 Solution

Condition on each patient's initial observed state and assume independent patient trajectories and observation times that do not carry additional information about the unobserved path. The Markov property factors each trajectory's likelihood function into its successive one-year transition probabilities. ThusMore explicitly, with $q=\lambda +\mu >0$ and $E=e^{-q}$,Successive transitions within one patient need not be independent unconditionally: this is a product of conditional factors justified by the Markov property. If initial-state probabilities are modeled rather than conditioned on, their likelihood contributions must also be included. Zero-count terms contribute zero; a positive count attached to a zero model probability makes the log-likelihood equal to $-\infty$.