Opinion: The ‘died with’ vs. ‘died of’ measles discussion misses something very important

During the pandemic, people heard variations of "they died with Covid, not from it," and the phrase is now back attached to measles. On Aug. 25, Pennsylvania reported two measles-associated deaths in Lancaster. That day, a county commissioner relayed the coroner's office position that one person had died "WITH measles, but not FROM measles." The coroner 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 CDC 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.

The authors say definitions do matter, and the question underneath the "with, not from" phrase is fair: 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 people will never fill out and may not understand without some background. One of the authors' husbands is an emergency physician who has filled out many; he has explained the process and expressed frustration and anger over the distortion 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, everyone dies of cardiac arrest, because in the end our hearts stop. But deaths are not recorded 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 the causal sequence. The piece's implication is that the "with vs. from" framing misses how death certificates actually establish causation, and that excluding such deaths from official counts can distort the measles toll.