Pennsylvania’s worsening measles outbreak that now involves nearly 500 cases has produced an uncomfortable lesson in public health—often the most challenging aspects are not identifying a disease, but rather communicating it precisely to the public.
The Controversy
The Pennsylvania Department of Health announced two “measles-associated deaths” among unvaccinated Lancaster county residents, the first measles-related deaths in over three decades within the state. Governor Josh Shapiro called the deaths “completely preventable” had the residents or community been adequately vaccinated against measles through the MMR vaccine that offers 97% protection against the disease when two doses are administered.
The Lancaster County Coroner Office provided a different assessment of at least one of the deaths. The infant who died in this case, tested positive for measles and acquired measles in utero before birth from the mother. The Coroner, Dr. Stephen Diamantoni, said the infant died from a lacerated spleen and that “measles was not the cause of death”.
These three different accounts of death; from the governor, the state department of health and the Coroner’s office appear contradictory. However, there is an important public health nuance here— multiple statements can each be true and do not need to be mutually exclusive.
Although the investigation is ongoing, the immediate cause of death could have been from a ruptured spleen, as the Coroner stated. Although the death was attributed to a lacerated spleen, it is also conceivable that a positive measles infection made the spleen weaker and more vulnerable to rupture, which would in fact be a “measles-associated” death, as stated by the Pennsylvania Department of Health. Finally, if the death was associated with measles, it is possible the death could have been prevented if the unvaccinated mother was vaccinated and did not transmit the infection to the infant; as Governor Shapiro insinuated. Thus, there could be truth to all three claims for the measles deaths.
For public health purposes, all of these distinctions should have been explained immediately and clearly to the American public.
Communication Challenges For Public Health
During an active outbreak, ambiguity creates an information vacuum. If different agencies use different language and terminology to explain infectious disease deaths without explaining why, the public is left to fill in the gaps. This creates an opportunity for misinformation to spread rapidly, particularly on social media.
This is precisely what makes public health so challenging; that communication must be done with precision, transparency and of course, humility. In retrospect, government and health officials should have clearly distinguished if laboratory tests confirmed measles infection, what was the immediate cause of death, if measles played or could have played a role in the death, and why the case could be included or classified as a measles-associated death. Communicators must also explain what is not known, and this transparency is critical to earn trust in public health from the general public. This clarity should never be sacrificed in public health communications.
The Larger Story
In communicating important public health to the American public, the larger story should not be the cause of death, but rather what interventions can mitigate the spread of disease, since nearly 500 measles cases have already been reported in the state of Pennsylvania. The most important intervention for measles is vaccination, with two doses providing 97% protection against infection. When communication is ambiguous, the larger story gets lost in controversy, with more focus on the cause of death and less on lifesaving interventions like vaccination that could move the needle in decreasing the spread of infection.
The Bigger Warning For America
This case study highlights another important challenge for America— trust is fragile, and once lost, it is extraordinarily difficult to rebuild. When officials disagree, even if legitimate based on terminology, the general public can interpret that disagreement as evidence that officials do not have a solid understanding of the outbreak. Public health must therefore communicate uncertainty without creating confusion.
The messaging should include what is known, what is unknown, why different agencies may interpret the same death differently, and what people can do to protect themselves and their children. This approach adds clarity and ameliorates confusion.
Although vaccination prevents measles, trust determines whether people accept the vaccine. When vaccination rates have been declining in America with continued increases in vaccine exemptions in schools, the stakes for effective public health communication have become that much more important.
