CIDRAP-CIDRAP Op-Ed: How we can hear ‘high risk’ for measles and write it off

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CIDRAP Op-Ed: How we can hear ‘high risk’ for measles and write it off

www.cidrap.umn.edu

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CIDRAP Op-Ed: How we can hear ‘high risk’ for measles and write it off​

Jess Steier, DrPh

Today at 12:43 p.m.
Measles

COVID-19


On August 25, the Pennsylvania Department of Health announced two measles-associated deaths in Lancaster County, the first in the state in 35 years. Citing patient privacy, the department initially released almost nothing about the people who died beyond the fact that both were unvaccinated.

Within hours, an age for the two patients was circulating anyway. My comment sections filled with people asking why I wasn't mentioning that the two who died were 80 years old. This number came from a fake screenshot of a news headline, and there was never any evidence to back it up. The state's dashboard shows no measles cases in anyone 65 or older in Pennsylvania this year. The largest age group in this outbreak is 25 to 49.

We've since learned that one of the two was a newborn, and there is now a dispute over what role measles played in that death. I've written about that elsewhere, and it isn't what this piece is about. What I noticed is how quickly everyone reached for an age before anyone had one, and how readily a fabricated one filled the gap.

We watched this happen in real time during COVID. As the first risk data came in, CDC's first US analysis of severe outcomes by age, published in March 2020, found that 80% of deaths had occurred in adults 65 and older. Within months, that finding had hardened into a phrase, "only the old and the sick." Flu brings the same refrain, something to worry about once you've got an AARP card. The frame has never been accurate for any of these diseases because, of course, we know that young and otherwise healthy people die from these things, too. Measles complications are more common in children under 5 years old and adults over 20. This pattern doesn't map onto 'old and sick' any more neatly than other infectious diseases' patterns do.

Most people in our comment sections during the pandemic weren't arguing in bad faith, though some clearly were, particularly the ones implying the deaths wouldn't have mattered if the people who died were old or immunocompromised. The rest were doing something more ordinary. They were trying to locate themselves relative to a threat, which is what all of us do when we hear about a death from an infectious disease. Asking who died is a way of asking whether this is about me. We've made it too easy to answer no.

Risk factors are real​

Age is a risk factor. So are immunocompromise, pregnancy, and a long list of chronic conditions. There are mechanisms behind all of it. The immune system generally becomes less effective with age, a process called immunosenescence, while chronic low-grade inflammation increases. Chronic conditions compound that. In a 2023 study of more than 12 million people in England, immunocompromised people made up 4% of the population but 22% of COVID hospitalizations and 22% of COVID deaths, even though most were vaccinated.

That's why vaccine recommendations look different for different people. Older adults and people with moderate or severe immunocompromise, for example, are recommended to receive additional COVID vaccine doses, because their risk is higher and their protection may wane faster. Abandoning any of this would cost lives, and targeted recommendations exist so the people who stand to benefit most understand that the recommendation is about them.

We've paid much less attention to what the same message teaches everyone it doesn't name.

A healthy 40-year-old who reads that the highest risk sits with the elderly and the immunocompromised concludes that this isn't about her.

This isn't new, and it isn't specific to infectious disease. Years ago, early in my doctoral training, I was an intern in tobacco control at the New York City health department. My hypothesis was that social smokers, the ones who smoke at parties or on weekends but not every day, were glossing over the anti-smoking ads plastered all over the city, because in their own minds they weren't smokers and the risks weren't theirs.

We ran focus groups with young adult non-daily smokers and looked at survey data to test it, and that's roughly what we found. They didn't call themselves smokers. They didn't think occasional smoking carried real health risks. Several of them said their own doctors didn't treat them as smokers, either. A message works only if people hearing it recognize themselves in the description.

A healthy 40-year-old who reads that the highest risk sits with the elderly and the immunocompromised concludes that this isn't about her. She's right about the epidemiology. What she takes from it goes wrong in two places. "Higher risk" describes a difference between groups. People hear it as "everyone else has no risk." Then, once a disease belongs to an identifiable group of other people, the only argument we've given her to act is her own protection. That reason doesn’t work on someone who has just decided she isn’t at risk, and we rarely offer her another.

Measles offers a clean example of what that reasoning misses. Beyond the acute illness, the virus can erase part of the immune memory a person has spent years building. This isn't a complication confined to the old or immunocompromised. A 2019 study in Science found that children lost between 11% and 73% of their existing antibody repertoire after measles, and even children with mild infections lost a substantial share. I wrote in a previous CIDRAP Op-Ed about how many measles cases get missed when death is the only outcome we count.

Dismissing the vulnerable​

Risk stratification exists to direct protection toward the people most likely to be harmed. The phrase "only the old and the sick" distorts that same data into a reason to stop attending to those people. The analysis built to prioritize the vulnerable gets used to write them off.

Whether a death counts less because it happened to someone older or sicker is a moral question, and my answer is no. This piece is about a different problem: what happens to everyone else's sense of their own risk.

We didn't create that inversion, but our messaging can make it easier, and we haven't taken that seriously enough.

The category is not ‘other people’​

High-risk status isn't a fixed population. People age into it, and adults 65 and older are already about 18% of the country, with that share climbing. People also become pregnant. And they start immunosuppressive medications, receive transplants, get a cancer diagnosis, and develop conditions that change what an ordinary infection does to them. Every one of us begins life in one of the most vulnerable categories there is.

"Only the old and the sick" works as a phrase because it sounds like it describes a discrete population the reader isn't part of. The reality is that no one stays outside of it permanently.

What this means for how we message​

1. Lower is not the same as low, and low is not the same as none. "Higher risk" is a comparison between groups, not a statement about anyone's absolute odds. When we can give the absolute number, we should. Without one, "lower" becomes "none."
2. Admit that categories are porous. Some people are already inside one and don't know it, because nobody has ever told them their particular condition counts. Presenting high-risk status as a fixed trait of other people teaches the wrong thing about how risk works.
3. Talk about outcomes other than death. Immune amnesia after measles, encephalitis, long COVID, months of recovery after a hospitalization. These fall on people well outside the highest-risk groups, and they're what we mention least.

The risk factor people skip past ​

Everyone wanted to know how old the people in Lancaster County were. The state had said in its first announcement that both were unvaccinated, and that detail was in every story written about them. It just wasn't the answer anyone was looking for.

As of writing this, Pennsylvania has confirmed 497 cases (100 in the past week) and 87 hospitalizations, and not one case has occurred in a fully vaccinated person. Nationally, the latest CDC count is 2,903 cases, the highest total since 1991. Ninety-four percent of them are unvaccinated or have unknown vaccination status.

The risk factor staring us in the face isn't age. It’s vaccination status.

Kindergarten coverage of the measles, mumps, and rubella vaccine in Lancaster County has fallen from 95.5% in 2017 to 87.6% last school year. If cases keep climbing at this pace, the United States is on track to lose its measles elimination status, held since 2000, when the World Health Organization's regional body reviews the data this November.

For measles, the risk factor staring us in the face isn't age. It’s vaccination status. And unlike age, it's one that people can change.

Dr. Steier is a public health scientist and scientific communicator. She is the founder of Unbiased Science, an organization that uses data visualizations, real-world analogies, and human voice to communicate complex scientific concepts for public understanding via multiple media modalities.

The opinions voiced in CIDRAP Op-Ed pieces are the authors' own and do not necessarily represent the official position of CIDRAP.