Pennsylvania’s health department requested CDC emergency Epi-Aid assistance for a measles outbreak exceeding 700 cases and four measles-associated deaths—but said it would rescind the ask if the CDC will not publicly recognize those fatalities, escalating a standoff with HHS Secretary Robert F. Kennedy Jr.

In a letter to CDC Director Erica Schwartz reviewed by Reuters, state Health Secretary Debra Bogen wrote that refusing to recognize the deaths “undermines our response.” When the first two fatalities were announced Aug. 25, cases stood at 393 across 28 counties; the outbreak has since spread across 37 counties. Penn State’s Matthew Ferrari said true burden could be far larger and that state caution about misaligned federal messaging on death counts is understandable. MMR vaccination doses administered by the state fell from over 3,500 in August to about 1,100 in the first half of September.

Kennedy has cast doubt on whether reported U.S. measles deaths were caused by the virus and instructed CDC not to include Pennsylvania’s fatalities in national tallies—moves disease experts call unusual interference. He and Schwartz have blamed Governor Josh Shapiro for not accepting earlier Epi-Aid offers; Shapiro has criticized Kennedy’s vaccine skepticism. HHS spokesperson Grace Davis Jamison said CDC had not received the request through “normal channels,” that assistance and fatality tabulation are separate, and that CDC “will not submit to political blackmail.”

State and federal sides agree Pennsylvania faces a large outbreak and has discussed CDC help. They clash over cause attribution and whether counting deaths can be a condition of aid—leaving outbreak response entangled with national vaccine-policy conflict during the worst U.S. measles resurgence in more than three decades.