Daily · West Post
During the pandemic, we all heard some variation of “they died with Covid, not from it.” The phrase is back, this time attached to measles. On Aug. 25, Pennsylvania reported two measles-associated deaths in Lancaster. That day, a county commissioner relayed the coroner’s office’s position that one person had died “WITH measles, but not FROM measles.” (The coroner has attributed that death, an infant’s, to a ruptured spleen; without the medical records or full autopsy, the public can only go on what the coroner has shared with reporters.) The Centers for Disease Control and Prevention then left both deaths out of its national measles update and put an asterisk in the deaths column.
Pennsylvania has since reported two more , for a total of four. The CDC added one of these deaths to its data on Wednesday but still does not list the other three. On Sept. 16, in her first interview as CDC head, Erica Schwartz was asked about the CDC’s decision to leave the Pennsylvania deaths out of its count.
She pointed back to Covid , saying that when someone with COVID was hit by a bus, “often that was called a Covid-related death,” and that definitions matter. Definitions do matter, and the question underneath the “with, not from” phrase is a fair one. A positive test and a death are two separate facts, and people want to know how one gets connected to the other.
That connection is documented on the death certificate, a form most of us will never fill out and may not understand without some background. One of our husbands is an emergency physician and has filled out many. He’s explained the process to me and has expressed frustration (and anger) over the distortion that’s playing out.
How the form works explains why a person who tests positive for Covid and is then hit by a bus isn’t a Covid death, and why a child who develops fatal pneumonia because of measles is a measles death. Literally speaking, we all die of cardiac arrest If we wanted to be literal about it, the cause of death for nearly everyone would be cardiac arrest, since in the end our hearts stop. We don’t record deaths that way because in almost every case something caused the heart to stop.
The CDC’s handbook for physicians tells certifiers not to list cardiac or respiratory arrest as a cause of death for this reason. Pennsylvania’s death certificate manual says the same in capital letters: “DO NOT enter terminal events such as cardiac arrest” without showing what caused them. Death is usually a cascade, and the certificate is designed to capture it.
The first part of the U.S. standard death certificate lists the sequence in reverse order. The top line is the immediate cause, meaning the final disease, injury, or complication before death. Each line beneath it is the condition that led to the one above, and the last line is the underlying cause, the disease or injury that initiated the chain of events.
The second part is for other significant conditions that contributed to the death without being part of that chain. The Pennsylvania Department of Health’s training for certifiers uses this example. A patient dies of bleeding esophageal varices, which were due to portal hypertension, which was due to liver cirrhosis, which was due to hepatitis B.
The top line of that certificate is the bleeding, and the underlying cause is hepatitis B because the virus started the sequence. Homicide law relies on similar reasoning when a gunshot victim dies of complications from the wound months later. We apply this logic to car crashes and gunshots all the time, and it applies to infections in the same way.
Where the bus story came from The bus story has a traceable origin. Early in the pandemic, some federal and state officials said that anyone who died with Covid was being counted. Some early tallies came from case surveillance — the fast, preliminary reports that health departments send to the CDC when a person with a positive test dies.
Death certificate data follows weeks later and becomes the basis for official mortality statistics. When a Washington, D.C., TV station went looking in late 2020 for crash victims counted as Covid deaths, it found a Florida motorcyclist who had been added to a county’s preliminary tally and was removed after the medical examiner reviewed the death. The CDC’s mortality statistics chief described that correction as the system working as designed.
On the certificate itself, the chain for a person who tests positive and is then hit by a bus starts with the injuries from the crash. If Covid neither caused that sequence nor contributed to the death, it doesn’t belong in part one or part two. The CDC’s certification guidance says Covid belongs on a certificate when it played a role in the death, and a CDC review of Covid mortality data adds that a contributing cause is one the certifier judged significant, not an incidental finding.
So, at least one trauma death did land in a preliminary tally at the height of pandemic chaos and was later corrected, and nothing in the reporting from that period supports the claim that such deaths were “often” counted in official mortality statistics. Were Covid deaths overcounted? To be fair, the “with Covid” concern had a real basis in hospitalization data.
When hospitals were testing every admission during the Omicron wave, people admitted for something else could test positive and be included in Covid hospitalization counts, as physician Jake Scott described for CIDRAP. Death certificates show Covid’s role in deaths changing over the same period. Covid was the underlying cause on 88% of the certificates that mentioned it from 2020 through mid-2022, and that fell to 76% for 2022 as a whole as certifiers more often listed it as a contributing cause.
Excess mortality offers an independent check because it doesn’t depend on deciding what caused each individual death. It compares deaths from all causes with the number expected in a typical year. The CDC estimated about 299,000 excess deaths in the U.S. from late January through early October 2020, and about 198,000 of them were attributed to Covid.
The rest likely reflect a mix of unrecognized Covid deaths and indirect effects of the pandemic. Excess mortality can’t tell us whether every death was classified correctly. It does show that deaths rose by far more than the number attributed to Covid, so inflated certificates can’t account for the toll.
What this means for counting measles deaths In the same interview, Schwartz described measles accurately, saying it can cause pneumonia and a fatal brain disease called subacute sclerosing panencephalitis. Those complications are how measles kills us, which means measles will rarely be on the top line of a certificate. If a child develops measles, then pneumonia, then respiratory failure, measles is the underlying cause because it started the chain.
As the American Academy of Pediatrics explained, a child can die from complications of an infectious disease even if that disease isn’t the final condition listed. Schwartz said the CDC is waiting for the National Center for Health Statistics to confirm measles as the underlying cause on the death certificates, and has asked the Council of State and Territorial Epidemiologists for a formal definition of a measles death. Underlying cause is the right standard for official mortality statistics, and a clearer surveillance definition would help.
Final death certificate data can take months, though, and outbreak surveillance hasn’t traditionally waited for it. The CDC’s measles updates have relied on deaths reported by state health departments, and last year the agency counted a New Mexico death while that investigation was still open. During Covid, fast surveillance reports came first and certificates corrected them later.
Holding measles deaths out of the national update until certificates are final reverses that order. Every death has something that kicked off the cascade. Arguing over whether someone died “with” or “of” a disease gets us stuck on the last thing that happened, when the death certificate asks what happened first, whether that was a fall, a gunshot, Covid, or measles.
Schwartz — who also emphasized that the measles, mumps, and rubella vaccine is safe and effective — has said her priority is rebuilding trust through accuracy and transparency. Showing the public which measles deaths states have reported, which are under review, and what standard is being applied would serve both. Elana Pearl Ben-Joseph is a pediatrician and senior medical and scientific editor of Unbiased Science .
Jess Steier is a public health scientist and founder of Unbiased Science .
Source: STAT
