CDC counts one of Pennsylvania's four measles deaths under Kennedy's new rule

The two figures come from different definitions. During active outbreaks, the CDC has historically used notifications from state medical officials to publish "associated" deaths in real time. That category covers any death with a positive laboratory result for the outbreak condition ^[7]. Pennsylvania's four were counted that way ^[3]. The federal dashboard will now recognize a measles death only when measles is the underlying cause on the death certificate. A contributing cause does not qualify ^[8].

Underlying cause has a strict meaning. On the U.S. standard death certificate, the top line is the immediate cause, and each line below it is the condition that led to the one above. The last line is the disease or injury that started the chain. A second part lists conditions that contributed without being in that chain ^[10]. Pennsylvania's training for certifiers traces bleeding esophageal varices back through portal hypertension and cirrhosis to hepatitis B. Hepatitis B is the underlying cause because the virus started the sequence ^[11]. By the same logic, the authors of one STAT opinion piece wrote, a child who develops fatal pneumonia because of measles is a measles death ^[12]. A patient whose measles appears only in the second part is outside the new federal count ^[8].

The "with, not from" question is fair for at least one of the four. A county commissioner relayed the coroner's office's position that one person died "WITH measles, but not FROM measles." The coroner has attributed that death, an infant's, to a ruptured spleen ^[2]. Without medical records or a full autopsy, the public has only what the coroner has told reporters ^[2].

On Sept. 16, in her first interview as CDC head, Erica Schwartz was asked about leaving the Pennsylvania deaths out, and she pointed to Covid. When someone with Covid was hit by a bus, "often that was called a Covid-related death," she said ^[9]. That example has a documented ending. Early Covid tallies came from fast, preliminary case reports. Death certificate data followed weeks later and became the basis for official mortality statistics ^[24]. In late 2020 a Washington TV station found a Florida motorcyclist who had been added to a county's preliminary tally. He was removed after the medical examiner reviewed the death, and the CDC's mortality statistics chief called that correction the system working as designed ^[13]. The new rule keeps only the slower of those two counts ^[6].

How slow depends on the certificate, according to former senior NCHS leaders writing in STAT. Submission times vary from state to state ^[15]. Once NCHS codes the data, it reaches CDC WONDER within one to two weeks. Certificates naming rare causes can go to manual adjudication, which can take weeks to months ^[14]. Measles deaths are rare. Pennsylvania's four already exceed the highest annual U.S. count since 1992 ^[17], so no year in that span recorded more than three ^[21].

Then there is suppression. NCHS does not report counts from one to nine, so the national measles death total must pass a threshold of 10 before CDC WONDER, and the dashboard that draws on it, shows an actual number ^[16]. On the associated-death measure, no year since 1992 would have cleared that bar ^[21]. Neither STAT piece addresses whether the smaller federal figure affects money for the response.

In my view the former NCHS officials have the stronger case. Both counts are legitimate. Official mortality statistics rest on the certificate count ^[24], and the notification count was the one CDC used for timely response during outbreaks ^[7]. Pennsylvania's cases now exceed 800, clustered in communities with a history of vaccine hesitancy ^[18]. Relying strictly on NCHS statistics "will not provide the surveillance information needed at the beginning of an active outbreak when counts are low," they wrote ^[19].