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Over five days in August, Pennsylvania health officials called the Lancaster County Coroner’s Office at least three times and sent an email asking to discuss the death of an infant who had tested positive for measles.

They did not connect with coroner Stephen Diamantoni before Gov. Josh Shapiro came to the county to announce at an Aug. 25 news conference that two unvaccinated Lancaster residents had died in a growing measles outbreak, the state’s first measles-associated deaths in 35 years.

Soon after, the county coroner — an elected Republican who has presided over the office for nearly two decades — was telling reporters the state had not talked to him directly, raising questions about the state’s communications.

His comments, coupled with his position that he did not believe one of the two infants affected had died from measles, kicked off a viral exchange of misinformation cited by anti-vaccine activists — and spiraling up to federal health leaders — to discredit the dangers of Pennsylvania’s growing measles outbreak.

Now emails from the coroner’s office, obtained by The Inquirer through an open-records request, show that state officials made significant outreach to Diamantoni, far beyond his prior statements acknowledging only that his deputy spoke with state officials shortly before the news conference.

In fact, doctors from the state health department had tried to contact his office about the case for days, with increasing urgency. At one point, a doctor told one of Diamantoni’s staffers that they were ready “24/7” to speak with someone from the office.

Yet two weeks after the announcement, he continued to emphasize the state’s lacking communication in an in-person interview with The Inquirer. “I have not received any information directly from the state [health] department,” he said on Sept. 9.

By then, his statements had enabled President Donald Trump’s health secretary, Robert F. Kennedy Jr., to question whether the deaths reported in Pennsylvania were real.

The Centers for Disease Control and Prevention for weeks omitted the first two deaths and those subsequently reported by the state in its national reporting, marking an extraordinary departure from public health norms. As of Thursday, the agency had updated its tally to recognize two deaths nationally this year, while Pennsylvania has reported five measles-related deaths.

Asked to comment on the records, Diamantoni said he was not aware of the state’s outreach ahead of Shapiro’s announcement.

He said state officials should have been more explicit in the calls they made to his office staffers, who sent him and his deputy emails relaying messages. The communications did not make it clear that they needed to speak to him about a measles-associated death, Diamantoni said, adding that he is easy to reach.

“It didn’t sound like there was urgency. It didn’t sound like anyone indicated that there was a measles death that we want to talk to the coroner about,” he said.

Public officers like Diamantoni have an obligation to ensure staff can get timely messages to him, especially in a public health emergency like a measles outbreak, said Kathleen Hall Jamieson, director emerita of the Annenberg Public Policy Center at the University of Pennsylvania. Likewise, she noted, state officials must ensure communications with the public are transparent and easy to understand.

State officials did not immediately say how they define a “measles-associated death” and have provided few details on the deaths themselves, leaving county coroners to fill in the blanks.

Public health experts have noted that the politically charged back-and-forth and competing narratives around the deaths risks confusing the public at a time when clarity is crucial — amid the largest measles outbreak in the country, with state officials reporting nearly 1,000 cases and five measles-associated deaths.

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The contradictory communications from the state and the local coroner’s office around the initial Lancaster deaths set the stage for Kennedy to attack Shapiro in an X post, claiming the Democratic governor may have “fabricated” two of the deaths in Pennsylvania.

Shapiro has sharply criticized Kennedy, a longtime anti-vaccination advocate, for spreading misinformation about vaccine safety and Pennsylvania’s outbreak, now the largest in the nation this year, with the most deaths reported by any state since 1992.

Asked for comment on communications with Diamantoni, state officials provided a statement by email saying Pennsylvania law bars them from providing further information on the initial measles-associated deaths.

The health department’s epidemiology team “thoroughly investigates and verifies” measles-associated deaths to ensure that they meet the state’s definition, and does not announce deaths until they have finished an investigation, health department press secretary Neil Ruhland said in an email.

He said state law does not require the department to report deaths to a coroner’s office; rather, coroners and “other certifiers” report deaths to the state health department.

“PA DOH has followed this explicit process for all measles-associated deaths in Pennsylvania,” Ruhland wrote.

‘No one looks good’

News outlets began calling Diamantoni as soon as the first measles-related deaths were reported in Lancaster, where he is a family medicine doctor and former Lancaster City Council president. First elected to the coroner’s office in 2007, he said he views his duties as apolitical and describes himself as a strong advocate for vaccination.

He told media outlets he had been surprised by the state’s announcement, as his office had not identified any deaths from measles.

The office had investigated the death of an infant who tested positive for the disease, but Diamantoni has maintained that the child had died from a lacerated spleen, not the highly contagious illness.

As his claims were widely reshared on social media and in national media stories, state officials said they stood by their findings that both deaths were measles-related. They were not told that the infant’s death was not associated with measles, they said.

Diamantoni told The Inquirer repeatedly that state health officials had never spoken personally with him about the death of an infant later identified as Ivan Miller, who was hours old when he died on Aug. 14.

He said that state health officials had only reached out hours before their news conference, and that his deputy, Eric Bieber, had spoken to them.

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Internal office records reveal that five days before the news conference, a staffer in the coroner’s office e-mailed Diamantoni, saying that an infectious-disease doctor with the state health department was looking to speak to “one of you” about “the positive measles case with the infant we just had.”

The state health department followed up on its initial Aug. 20 call with subsequent emails and calls on Aug. 21, a Friday, and Aug. 24, the following Monday, records show.

One doctor included his state-issued cell phone number in an email to a coroner’s office staffer and Bieber and emphasized that he was available “24/7” to discuss the case.

When Bieber spoke to representatives from the state health department on Aug. 25, the office did not realize that the state was about to announce two measles-associated deaths, according to Diamantoni.

Diamantoni added that since he did not believe Ivan Miller’s death was caused by measles, he had not been expecting any outreach from the state.

“I don’t think it would have brought a red flag to me. It just looked like a request we usually receive from different individuals, different agencies, requesting cause and manner information,” Diamantoni said.

Yet it is the responsibility of public officials to establish communication procedures at their offices, especially when a contagious disease is spreading and the public needs clear information, according to Penn’s Jamieson.

In public offices, she said, “you shouldn’t be seeing a situation in which the person doesn’t get the information, or is able to say, ‘I didn’t get it.’”

State officials could have communicated more clearly in announcing the deaths as well, she said, noting that they did not immediately define “measles-associated death” in an initial news release.

Jamieson said it is important for health officials to explain “what we know, what we don’t know, and how we’re finding out what we don’t know” in terms the public can understand.

“Anytime the public is listening to voices that are supposed to be speaking with authority, and the public, instead of hearing a clear message, is confused, you have a problem,” she said. “No one looks good.”

Measles-associated deaths in Pennsylvania

State officials have repeatedly cited state privacy laws in response to criticism of their communications, saying they cannot provide detail about how they investigated the measles-associated deaths.

The state defines a measles-associated death as one that occurs within 30 days of symptom onset in a person with clinical evidence of infection and a positive laboratory test for measles, and who did not die of another unrelated cause, like a car crash.

Officials have provided little information beyond the fact that none of the five people who have died were vaccinated, and their county of residence.

Local coroners like Diamantoni have offered more details.

For example, in early September, Jefferson County’s coroner, also an elected Republican, confirmed the death of a 40-year-old woman from measles. He disclosed that the woman also had severe respiratory conditions, including chronic obstructive pulmonary disease, that made her vulnerable to serious complications from a respiratory illness like measles.

Later in the same week, the Mifflin County coroner, another Republican, confirmed that an unvaccinated 18-year-old had died from a rare neurological complication of measles.

Diamantoni has shared that Ivan Miller, who died at a birthing center in Lancaster County, tested positive for a measles infection acquired before birth. His family, who is Amish, told the Atlantic that his mother had a severe case of measles and gave birth early.

Although Diamantoni did not consider measles to have caused the death, he said, measles was included on the boy’s death certificate in a section that lists “significant conditions contributing to death but not resulting in the underlying cause.”

Physicians have noted that measles can weaken the spleen, putting it at risk of rupture. Diamantoni cited a lacerated spleen as the primary cause of death.

The second death, another Amish infant, was not initially reported to Diamantoni; Lancaster’s Clinic for Special Children, which treats Amish children with genetic conditions, had treated the baby until her death.

Diamantoni’s office investigated the death about a week after the state’s news conference; he later told reporters that the baby was 6 weeks old and had Amish lethal microcephaly, a fatal genetic condition that makes respiratory illnesses particularly risky. Diamantoni said measles caused the baby’s death.

On Wednesday, state health officials announced a fifth death, a Lancaster County resident who tested positive for measles and died. Diamantoni told The Inquirer that he had not handled that death, but that state health officials had informed him about it. He said they provided no further information.

State officials did not say whether the person, who was unvaccinated, died in Lancaster County.

Diamantoni told an Inquirer reporter in early September that he was proud that his office was one of the first in the country to be certified by the International Association of Coroners and Medical Examiners.

“People may not always agree with our findings, but they’re well investigated and well thought out,” he said.

Staff writer Gillian McGoldrick contributed to this article.