered, but his case turned out to be at the leading edge of a Legionnaires’ outbreak that sickened at least 87 people in the Flint region, killing nine of them, from June 2014 through October 2015.

State officials still say they cannot conclusively link the outbreak to Flint’s contaminated water supply, partly because of a lack of sputum cultures that should have been collected from patients. But the possibility of a link was raised in internal government emails as early as October 2014, and state officials did not inform the public of the outbreak until last month.

The Legionnaires’ cases started popping up as Flint residents were complaining about the foul-smelling, discolored water flowing into their homes after the city switched to a new water source, the Flint River, in April 2014. Soon they were reporting rashes and stomach ailments, and whistle-blowers eventually pointed to alarming levels of lead in the water supply and in children’s blood.

An examination of government emails, and interviews with people who survived Legionnaires’ and relatives of those who died, shows the government response to the Legionnaires’ outbreak followed the same pattern that prevailed throughout the Flint water crisis: a failure to act swiftly to address a dangerous problem or warn the public.

Even as more residents became critically ill with Legionnaires’ disease, and some died, the officials remained mired in jurisdictional battles, according to emails released by the Michigan Department of Health and Human Services and the health department in Genesee County, which includes Flint. Some at the state level seemed more concerned about following bureaucratic protocol, and not raising public alarm, than protecting residents.

Janet Stout, an expert on Legionnaires’ disease at the University of Pittsburgh whom county health officials asked for help last year, said state health and environmental officials had seemingly willfully impeded the investigation — health officials by refusing to invite the Centers for Disease Control and Prevention to dispatch experts to help with the investigation, and environmental officials by not helping the county get the answers it needed about Flint’s water.

“The people that were pushing this aggressively were at the bottom, the county, and they were not getting cooperation from the levels above them,” Stout said.

State health officials said the county had repeatedly rebuffed their advice and offers of assistance during the outbreak, although they did step in starting early in 2015. Jennifer Eisner, a spokeswoman for the State Department of Health and Human Services, said that while it “presented the Genesee County Health Department with the investigation requirements,” the county “either did not fulfill them or did not acknowledge a need for additional support from the state.”

‘A ridiculous tragedy’

The revelations in January about the extent of the outbreak left Monahan and several others who contracted Legionnaires’ disease during that period stunned and furious.

“What gets me is how fast the state has just denied — ‘We can’t prove it’s the water,’ ” Monahan said. “I think they’re so afraid of tying nine deaths to this. The whole thing is just such a ridiculous tragedy.”

Low levels of Legionella bacteria are commonly found in cold water coming into buildings, and they usually do not make people sick. Problems arise when the bacteria multiply in warm-water distribution lines, with large buildings like hospitals and hotels at particular risk. People get Legionnaires’ disease from inhaling mist that contains the bacteria, or by getting contaminated water in their lungs by choking on it, sometimes without notice.

The switch to Flint River water caused pipes to rapidly corrode, because the city and state failed to treat it with anti-corrosion chemicals. Stout said she believed the corrosion, combined with the dislodgment of other materials that typically line pipes, allowed Legionella to grow in city water as it warmed over the summer in building distribution systems.

The state concluded that about 30 percent of the people who became sick had no known exposure to Flint water in the two weeks before their illness.

Most of those who contracted the disease during those 18 months remain anonymous. Some names emerged in court documents, as three Genesee County residents who recovered from Legionnaires’, and the family of a fourth who died from it, have sued McLaren Flint, a hospital that many of those who fell ill with Legionnaires’ had visited in the two weeks before they got sick.

The lawsuit says the hospital failed to “exercise reasonable and ordinary care” to warn them of “dangerous conditions” there. It also names as defendants several current and former employees of the State Department of Environmental Quality, which has been widely faulted for its slow response to Flint’s water crisis.

Among those suing McLaren is Connie Taylor, who has survived the disease but at a tremendous toll: She now needs kidney dialysis three times a week.

A widow with diabetes, she was admitted to McLaren for stomach problems in September 2014. She went home the next day, but within a week she returned to McLaren complaining of exhaustion and chest pain.

A chest X-ray showed she had pneumonia, she said, and she was readmitted to the hospital. Within days, she was transferred to the intensive care unit, and doctors told her daughters that she might not survive.

“It just took me right down,” Taylor, 62, said. “They called my family in from out of town. And then my kidneys failed.”

She left the hospital in late September — but without knowing she had had Legionnaires’ disease. Only last month, when Gov. Rick Snyder’s administration informed the public of the outbreak, did she request her medical records chart and find that she had tested positive for Legionella during her hospital stay, she said.

Taylor said she would require the dialysis treatments for the rest of her life, unless she qualifies for a kidney transplant.

“This was something I didn’t have to go through,” she said, “and it’s changed my life tremendously.”

Months without warning

No public announcement of an outbreak — or even a countywide warning to medical providers — was issued in 2014 or 2015, an omission that several infectious disease experts described as bewildering and highly unusual given the number of cases.

In New York City last summer, health officials warned the public within weeks about an outbreak of Legionnaires’ disease in the Bronx that ended up being the largest in the city’s history. They also provided frequent updates on the outbreak, which they traced to a hotel cooling tower after matching Legionella samples collected from the tower and from patients’ sputum.

In the Michigan outbreak, the state laboratory tested sputum samples from only 11 of the 87 cases, Eisner said, adding that hospitals, not the state, were responsible for collecting and sending them for testing. She also said it was the county’s job to inform health providers about the outbreak, a contention county officials have disputed.

Laurie Prochazka, a spokeswoman for McLaren, declined to answer specific questions about the Legionnaires’ outbreak, citing the lawsuit. But in a statement, she said the hospital had “consistently followed all statutory regulations and notification requirements” and that its water “meets safety and quality standards.”

The hospital, which hired Stout as a consultant last summer, recently announced a series of steps it had taken to “safeguard and reinforce the quality” of its water system, including installing five secondary water disinfection systems at a cost of $300,000.

In state and county government offices, emails show mounting concern over the outbreak, but bureaucratic inertia even as people like Taylor were fighting for their lives.

As she was recuperating in October 2014, the Genesee County Health Department was starting to ask officials in Flint and at the State Department of Environmental Quality for help determining the source of the outbreak, emails show.

Around the same time, the state health department appeared concerned that the county’s investigation was falling short and that the state’s efforts to help were being rebuffed. The department had “tried to offer our services to Genesee and thus far have gotten very little information and/or willingness to receive assistance,” a state epidemiologist wrote in an email dated Oct. 13.

Similarly, Genesee County officials were complaining about the response of local officials. In March 2015, emails from county health officials showed rising frustration about their unsuccessful attempts to get information from Flint about its water. In an email in January 2015 that had accompanied a public records request — and that was also forwarded to the state — Jim Henry, the county’s environmental health supervisor, said the increase in Legionnaires’ cases “closely corresponds with the time frame of the switch to Flint River water.”

Forwarding the email to several high-level state officials, Brad Wurfel, a spokesman for the State Department of Environmental Protection, called it “beyond irresponsible” for Henry to suggest a connection.

On June 4, a state health official wrote in a memo that “the outbreak is over,” angering county officials, emails from Henry show. In the months after that pronouncement, 39 more Legionnaires’ cases were reported.

The state was angry that the county officials had bypassed it to request help from the Centers for Disease Control and Prevention, including with collecting and testing respiratory cultures from Legionnaires’ patients.

“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,” wrote Jim Collins, director of the state health department’s communicable disease division, on June 8. He added that the state had “not seen any information that would rise to the level of warranting” such a request.

An outbreak advances

Kristen Nordlund, a spokeswoman for the CDC, said in a statement that although the agency had provided “technical assistance via phone and email” starting in February 2015, the state did not invite its experts to Michigan until last month.

During the crucial months of 2014, the outbreak steadily advanced: five cases reported in Genesee County in June 2014, five in July and 10 in August. In all, 42 were reported from June through December 2014, state reports show.

Debra Kidd, a grandmother from Burton, adjacent to Flint, came down at the end of July with what seemed to be a migraine headache. Her son took her to the emergency room at McLaren on July 25, and after a few hours of observation and an injection to treat Kidd’s headache, they left.

But Kidd deteriorated over the weekend, said her son, Troy Kidd. When she went to her own doctor on Monday, he sent her to a different hospital, Genesys Regional Medical Center in nearby Grand Blanc.

There, Kidd, barely able to breathe, was put on a ventilator and into a medically induced coma, Kidd said. Her illness was diagnosed as Legionnaires’ disease the next day, and she died on Aug. 2, after her family decided to take her off the ventilator. She was 58 and had been in good health, Kidd said.

Kidd said he thought to connect her death with the Flint water only after the state announced the outbreak last month. He now believes his mother was exposed to Legionella bacteria in the McLaren emergency room on July 25.

“Accountability has to be laid on somebody’s lap,” he said. “I want answers; I want to know why.”

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