A few years back, someone close to me died in California and I found myself helping the family deal with obtaining the state certificate of death. I remember being somewhat surprised to learn that California death certificates do not simply list a cause of death, as do some other states. An “immediate cause of death” is listed, of course, but so, too, is the “immediate underlying cause” and then other factors or conditions are listed sequentially that led to the death. Some might say that California death certificates tell more than they need because they read like mini-novels about the end of a person’s life. I do, however, wish the whole country were on such a system as that would make it easier to report on one difficult aspect of the cantaloupe-related Listeria outbreak involving Jensen Farms – how many people actually were killed in the tragic event. As Eric and Ryan Jensen went back to U.S. District Court in Denver this past week to plead guilty to six federal misdemeanor counts each, almost all media reported that the Listeria outbreak connected with Jensen Farms cantaloupe resulted in 33 deaths. That was the final official number in the report from the U.S. Centers for Disease Control and Prevention in Atlanta issued on Aug. 27, 2012. That report was titled “Final Update Addendum.” It adds three people to the death toll. CDC’s “FINAL Update” was issued almost a year earlier on Dec. 8, 2011, just weeks after the outbreak. CDC was reacting to those with family members who were victims of the outbreak whose deaths were happening later or from secondary causes. So, in addition to adding the three deaths to that “FINAL Update Addendum,” CDC also added this: “Ten other deaths not attributed to Listeriosis occurred among persons who had been infected with an outbreak-associated subtype. State and local public health officials reviewed causes of death listed on death certificates to determine whether to attribute these deaths to Listeriosis. Deaths included in this review occurred as recently as February 29, 2012.” One lesson we’ve learned in the major Listeria outbreaks that have occurred in the U.S. and Canada is that many of the elderly victims never really recover. They require continuous care, often never leaving a hospital or residential care facility once they’ve been infected with Listeriosis. In states with simple death certificates, the one-line cause of death might be pneumonia. But only in a state such as California would the family have a document showing the “immediate underlying” cause of death was Listeriosis. At Food Safety News, we believe that all the deaths attributed to the outbreak should be counted since it’s clear these lives were shortened because they had the great misfortune to consume contaminated cantaloupe. That’s why we report that up to 43 deaths can be blamed on the outbreak, not 33, and the fatality rate for the overall outbreak is just shy of an astounding 30 percent. Families of victims also want the truth. CDC, as the lead on these matters for state and local health agencies, needs to come up with a system that does not rely upon the widely varying state death certificates for tracking victim outcomes to the end. More states could also adopt the California-style death certificates. They document enough information on the death to allow one to ask the “but for” question. In other words, were it not for the Listeria, would this person have died when they did? We have no doubt that is how the families who lost someone in this outbreak view it, and this reality should have an official status. CDC and state and local health agencies need to begin understanding that their role is not just to do lab work, but to also engage with the victims of these outbreaks. And follow them all the way to the end.