The Flint water crisis may be best recognized for reigniting concerns about the levels of lead in municipal drinking water, but it’s less often associated with a deadly outbreak of Legionnaires’ disease — a severe form of pneumonia caused by waterborne bacteria that can be lethal if left untreated.

“Flint’s Deadly Water,” the new PBS Frontline investigation that first aired Tuesday, lays out a devastating case for why the extent of Flint’s 2014 Legionnaires’ outbreak — and the attendant death toll — may be far worse than previously reported.

For years, state health officials in Michigan have set the official death toll for the Legionnaires’ outbreak amid the Flint water crisis at 12 people. But during the roughly year-and-a-half the outbreak spanned, Frontline reporters found that 115 people in Flint died of pneumonia.

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The stark difference in numbers, along with evidence culled from court records, internal emails among state government officials, interviews with victims, and data analysis, suggests there were dozens of deaths that stemmed from undiagnosed and untreated cases of Legionnaires’ disease that ultimately fell outside the state’s official count (which, per standard public-health reporting methods, only counts people diagnosed with Legionnaires’ who either died in the hospital or within a month of leaving it).

“Legionnaires’ manifests as a type of pneumonia, and if you walk into the physician’s office with pneumonia, they may just give you a round of antibiotics. And if they don’t know about the outbreak, they won’t usually test for it,” said Kristin Nelson, a researcher with Emory University who was among a team of experts commissioned by Frontline to analyze their reporting.

Nelson said physicians often won’t suspect Legionnaires’ as the cause behind a case of severe pneumonia and thinks it may be the reason there was a significant discrepancy between the likely number of Legionnaires’ deaths her team found and the number of deaths the Michigan Department of Health and Human Services has reported.

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To test the theory in Frontline’s findings, Nelson, along with epidemiologists Zach Binney and Allison Chamberlain, charted seven years’ worth of nonviral pneumonia deaths using Centers for Disease Control and Prevention data to compare Genesee County, which encompasses Flint, and 45 control counties in neighboring states that have similar size and climate as Flint.

Throughout the seven-year span, non-viral pneumonia deaths in both Genesee County and the control areas followed seasonal trends: rising in winter months and dropping in summer ones. But in the summer of 2014, when the MDHHS first tracked the start of Flint’s Legionnaires’ outbreak, pneumonia death rates jumped in Genesee, while falling — per the seasonal trend — in the control areas.

“We found 70 more pneumonia deaths in Genesee County than normal, based on what was going on in control counties at the time,” Binney said in an interview. “You see pneumonia mortality in Genesee maintain or rise, and you see it drop in the control counties. We’re not saying all 70 of these deaths are Legionnaires’ deaths — only that [data] is consistent with the idea that there was a substantially larger outbreak than reported.”

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What’s more, the pneumonia deaths correspond with the nearly 90 cases of Legionnaires’ disease the MDHHS tracked during the year-and-a-half-long outbreak.

Although independent researchers determined the MDHHS likely undercounted at least 70 Legionnaires’ deaths during Flint’s water crisis, Binney clarified that the team doesn’t have reason to suspect the undercount was intentional:

“We don’t consider it likely that there were known cases that weren’t reported. We don’t know, and we’re just speculating, but based on our experience, someone simply doesn’t get tested for Legionnaires [so] they don’t get included in the case count.”

Binney, who praised the thoroughness of Frontline’s reporting, was careful to note that his team’s job was limited to testing if Frontline’s theory that Legionnaires’ deaths could be significantly undercounted could be substantiated (it could); their analysis does not address the 115 records with pneumonia listed as cause of death or the actual source of the Legionnaires’ outbreak. In fact, the source of the outbreak remains in dispute: A peer-reviewed report published in the Proceedings of the National Academy of Sciences by a team of state-commissioned researchers concluded that 80 percent of local Legionnaires’ cases could be attributed to changing the water supply source from Lake Huron to the Flint River in 2014. The MDHHS disputed the report’s findings as “incomplete” and “inaccurate.”

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“The consensus in the Legionnaires’ community is that it’s pretty badly underdiagnosed, so it would not be surprising to find it during an outbreak, especially if communication [from public health officials] isn’t strong,” Binney said.

While neither Frontline nor the independent analysis found an intentional coverup of Legionnaires’ deaths, the investigation presents ample evidence that county and state health officials mismanaged the response to the outbreak. Michigan health officials declined to give Frontline on-camera interviews, but a spokesperson for the department said the Legionnaires’ outbreak couldn’t be definitively connected to water, because the water was never tested.

While county and state health departments tracked the spike in Legionnaires’ cases throughout 2014 and into 2015, the public — including many in the health-care community — weren’t notified of the outbreak for approximately 18 more months, well after the outbreak’s peak. Health researchers testified that they were blocked by state officials from testing water samples, and water filters in homes, and the state disputed a report into the water crisis, insisting the Legionnaires’ outbreak was linked to the McLaren hospital in Flint, not the city’s water supply.

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Todd Flood, the special counsel appointed to investigate the Flint water crisis, had particularly strong criticism for Nick Lyon, the former director for MDHHS.

“Though he’s presumed innocent, we’re saying he had a duty to tell the people. He failed to do that duty,” Flood said in the documentary. “He then kept things under wraps, the spike was continuing to go up, and sure enough, in the summer of 2015, multiple people got sick, and multiple people died.”

Lyon’s attorney denied to Frontline that MDHHS blocked the scientists’ requests to test water and said Lyon was simply trying to ensure the state was funding “necessary and appropriate” research.

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Lyon and seven other state officials faced criminal charges, including involuntary manslaughter, related to the crisis, before all charges were dropped this summer.

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