Who Counts?

Pennsylvania: The Second Death, and the First On Friday, September 4, the Lancaster County coroner confirmed that a second death referred to his office was caused by measles. The patient was an infant born in July who died on August 18. The state took weeks to notify the coroner. There may be bureaucratic reasons for that, or bureaucratic weaseling, but in an environment this saturated with disinformation, and after what happened with the first death, you would think the state would want to be proactive. I find the delay inexcusable. This child was born withAmish lethal microcephaly, a fatal disorder in which infants are usually transitioned to comfort or palliative care shortly after birth. The timing of the measles infection is not yet public, but a child who lived two months most likely acquired it after birth. I anticipated the underlying condition will be used to argue that this child died of microcephaly, not measles. The condition surely played a role. But children with this disorder typically die of respiratory infections, and the coroner has determined that measles was the respiratory infection that killed this child. That is what "died of" means. On the first death, I now believe we have enough information to say measles played a significant role. That is based on The Atlantic's interview with the parents, an Amish family in which the father was vaccinated and the mother was unvaccinated but not overtly anti-vaccine. She contracted measles during the pregnancy, severe enough to need medical attention. The baby was born in distress at Christiana Birthing Center, was not breathing, received CPR, was classified as a stillbirth, and had lung tissue that tested positive for measles. The link is clear to me. The questions about the splenic laceration and any trauma from CPR need to be answered by the pathologist who performed the autopsy, not the coroner who did not. When county, state, and federal governments are squaring off against each other in the middle of a public health emergency, a weeks-long information vacuum is exactly what you cannot afford. It handed the CDC, and the secretary who controls it, a major opening. The outbreak by the numbers •About 577 casesin Pennsylvania, second in the nation behind South Carolina. •Roughly three dozen of 67 countiesreporting, with 10 showing ongoing spread. •About 20% of cases diagnosed in the last week.More testing is happening, and the cadence is rising, not falling. •17% of cases hospitalized, 91 total hospitalizations, 30% of cases in children. •6,395 early MMR dosesadministered by the state Department of Health to infants six to twelve months old, the window where we see the most severe pediatric disease. Those children will need a third dose later, since the vaccine does not take as well under a year of age, but this is a prudent move by parents. •Nationally, 3,134 US cases, 8% hospitalized.This is an undercount. Ohio is on its third outbreak, Douglas County, Illinois has a new one, and New Jersey, bordering Pennsylvania at 91.3% coverage, is poised to discover one of its own. Every one of those hospitalizations is avoidable, and every one creates downstream problems. At Children's Hospital of Pittsburgh, two out-of-county patients who tested positive exposed more than 100 people inside the hospital. That will be the norm at every referral hospital in the country for as long as this continues. Lancaster County is trying to mitigate as best as they can with not so great results. For example, a pop-up clinic at a school in Ephrata, where one third of kindergartners are unvaccinated, drew six people.Six. This outbreak will burn in Lancaster County until population immunity rises, either through vaccination or through the virus running out of susceptible hosts. But, this is now a political issue, and I think Pennsylvania is going to be a measles hotspot for some time. The politics of a measles year Pennsylvania is in a gubernatorial election year, and the outbreak has become a campaign prop. New state reporting regulations that would speed notification of reportable diseases, expand the list of diseases the state tracks, and enable better contact tracing are being characterized in the press and by the political class as draconian. They are nothing of the sort. They are modernization, and they are the tools a health department needs to carry out its core function, which is communicable disease control. State Treasurer Stacy Garrity, who is running for governor, hasattacked the incumbentover the information vacuum. That criticism is legitimate. But you cannot make it while declining to address the outbreak in the state you want to govern. So, Treasurer Garrity: Let's focus not on the communications around the two deaths, but the on-the-ground response. How would you manage it differently? How would you raise MMR coverage? And to those who keep telling me this is just the midterm disease: I wish it were. It will outlast November. Brandon McGinley's op-edin the Pittsburgh Post-Gazette invoked C. Everett Koop, the Philadelphia pediatric surgeon who became Reagan's surgeon general and who publicly broke with political appointees over HIV/AIDS and harm reduction. McGinley wants someone like that again. The truth is that he may want that and I may want that but no politician does. They do not want a physician with a backbone whose loyalty runs to Pasteur, Jenner, and Fleming rather than to the president or governor. After Koop, the surgeon general's office was effectively neutered so no administration would be caught in that position again. Recall that Rochelle Walensky, Biden's first CDC director, suggested schools could reopen without every teacher vaccinated, and the White House, mid-negotiation with the teachers' unions, forced an immediate walk-back. She had to state that her recommendation came "in her personal capacity" and not as CDC director. A physician who becomes a political appointee is no longer a physician. That is why we will not see another Koop. Who Counts the Dead? The CDC Under RFK Jr. At her confirmation hearing, Erica Schwartz said she could not imagine RFK Jr. asking her to do something unscientific. That was never credible, because the only reason she was in the chair was that her predecessor, Susan Monarez, was asked to do something unscientific, refused, and was fired. This week Dr. Schwartz was asked, and she complied. Both Pennsylvania deaths remain off the CDC tally while the secretary calls them fabricated.Lisa Jarvisat Bloomberg called it a test she predictably failed. Understand how unusual this is. States report measles deaths and the CDC takes them at their word.Demetre Daskalakis and Deborah Houry, who resigned from the agency in solidarity when Monarez was fired, pointed out in STAT that last year's deaths in Texas, under a Republican governor, were counted with no lag and no pushback. So was the death in New Mexico, under a Democrat. Pennsylvania has a Democratic governor with ambitions. Is the rule changing for one state? Is a rule being invented to reach a result? The fact that I have to raise politics at all tells you the process is already tainted. Three pieces in CIDRAP this week deserve your attention: •Jake Scottdismantled the "died with versus died of" framing. That distinction is a COVID-era artifact from when every hospital admission was screened, so a psychiatric admission or a pre-surgical patient could incidentally test positive. Those should never have been counted as COVID outcomes, though the result mattered for PPE. Measles is not a screening test. Nobody gets tested without clinical suspicion. Transposing the COVID frame onto measles is an insidious way of smuggling in doubt. •Jess Steiernamed the distancing reflex. When the deaths were first reported, disinformation claimed they were 80-year-olds, which made no sense, since anyone born before 1957 is immune from infection. Then it became "that one was immunocompromised," or "that one had microcephaly." It is the same instinct that says the crash victim was not wearing a seatbelt. It is a bias, and it cannot be an excuse for inaction. •Unbiased Sciencemade the structural point. The CDC used to be the single place you went for what a disease is, what is spreading, and what the burden is. Now it is a patchwork, and others filling the void is not the same as the CDC doing its job. That is by design. Remember that RFK Jr. likened the CDC to a Nazi death camp, and someone inspired by that rhetoric shot up the agency. The dismantling is proceeding through the vaccine schedule as well. Rotavirus has been dropped from the CDC schedule, a vaccine that is already hard to deliver because the series must start by 15 weeks and finish by eight months. Space out appointments the way the secretary and the president want, and you miss it entirely. The American Academy of Pediatrics recommends it. Yes, Denmark does not give it. Denmark is wrong, and no Danish infant should have to be hospitalized with a preventable diarrheal illness. The hepatitis B birth dose, a vaccine that prevents liver cancer, has also been attacked, and University of Pennsylvania data show birth dose refusals up 107% from 2018 to 2025. That is the world he wants. What should Dr. Schwartz have done on Monday? Explain measles-associated versus measles-caused. Explain how the CDC adds deaths and why it defers to states. Explain the difference between a coroner's ruling and a surveillance case definition. She will not, because she speaks truth to power only in private. Ebola in the DRC: Failing on the Basics The Congo outbreak stands at6,250 cases and 3,039 deaths, a case fatality ratio near 50%, and it continues to grow across six provinces. Ituri is the epicenter, with North Kivu and Haut-Uele the other two main foci, and new health zones are added weekly. TheCDC graded the responseon five core metrics: case detection, contact tracing, laboratory testing, isolation, and safe burial.Subpar on all five.There are checkpoints where nothing is happening because the workers are not being paid. I do not know how anyone expects this work to be done for free. Every headline about new antivirals, monoclonal antibodies, and vaccine trials is welcome, but none of it substitutes for bread-and-butter public health. Ebola outbreaks end when communities own them, and communities will not own an outbreak while the basics are broken. Expect this in the news for more than a year before real containment. Some signals worth watching. People are fleeing the affected area out of fear, which may mean the population is beginning to recognize Ebola as a danger it can act against, but movement also raises the stakes for the Central African Republic and Burundi. Burundi is already preparing for imported cases and using mobile phone mobility data to anticipate where resources will be needed. Bunia, the capital of Ituri, is experiencing aboom in coffin-making, an echo of 1918. Schools in Ituri are open, though attendance is unclear. And an Endpoints piece raised the next problem: there is money for trials, but when trials turn into products, where does the money for deployment come from? Respiratory Season Without a Functioning CDC We are entering respiratory virus season with the federal vaccine ecosystem in disarray. This week the Vaccine Integrity Project at CIDRAP, led by Mike Osterholm, released evidence-based respiratory season guidance for flu, COVID, and RSV together with the AMA, the American Academy of Family Physicians, IDSA, the American Academy of Pediatrics, and ACOG. Clinician-friendly tables, ready to use. Someone had to fill the gap, because these vaccines are hitting drugstores now and the agency whose job it is to tell people how to use them did not. The Southern Hemisphere flu season appears to have been mild, which may portend a gentler season here than last year's. Some data points on why the vaccines matter: •RSV vaccine in Medicare nursing home residents:73% fewer hospitalizations, 56% fewer deaths, and a 60% reduction in blood clots. RSV vaccines are game-changing for older adults and for pediatrics. •Flu vaccine and severe disease (VISION data, Open Forum Infectious Diseases):ICU admissions cut 66% in children and 43% in adults. Preventing severe disease is what the flu vaccine is for. •Timing:flu clinics are opening now. Get vaccinated before Halloween, ideally late October, so protection carries through February. If September is your only window, take it. •GSK's mRNA flu vaccineis on FDA fast track, joining Moderna's approved product. It targets not only hemagglutinin, which every current flu vaccine targets, but neuraminidase as well. That could mean broader and more durable protection. Worth watching. •FluMist and pneumococcus:Michael Mina has been pursuing a signal that recipients of the intranasal vaccine, now self-administered, carry and transmit more Streptococcus pneumoniae, a cause of pneumonia, ear infections, and sinusitis. I do not know the clinical significance or how it interacts with pneumococcal vaccination. There were rumors this went unstudied for fear of giving anti-vaccine activists an opening. It needs to be studied regardless. They misuse every piece of information anyway. On COVID: wastewater is rising in the South, in Texas and Mississippi, which is the usual August pattern, and hospitals look fine. A long COVID trial of Paxlovid built on the viral persistence hypothesis failed, likely because it enrolled all long COVID patients rather than enriching for those with documented persistence. Long COVID is an umbrella term and trials need to treat it that way. In patients with kidney and liver disease, remdesivir was associated with 25% lower mortality. We used to think of it as a drug that got you home faster. It has proven its value. And Visby has released the first combination COVID and flu molecular PCR test cleared for home use. A Record Cyclospora Year, and the Global Food Supply The US is at roughly18,445 cyclospora cases and close to 1,000 hospitalizations, and Michigan reported a bimodal curve that nobody caught between the two peaks. People keep asking whether the CDC, USDA, and FDA cuts caused this. Partly, yes. The deeper issue is a globally distributed food supply chain with many points of contamination, after which product goes everywhere. Risk will never reach zero, which means you have to find outbreaks before they happen: batch testing, farm surveillance, all of it. Instead, the USDA has cut cyclospora research, and from what I have read, specimens from this outbreak are not being stored. We will close the worst cyclospora year on record knowing less than we could have. That is shortsighted. If fiscal restraint were the actual motive, we would not be building ballrooms, reflecting pools, and arches. This is health security, and it has value for people. Michigan's chief medical executive, Natasha Bagdasarian, who carried much of the response, said it plainly: her state did work normally handled by the federal government because the CDC is no longer functional in the way it once was. The fallout is economic, too. Local lettuce growers in my hometown of Pittsburgh are seeing a surge while importers lose revenue. Infectious disease reshapes consumer preference, and every business needs some awareness of what an outbreak could do to its operations. Elsewhere in food: the UK has a salmonella outbreak traced to imported eggs, of which it now brings in about 1.6 billion, up 60% since 2021. Salmonella is everywhere we put our hands, in food, dirt, and dairy, which is why it is so prolific; there is a mango outbreak as well. Everything Sprouts recalled radish sprouts for Shiga toxin-producing E. coli, which can cause kidney failure, likely cross-contamination from its earlier alfalfa sprout outbreak. And an E. coli outbreak inblueberriescentered on Florida and Georgia has produced 17 cases and six hospitalizations. Washington: Scapegoats, the Pentagon, and Eroding Norms Dr. Fauci sat down with Lawrence Gostin atGeorgetownand said he became the face of the pandemic response. He is right. But why? Because governors, mayors, school boards, and the president abdicated to him, and now they have scapegoated him. TheNew York Timesreports multiple Department of Justice investigations connected to COVID and to Fauci or people around him. I do not expect them to be probative. Nobody is trying to find anything out. They are hammering the scapegoat to deflect blame for what they themselves did not do. No one is conducting a real what-went-right, what-went-wrong review of COVID, and the blame game is a way of avoiding one. Separately, theDepartment of Defensewill reportedly collaborate with NIH, with a transfer of funds, on chemical, biological, radiological, and nuclear work, mostly chemical and biological, under Dr. Robert Kadlec. There is controversy over whether this is real collaboration or a way of routing money to DOD. I am giving it the benefit of the doubt. DOD has always had a large and genuinely excellent footprint in infectious disease, and under RFK Jr., it may be the only place government-funded mRNA vaccine research can actually happen. On the chem-bio front, there is a report ofchlorinegas use in Sudan's civil war. Chlorine is a World War I weapon. Its reappearance tells you the norms against chemical weapons have eroded and that instruments like the Chemical Weapons Convention are pieces of paper that rogue states and rogue actors will ignore. Microbiome Notes Three items, with one caveat that applies to all of them: this science is very young. •Necrotizing enterocolitis, a devastating and often fatal neonatal disease likely rooted in microbiome imbalance, is being targeted with probiotics. So far they appear to reduce incidence but not mortality. Work remains. •The oral microbiome:aBBCpiece noted that people following a Mediterranean diet have less gum disease. There is a real signal there. •Prebiotic sodas, covered in the Pittsburgh Tribune-Review, are built on prebiotics like fiber and inulin that nurture a healthy microbiome. The open question is how much is actually in the can and how many cans you would need to drink to get a meaningful dose. The Invisible Wiring A coroner in Lancaster County counted a death the federal government will not. On the first death, we have PCR-positive lung tissue and unresolved questions about the spleen and CPR that the pathologist and coroner owe us a mechanism for, but the narrative in The Atlantic makes measles' contribution clear. The CDC carries neither death. States report, the CDC accepts. That is how Texas and New Mexico were handled last year, with no lag and no argument. Something changed, and the only visible variable is politics. The rest of the week runs on the same current. Ebola checkpoints in Ituri sit empty because nobody paid the workers. This fall's flu, COVID, and RSV guidance was written by medical societies because the agency whose job it is did not do it. The USDA is not banking specimens from the worst cyclospora year on record. A politicized tally, an unpaid checkpoint worker, an empty specimen freezer. They sound like different problems. They are the same one. Public health runs on invisible wiring and plumbing: wages, freezers, surveillance systems, the person who writes the number down. Nobody gets credit for funding it, and everything else sits on top of it. New antivirals cannot substitute for it. Neither can vaccine trials or press statements. Notice who is doing the work anyway. County health officers, county coroners, medical societies, state and city and county health departments, hospitals. All of them absorbing federal responsibilities to hold together an ecosystem that RFK Jr. has disrupted. That is not a fix. It is a patch, and patches tear. If you cut the wiring, cut the plumbing, and politicize the count, you do not get calm, whatever is being promised to the base. You get blindness dressed up as calm.