BUDAPEST — In the days since the Hungarian Parliament gave Prime Minister Viktor Orban the right to rule indefinitely by decree, nominally in the name of combating the coronavirus pandemic, his government has been energized by much other than the disease.
First, his deputy briefly toyed with a plan to strip powers from city mayors, many of whom represent opposition parties. Then he threw a cloak of secrecy over one of Hungary’s most expensive infrastructure projects, announcing a bill that would classify key information about a Chinese-funded railway for a decade. Next, he slashed bureaucratic obstacles to expedite a contentious construction project opposed by the opposition. Finally, he announced plans to scrap state recognition of gender transition.
By comparison, Mr. Orban took a gentler approach to testing for the coronavirus.
By Saturday, Hungarian officials had detected fewer than 700 cases, one of the lowest tallies in the European Union. The chief medical officer, Cecilia Muller, also said that the disease was still spreading only within clusters of people, rather than through the general population at large. On Sunday, reported cases grew to 733.
But some doctors fear that the numbers are so low only because the government has tested so few people. By Saturday, officials had conducted fewer than 20,000 tests — also one of the lowest totals, as a proportion of the national population, in the European Union.
“We do not have enough tests, so we do not know the realistic data,” said Balazs Rekassy, a former manager of a state health clinic who advises the Budapest mayor, an opponent of Mr. Orban, on medical matters.
“Mr. Orban is very smart — he’s taking this special situation to his advantage,” said Dr. Rekassy. “He’s trying to strengthen his power and create long-term political advantages.”
New restrictions on journalism that the government deems fake and harmful to the coronavirus response have made it harder to research the scale of the pandemic in Hungary. Many doctors are now reluctant to speak out publicly about specific problems, individual hospitals have been barred from releasing information and journalists are warier of publishing it.
But beneath the veil of silence, there are indications that the situation may be graver than records show.
The coronavirus may have begun to spread through the Hungarian population nearly a month ago, in a process technically known as community transmission, according to a secret readout written by a foreign diplomat who had been briefed in early March by the country director for the World Health Organization, Dr. Ledia Lazeri. The readout was later obtained by The New York Times.
Dr. Muller, the chief medical officer, said on Friday that Hungary was still in the cluster-spreading phase. She hinted that the country was on the threshold of community transmission.
But according to the diplomat’s secret readout, the W.H.O. privately believed that community transmission had begun by the second week of March, since the disease’s first known victims in Hungary moved freely through the country before being diagnosed and one even left for Serbia.
The main facility used for testing at that time, St. Laszlo Hospital in Budapest, was also helping to spread the disease rather than contain it, because infected people were unwittingly mingling there with those yet to catch the disease, the readout stated.
The W.H.O. also concluded that the Hungarian government’s data was unreliable, since so few people were being tested, the readout said.
Asked to comment on the readout, Dr. Lazeri denied making these assessments. An independent epidemiologist currently advising the government, Gergely Roth, also said the country had not yet entered the community transmission phase, and said the term had a contested definition.
But diplomats from other missions said they had heard troubling information from a W.H.O. official.
The W.H.O. did not comment when asked three times whether the organization believed Hungary had entered the community transmission phase. But a spokesperson said on Saturday night that the W.H.O. was “working with countries to define their transmission status according to a new ranking system,” and noted that as of Saturday night the Hungarian government considered the country to be “entering community transmission.”
As of Sunday, only 34 people are reported to have died from the virus in Hungary, but doctors worry that some deaths may have been attributed to other causes. A 99-year-old woman who died on March 11 in Budapest was reported to have died of pneumonia, even though her daughter, who visited her regularly and fell ill with similar symptoms at the same time, later tested positive for the virus.
The government has also quietly closed parts of the St. Imre Hospital in Budapest, after the disease spread among staff, two senior state doctors said on condition of anonymity. The hospital declined to comment, referring reporters to a government spokesman, who did not reply to two requests.
Some critics said the government had been slow to use the test facilities it already had at its disposal. Officials did not start testing at laboratories at the Semmelweis Medical School, which alone has the capacity to process at least 400 tests per day, until mid-March.
Like many other countries, “Hungary did not respond in time,” said Andras Falus, a professor emeritus at the school.
But other doctors praised the government as doing a good job in tough circumstances, at a time of profound economic upheaval in which no country has tested enough people, let alone perfected its response to the pandemic.
“I do not see right now, for the time being, that there is a big turd in the crepe,” said Gabor Zacher, an emergency doctor with the Hungarian ambulance service. Dr. Zacher has criticized the government’s health measures in the past, but praised its recent social distancing measures.
Hungary implemented social distancing measures earlier than several other European countries, said Gergely Rost, an epidemiologist whom the government recently enlisted to advise Mr. Orban on the likely spread of the virus.
“As a consequence, we still don’t have too many,” said Dr. Rost, a lecturer at the University of Szeged, a college in southeastern Hungary. “At the moment, the epidemic is pretty much suppressed.”
Because of a lack of tests, the real number of cases is likely to be up to nine times higher than the current tally of infections, Dr. Rost said. But “numbers are underestimated in every country, even those who have tested more.”
For some, the problems with Mr. Orban’s response to the pandemic stem less from his actions since the start of the crisis, and more from his systemic neglect of Hungarian health care since re-entering office in 2010.
Under Mr. Orban, his government’s health care budget dropped as a proportion of national economic output, even as state spending rose in other sectors. He also abolished the Health Ministry, assigning its responsibilities to a larger department.
Around 10 percent of Hungarian doctors left the country in the first seven years of Mr. Orban’s current tenure in search of better-paid work, senior doctors estimated. The salary of a Hungarian general practitioner, as a proportion of the average national wage, is one of the lowest in Europe.
Under Mr. Orban, the cancer death rate rose and is tied for the worst in the European Union. Even before the coronavirus outbreak, the government refused to disclose the number of infections contracted in state hospitals for fear of alarming the public.
In the context of the coronavirus, his government’s most unhelpful action was the dismantling in 2017 of a state-run health authority that included a dedicated team of epidemiologists. Following the authority’s closing, these experts on pandemics either left government or were dispersed to other parts of the health system, undermining the government’s ability to react to a disease like the coronavirus.
“The extremely well-functioning pandemic defense network was weakened in recent years,” says Erzsebet Pusztai, a health care expert. “The previous unified organization was taken apart and distributed under government offices, and many experts left. And this serious pandemic found it in a very weakened condition.”
Years of low funding have left health facilities under-resourced, and contributed to a recent row about whether the government or health care workers should pay for their masks and visors.
“Health care workers are going unarmed into battle — we hardly have any protective masks,” said Dr. Peter Lehoczky, the director of outpatient care in a district of Budapest. “The feeling is that we are trying to shoot down a rocket with a slingshot.”
Benjamin Novak reported from Budapest, and Patrick Kingsley from Berlin.
WASHINGTON — The Trump administration is close to recommending that all Americans wear cloth masks if they go out in public, a change in position that reflects new concerns that the coronavirus is being spread by infected people who have no symptoms and new data suggesting the United States is not yet slowing the rate of infections.
At a White House briefing Thursday evening, both President Trump and Vice President Pence said that new guidance on masks would be issued by the Centers for Disease Control and Prevention in the coming days. But the comments of both Mr. Trump and a top official on the administration’s coronavirus response task force during the session suggested that the issue hasn’t been entirely resolved within the administration.
“If people want to wear them, they can,” President Trump said, declaring that while the administration was “coming out with regulations” on mask wearing soon, whether to follow them was a personal choice.
Dr. Deborah Birx, the White House’s coronavirus response coordinator, sounded a sharper note of caution, saying that she did not want Americans to get a false sense of security from wearing masks. Washing hands and keeping six feet away from other people were more protective steps, she said, and suggested that the still-unannounced new guidance remained under debate.
“The eyes are not in the mask. If you are touching things and touching your eyes, you’re exposing yourself in the same way,” Dr. Birx said. “This will be an additive piece if it comes out, rather than saying it is a substitute for it. It is not a substitute for the presidential guidelines that have already gone out.”
During the same briefing, Dr. Birx suggested that despite all the harsh measures such as stay-at-home orders and business closures, the U.S. is not yet flattening the spike in new infections.
“We have to change that slope. We have to change the logarithmic curve that we’re on,” she said of the steep increases in cases in many parts of the country. “We see country after country having done that, what it means in the United States is not everyone is doing it.”
Dr. Birx said that recommendations against gatherings of more than 10 do not mean people should be having dinner parties or cocktail parties of less than 10 people.
“We’re only as strong is every community, every county, every state, every American following the guidelines to a tee,” she said. “And I can tell by the curve, and as it is today that not every American is following it. And so this is really a call to action.”
Her caveats on masks reflect what has been a common view among many public health bodies about the effectiveness of masks for the general public. Until now, the C.D.C., like the World Health Organization, has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason has been to preserve medical-grade masks, including N95 respirator masks, for health care workers who desperately need them at a time when they are in continuously short supply.
Still, as the coronavirus devastates the United States, the C.D.C. has been drafting new guidelines recommending that everyone wear face coverings in public settings, like pharmacies and grocery stores, to avoid unwittingly spreading the virus, according to a federal official.
Public health officials have continued to stress, however, that N95 masks and surgical masks should be saved for front-line doctors and nurses, who have been in dire need of protective gear. In the briefing, President Trump suggested that homemade face coverings, like scarves, would suffice.
On Wednesday, Mayor Eric Garcetti of Los Angeles urged a similar approach, suggesting that all of that city’s residents to wear homemade nonmedical face coverings, or even bandannas, when food shopping or doing other essential errands. Health officials in Riverside County, Calif., made a similar recommendation on Tuesday.
Since the beginning of the coronavirus outbreak, the Trump administration has had shifting positions on whether regular citizens should cover their faces in public.
“Seriously people — STOP BUYING MASKS!” the surgeon general, Dr. Jerome M. Adams, said in a tweet in late February. “They are NOT effective in preventing general public from catching #Coronavirus, but if health care providers can’t get them to care for sick patients, it puts them and our communities at risk!”
He was most concerned about widespread hoarding of the tightfitting N95 masks that can stop infectious particles even finer than a micron in diameter, and that even many health care workers have not been able to find.
But earlier this week, Mr. Trump said that broad use of nonmedical masks, at least, was “certainly something we could discuss.”
Dr. Robert Redfield, the director of the C.D.C., confirmed in a radio interview earlier this week that the agency was reviewing its guidelines on who should wear masks. Citing new data that shows high rates of transmission from people who are infected but show no symptoms, he said the guidance on mask wearing was “being critically re-reviewed, to see if there’s potential additional value for individuals that are infected or individuals that may be asymptomatically infected.”
While wearing masks to prevent the spread of disease is a widely accepted practice in many Asian countries, it remains to be seen how Americans would react to such a recommendation. But a growing number of public health experts have been recommending universal mask use.
A recent white paper from the American Enterprise Institute had argued the move could have substantial public health benefits. One of its authors, the former F.D.A. commissioner Scott Gottlieb, had been forcefully advocating for the policy in media appearances.
And a white paper from a group of Yale researchers released on Thursday estimated that universal mask use could reduce infections by around 10 percent, creating a value of $3,000 to $6,000 per American, based on estimates of the value of saved lives. The authors included Sten H. Vermund, the dean of the Yale School of Public Health, and Albert Ko, the chairman of Yale Medical School’s department of epidemiology and microbial diseases.
Both papers recommended that members of the public wear homemade cloth masks, to preserve limited supplies of surgical masks and higher-grade respirators for health care workers.
“It is critically important that public adoption not come at the expense of medical mask availability for health workers,” said Jason Abaluck, an associate professor of economics at the Yale School of Management and a co-author of the paper. “This is why we emphasize universal adoption of cloth masks.”
The researchers emphasized that the primary benefit of mask wearing was to prevent infected people from spreading the virus by expelling infected droplets.
As many as 25 percent of people infected with the new coronavirus may not show symptoms, the director of the Centers for Disease Control and Prevention warns — a startlingly high number that complicates efforts to predict the pandemic’s course and strategies to mitigate its spread.
In particular, the high level of symptom-free cases is leading the C.D.C. to consider broadening its guidelines on who should wear masks.
“This helps explain how rapidly this virus continues to spread across the country,” the director, Dr. Robert Redfield, told National Public Radio in an interview broadcast on Tuesday.
The agency has repeatedly said that ordinary citizens do not need to wear masks unless they are feeling sick. But with the new data on people who may be infected without ever feeling sick, or who are transmitting the virus for a couple of days before feeling ill, Mr. Redfield said that such guidance was “being critically re-reviewed.”
Researchers do not know precisely how many people are infected without feeling ill, or if some of them are simply presymptomatic. But since the new coronavirus surfaced in December, they have spotted unsettling anecdotes of apparently healthy people who were unwitting spreaders.
“Patient Z,” for example, a 26-year-old man in Guangdong, China, was a close contact of a Wuhan traveler infected with the coronavirus in February. But he felt no signs of anything amiss, not on Day 7 after the contact, nor on Day 10 or 11.
Already by Day 7, though, the virus had bloomed in his nose and throat, just as copiously as in those who did become ill. Patient Z might have felt fine, but he was infected just the same.
Researchers now say that people like Patient Z are not merely anecdotes. For example, as many as 18 percent of people infected with the virus on the Diamond Princess cruise ship never developed symptoms, according to one analysis. A team in Hong Kong suggests that from 20 to 40 percent of transmissions in China occurred before symptoms appeared.
The high level of covert spread may help explain why the novel coronavirus is the first virus that is not an influenza virus to set off a pandemic.
The new virus spreads about as easily as flu, “and when’s the last time anyone thought anything about stopping influenza transmission, short of the vaccine?” said Dr. Michael T. Osterholm, an infectious disease expert at the University of Minnesota.
With any vaccine still in early development, the best way to mitigate the pandemic is social distancing, he and other experts said. Because people may be passing the virus on to others even when they feel fine, asking only unwell people to stay home is unlikely to be enough. This is why many experts, going against recommendations by the C.D.C. and the World Health Organization, are now urging everyone to wear masks — to prevent those who are unaware they have the virus from spreading it.
Like influenza, some experts now say, this virus appears to spread both through large droplets and droplets smaller than five micrometers — termed aerosols — containing the virus that infected people might release especially while coughing, but also while merely exhaling. They emphasized that the level of virus in both types of particles is low, so simply jogging or walking by an infected person does not put people at risk.
“If you have a passing contact with an infectious person, you would have a very, very low chance of transmission occurring,” said Dr. Benjamin Cowling, an epidemiologist at the University of Hong Kong.
The risk goes up with sustained contact — during face-to-face conversation, for example, or by sharing the same air space for a prolonged time. In addition to its confusing stance on masks, “the W.H.O. has been saying aerosol transmission doesn’t occur, which is also perplexing,” Dr. Cowling said, adding, “I think both are actually wrong.”
Experts agreed that infections were being passed along by people who do not report symptoms — what they call asymptomatic transmissions — but they also noted some confusion around the term.
“There’s no standard definition for it, and you could say to yourself, Well, that’s kind of ridiculous: You either have symptoms or you don’t,” said Dr. Jeffrey Shaman, an infectious diseases expert at Columbia University. But studies by his team have shown, he said, that some people never notice their symptoms, others are unable to distinguish the infection from their smoker’s cough or allergies or other conditions, and still others may feel every pain acutely.
There is also a largely semantic debate about what proportion of people who appear to be perfectly fine but then become ill — as in the report in The New England Journal of Medicine of an apparently asymptomatic spreader who later acknowledged having felt mild symptoms.
Ultimately, Dr. Shaman said, these definitions are unimportant.
“The bottom line is that there are people out there shedding the virus who don’t know that they’re infected,” he said.
Where the definitions may matter is in being able to understand the true scope of the pandemic.
Dr. Cowling’s team has analyzed data from China at various stages in the pandemic. The W.H.O.’s mission to China concluded that most people who were infected with the virus had significant symptoms. But in the early weeks of the epidemic, his analysis shows, China set a high bar for what constituted a confirmed case of infection — requiring respiratory symptoms, fever and a chest X-ray for pneumonia.
Their definition left out mild and asymptomatic cases and, as a result, the team vastly underestimated the scale and nature of the outbreak there.
“We’ve estimated in China that between 20 percent and 40 percent of transmission events occurred before symptoms appeared,” Dr. Cowling said.
A separate analysis of the hundreds of people cloistered aboard the Diamond Princess cruise ship bears out this scale. Once the ship docked in Japan on Feb. 5, researchers tested all of the passengers and reviewed those who tested positive for the virus on multiple occasions over a two-week period. They found that 18 percent of the infected passengers remained symptom-free throughout.
“The substantial asymptomatic proportion for Covid-19 is quite alarming,” said Dr. Gerardo Chowell, an epidemiologist at Georgia State University who worked on the analysis.
Dr. Chowell noted that the passengers on the ship tended to be older and therefore more likely to develop symptoms. He estimated that about 40 percent in the general population might be able to be infected without showing signs of it.
There have also been many hints, subtle and not, that the virus can be transmitted via aerosols. Sixty members of a choir in Seattle gathered on March 10 for a practice session for over two and a half hours. None of them felt ill, and they made no contact with one another. But by this weekend, dozens of the members had fallen ill, and two had died.
Their experience points toward airborne transmission via aerosols, which can travel farther than the large droplets the W.H.O. and the C.D.C. have emphasized. The virus is still most likely to be expelled with a cough or a sneeze, as far as eight meters (about 26 feet), according to one study. But studies on influenza and other respiratory viruses, including other coronaviruses, have shown that people can release aerosols containing the virus simply by breathing or talking — or, presumably, by singing.
“I think increasing evidence suggests the virus is spread not just through droplets but through aerosols,” Dr. Chowell said. “It would make a lot of sense to encourage at the very least face mask use in enclosed spaces including supermarkets.”
Several studies have shown now that people infected with the new coronavirus are most contagious about one to three days before they begin to show symptoms. This presymptomatic transmission was not true of the coronaviruses that caused SARS and MERS.
“This is where we got very lucky with SARS, was that it really didn’t transmit until after people were showing symptoms, and that made it much easier to detect it and shut it down with aggressive public health measures,” said Dr. Carl Bergstrom, an expert in emerging infectious diseases at the University of Washington in Seattle.
With the new coronavirus, there is transmission by healthy-seeming people, and often severe symptoms and a high fatality rate. “That whole combination makes it very, very tough to fight using standard public health measures,” he said.
A separate analysis from the C.D.C. on Tuesday offered new evidence that a significant portion of people with severe coronavirus infections in the United States have underlying medical conditions. The agency looked at 7,162 cases, a small subset of the 122,000 cases in the U.S., but the findings provided a stark portrait. Of 457 people in that subset who were admitted to intensive care units, 32 percent suffered from diabetes; 29 percent had heart disease; and 21 percent had lung disease. Overall, 78 percent of people with Covid-19 admitted to the I.C.U. had at least one pre-existing condition. The study did not look at deaths.
Rapid tests for infection might help detect people, especially health care workers, who are infected yet feel normal. Masks may help. But experts kept returning to social distancing as the single best tool for stopping the chain of transmission in the long term — not lockdowns, necessarily, but canceling mass events, working from home when possible and closing schools.
“We can’t assume that any of us are not potential vectors at any time,” Dr. Bergstrom said. “This is why even though I’m feeling great, and have felt great and haven’t been exposed to anybody with any symptoms of anything, that’s why it would be irresponsible of me to go out and about today.”
Matt Richtel contributed reporting.
Should healthy people be wearing masks when they’re outside to protect themselves and others?
Both the World Health Organization and the Centers for Disease Control and Prevention have repeatedly said that ordinary citizens do not need to wear masks unless they are sick and coughing. And as health care workers around the world face shortages of N95 masks and protective gear, public health officials have warned people not to hoard masks.
But those official guidelines may be shifting.
On Monday during the coronavirus task force briefing, President Trump was asked whether Americans should wear nonmedical masks. “That’s certainly something we could discuss,” he said. “It could be something like that for a limited period of time.”
Dr. Robert Redfield, the director of the C.D.C., confirmed in an interview with WABE in Atlanta, a National Public Radio member station, on Monday that the agency was reviewing its guidelines on who should wear masks. Citing new data that shows high rates of transmission from people who are infected but show no symptoms, he said the guidance on mask wearing was “being critically re-reviewed, to see if there’s potential additional value for individuals that are infected or individuals that may be asymptomatically infected.”
The coronavirus is probably three times as infectious as the flu, Dr. Redfield said. Some people are infected and transmitting the virus probably as long as two days before showing any symptoms, he said. “This helps explain how rapidly this virus continues to spread across the country, because we have asymptomatic transmitters and we have individuals who are transmitting 48 hours before they become symptomatic,” Dr. Redfield said in the interview.
“That’s important, because now you have individuals that may not have any symptoms that can contribute to transmission, and we have learned that in fact they do contribute to transmission,” Dr. Redfield said.
A federal official said Tuesday that the C.D.C.’s review of mask wearing for the public stemmed from a request by the White House coronavirus task force, which is leaning toward recommending it.
One concern, which Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, voiced in an interview with CNN, is that such a recommendation could cause even worse shortages of N95 and other medical masks for health care workers, who need them most.
“You don’t want to take masks away from the health care providers who are in a real and present danger of getting infected,” Dr. Fauci, a member of the task force, said on CNN on Tuesday morning.
Nonetheless, Dr. Fauci said: “The idea of getting a much more broad communitywide use of masks outside of the health care setting is under very active discussion at the task force. The C.D.C. group is looking at that very carefully.”
Masks work by stopping infected droplets spewing from the wearer’s nose or mouth, rather than stopping the acquisition of the virus from others. Both medical grade N95 masks and flat face masks are made of a special melt-blown fabric, which is able to stop infectious particles even finer than a micron in diameter. But in many Asian countries, where everyone is encouraged to wear masks, the approach is about crowd psychology and protection.
If everyone wears a mask, individuals protect one another, reducing overall community transmission. And places like Hong Kong and Taiwan that jumped to action early with social distancing and universal mask wearing have gotten their cases under much greater control.
There have been troubling reports that indicate the coronavirus may be able to travel farther in the air and stay in the environment longer than is possible by respiratory droplets, which have so far been assumed to be the primary mode of transmission of the virus.
One study in Singapore found traces of the virus in air vents in patient isolation rooms. In another study, researchers at the University of Nebraska Medical Center detected extensive contamination in patient rooms as well as in air samples collected from the hallways outside rooms.
Dr. Scott Gottlieb, the former commissioner of the Food and Drug Administration, said in an interview on Sunday that the C.D.C. should put out designs for cloth masks for the public. “The value of the mask isn’t necessarily to protect you from getting sick, although it may offer some protection,” he told CBS News. “It’s to protect you from other people. So when someone who’s infected is wearing a mask, they’re much less likely to transmit infection.”
He said studies involving the flu suggested that you could reduce your ability to spread the flu by about 50 percent if you wore a mask.
This is what the C.D.C.’s guidelines currently say:
“If you are sick: You should wear a face mask, if available, when you are around other people (including before you enter a health care provider’s office). If you are caring for others: If the person who is sick is not able to wear a face mask (for example, because it causes trouble breathing), then as their caregiver, you should wear a face mask when in the same room with them. Visitors, other than caregivers, are not recommended.
“Note: During a public health emergency, face masks may be reserved for health care workers. You may need to improvise a face mask using a scarf or bandana.”
In the radio interview, Dr. Redfield also emphasized that social distancing, staying at least six feet away from others in public spaces, and staying home, were important measures to keep in place for now.
LONDON — When Boris Johnson was campaigning for Britain to leave the European Union in 2016 — a path that many experts warned would end in disaster for the country — one of his close allies, Michael Gove, famously declared that “people in this country have had enough of experts.”
Now, Mr. Gove and Mr. Johnson are leading the British government as it confronts the calamity of the coronavirus, and Mr. Johnson, now the prime minister, insists the process is being guided by experts. The trouble is, those experts can often disagree with each other or change their minds about the right course of action.
That messy back-and-forth has been on vivid display this week with the publication of a startling new report on the virus from a team at Imperial College in London. The report, which warned that an uncontrolled spread of the disease could cause as many as 510,000 deaths in Britain, triggered a sudden shift in the government’s comparatively relaxed response to the virus.
American officials said the report, which projected up to 2.2 million deaths in the United States from such a spread, also influenced the White House to strengthen its measures to isolate members of the public.
Imperial College has advised the government on its response to previous epidemics, including SARS, avian flu and swine flu. With ties to the World Health Organization and a team of 50 scientists, led by a prominent epidemiologist, Neil Ferguson, Imperial is treated as a sort of gold standard, its mathematical models feeding directly into government policies.
But outside experts pointed out that the report’s alarming conclusions — that the virus would overwhelm hospitals and that governments had no choice but to impose radical lockdown policies — had been made in previous reports on coronavirus or on social media sites devoted to the outbreak.
“A lot of it is not what they say, but who says it,” said Devi Sridhar, director of the global health governance program at Edinburgh University. “Neil Ferguson has a huge amount of influence.”
Imperial College, experts noted, was part of the advisory group for the government’s now-abandoned strategy, which played down radical social distancing and accepted that the infection would spread through the population. The theory is that this would build up so-called “herd immunity,” so that the public would be more resistant in the face of a second wave of infections next winter.
But such a strategy, the report noted, would lead to a flood of critically ill patients in a country without enough beds. Instead, it said, Britain needs to pursue “suppression,” which involves far stricter lockdowns, like the closing of schools and the quarantine of infected people and their families. That would drive down the number of cases and spread out the flow of patients over a longer period, allowing hospitals to cope.
Dr. Ferguson has been candid that the report reached new conclusions because of the latest data from Italy, which has seen a spiraling rate of infections, swamping hospitals and forcing doctors to make agonizing decisions about who to treat.
“The U.K. has struggled in the past few weeks in thinking about how to handle this outbreak long term,” Dr. Ferguson said in an interview on Monday, just after the report was released. “Based on our estimates and other teams’, there’s really no option but follow in China’s footsteps and suppress.”
The report added, “this conclusion has only been reached in the last few days, with the refinement of estimates of likely ICU demand due to COVID-19 based on experience in Italy and the UK.”
But other experts said the burden on hospitals was clear as far back as the original outbreak in Wuhan, China. Lancet, the British medical journal, published an article in January, based on studying a small group of patients, which found that a third of people had to be admitted to intensive care units.
“I can’t help but feel angry that it has taken almost two months for politicians and even ‘experts’ to understand the scale of the danger from SARS-CoV-2,” said Richard Horton, the editor-in-chief of Lancet, on Twitter. “Those dangers were clear from the very beginning.”
Some said governments should treat the report’s projections about suppression policies with the same caution. It says social distancing measures might have to be imposed for 18 months or more, at least intermittently, until a vaccine is developed and tested. But the report acknowledges this is uncertain, given the possibility of drug treatments and the mystery of how the virus is transmitted.
“We’re all using the 1918 pandemic flu handbook,” Dr. Sridhar said. “But we’re in a different position than in 1918. We’re in 2020.”
After days of confusion about the wisdom of encouraging “herd immunity,” the government sought to play down the dispute, arguing that this was not a deliberate part of its strategy but a byproduct of it. But it shifted to a policy of urging people not to go to pubs, restaurants, theaters or museums.
On Tuesday, the government’s chief scientific adviser, Sir Patrick Vallance, said he expected these new, more stringent restrictions to last for months — and that the authorities would have to monitor very carefully what would happen when they are eventually lifted.
British officials recognize that their health service faces a moment of truth. All non-urgent operations in England will be postponed for at least three months, starting April 15, to free up 30,000 beds to help tackle the coronavirus.
Britain lags behind other European nations in its supply of ventilators. Plans are underway to ramp up their numbers from over 8,000 to 12,000, though officials are reluctant to promise that even this is sufficient.
Underscoring the change in tone, Britain’s finance chief, Rishi Sunak, announced a gargantuan fiscal stimulus to salvage reeling British businesses and to try to stem job losses. The package, worth £330 billion, or $422 billion, will include government-backed loans and tax breaks for companies and a three-month break in mortgage repayments for strapped homeowners.
“We have never in peacetime faced an economic fight like this,” said Mr. Sunak, who also promised support for airports and airlines in the coming days, after Britons were advised against all non-essential travel.
Mr. Johnson hinted on Tuesday that schools could be closed soon. But he still faces criticism for a lack of clarity, including his decision to urge people to avoid pubs and restaurants but not to order their closing. In fact, the government now intends to relax laws to allow pubs to stay open and produce takeout food.
To Mr. Johnson’s embarrassment, one of those promising to visit his local pub was his own father, Stanley Johnson.
Sheri Fink contributed to this report from New York.
At a time when the Trump administration is facing intense criticism for its failure to make coronavirus tests available to millions of nervous Americans, remarks by a federal health official on Tuesday appeared to suggest that the World Health Organization’s diagnostic tests were wildly inaccurate.
In a somewhat rambling answer to a question related to W.H.O. tests, Dr. Deborah Birx, the White House coronavirus response coordinator, said: “It doesn’t help to put out a test where 50 percent or 47 percent were false positives. Imagine what that would mean to the American people. Imagine what that would mean to tell someone they were positive when they weren’t.”
It was not clear where Dr. Birx got those figures, but obviously such an inaccurate test would be worthless. Late on Tuesday night, Dr. Birx confirmed that although she was responding to a question about the W.H.O. test, she was referring to a study of an early diagnostic test used in China.
The paper found that, in a specific subset of those tested in China — asymptomatic contacts of known cases — the tests wrongly found them to be positive 47 percent of the time.
But there have been no suggestions that the W.H.O. test, distributed worldwide, has such significant accuracy problems. On Tuesday night, Dr. Birx said she has not looked into the W.H.O. test, “but I assume it is functional.”
Dr. Birx was asked several questions by reporters about the lack of tests during the news conference, and came and went to the microphone several times.
Early on, she was asked a question that the administration has struggled to deal with: If federal officials have shipped millions of tests, as White House officials have said several times, why have only 60,000 Americans been tested?
Dr. Birx answered that tests in the United States were now being made by many producers, which is correct. Differing diagnostic tests are now made by state laboratories, medical school laboratories and private companies like Thermo Fisher, which she mentioned as an example.
Dr. Birx said she was strongly urging commercial providers to get their tests out, but of course, they first had to prove to the Food and Drug Administration that they were of high quality.
Later, she was asked about a criticism made by former Vice President Joseph R. Biden Jr. in Monday’s night’s debate. He said the W.H.O. had “offered tests to the United States but we didn’t buy them.”
In her answer, she did not refer to the W.H.O. tests at all, but said, “We don’t buy tests that haven’t been quality-controlled and they show us the data,” then adding that a test with high rates of inaccuracy would be a disaster.
Credit…Kamran Jebreili/Associated Press
A spokeswoman for the W.H.O. said she did not know what Dr. Birx was referring to, but the agency had been supplying kits to member nations since January.
The accuracy of the test was validated by three laboratories before it was rolled out, the spokeswoman said, and it had consistently showed “good performance in laboratory and clinical use, and neither a significant number of false positive nor false negative results have been reported.”
In any case, Mr. Biden’s assertion that the Trump administration refused tests offered by the W.H.O. appears to be wrong. The W.H.O. does not sell tests to wealthy countries, which usually prefer to make their own.
Dr. Anne Schuchat, deputy principal director of the Centers for Disease Control and Prevention, confirmed that the W.H.O. gave test kits “primarily to underresourced countries.” Another administration official, speaking on the condition of anonymity, confirmed that the W.H.O. had never offered to sell or give tests to the United States.
China, Hong Kong, France, Germany, Thailand and the United States have all designed their own tests, according to the W.H.O. website. Each one looks for the presence of two or three short stretches of viral genes.
For example, the C.D.C’s test looks at three targets on the N gene, while the tests ordered by the W.H.O. look at bits of the N gene, the RdRP gene and the E gene. Each gene performs a different function in helping the virus break into cells, hijack their DNA machinery and reproduce million of copies of itself.
For countries that are unable to make the tests or buy them from other countries, the W.H.O. asks academic or government laboratories to make tests.
It then delivers them to poor and middle-income countries at low or no cost, paying for them out of emergency funds or loans from institutions like the World Bank.
The test ordered by the W.H.O. was designed in a lab run by Dr. Christian Drosten at the medical school of Berlin’s Charity Hospital, which is considered one of the world’s top genomic laboratories.
In a Feb. 21 email, another W.H.O. spokesman said the test’s accuracy had been verified by three other laboratories before it was sent to a German diagnostics company for manufacturing. There had been no problems with the first shipment of 250,000 doses, he said.
Dr. Michael Mina, an assistant professor of epidemiology at the Harvard School of Public Health, said both the W.H.O. test and the initial C.D.C. tests were “exceptional” in their accuracy.
The problems with the C.D.C. test have been attributed to flaws in the manufacturing of reagents for kits, not in the C.D.C.’s design.
No test is accurate 100 percent of the time, but the errors are usually introduced by medical personnel who fail to take samples correctly or lab personnel who run the test incorrectly or accidentally contaminate it with stray DNA.
For example, in February an American passenger released from the cruise ship Westerdam, which went from port to port for many days before Cambodia allowed it to dock, tested positive for the virus as she passed through Malaysia, setting off a crisis.
The C.D.C. later said she did not have the virus and judged the Malaysian test to be a likely false positive.
Since Malaysia did not have its own test, it presumably used the W.H.O.’s. But Malaysia does not have a top-quality lab, and many labs make initial errors when they are rolling out a new test.
Sheri Fink and Ellen Gabler contributed reporting from New York. Abby Goodnough contributed reporting from Washington.
Representative Devin Nunes, a California Republican, on Sunday encouraged healthy people to dine out at restaurants, contradicting public health advisories that strongly encouraged social distancing and discouraged Americans from attending mass gatherings.
In an appearance on Fox News, Mr. Nunes said Americans should stop fighting over groceries and toilet paper.
“There’s a lot of concerns with the economy here because people are scared to go out,” he said. “But I will just say, one of the things you can do is, if you’re healthy, you and your family, it’s a great time to just go out, go to a local restaurant. Likely you can get in easily. Let’s not hurt the working people in this country that are relying on wages and tips to keep their small business going.”
On Twitter on Sunday afternoon, he wrote that there was no food shortage and not to panic. “If healthy, support local workers and economy — shop and eat local!” he wrote.
Gov. Kevin Stitt of Oklahoma, a Republican, also encouraged people to support local businesses. On Twitter on Saturday, he shared a photo of his family at a packed food hall called the Collective OKC in the heart of Oklahoma City.
In the Twitter post, which has been since deleted, he wrote: “Eating with my kids and all my fellow Oklahomans at the @CollectiveOKC. It’s packed tonight! #supportlocal #OklaProud.”
Public health experts, however, are urging just the opposite: Stay home if you can.
The Centers for Disease Control and Prevention and the World Health Organization have encouraged people to avoid highly populated areas to curb the spread of the coronavirus.
They’ve recommended practicing “social distancing” — increasing the physical space between people. By maintaining a distance of at least six feet from others when possible, the spread of the virus might be slowed.
Representatives from the offices of Mr. Nunes and Mr. Stitt could not be immediately reached on Sunday afternoon.
Dr. Anthony S. Fauci, the director of the National Institute of Allergy and Infectious Diseases, appeared on the Sunday morning news programs and said that Americans would have to make personal sacrifices and comply with government guidelines to avoid a “worst-case scenario.”
He said stronger efforts were coming to slow the spread of the coronavirus over the next several weeks, a period he characterized as crucial for controlling the outbreak.
“Americans should be prepared that they are going to have to hunker down significantly more than we as a country are doing,” he cautioned on NBC’s “Meet the Press.”
In an interview on CNN, Dr. Fauci said that disruptions to daily life were likely to continue.
“For a while, life is not going to be the way it used to be in the United States,” he said. “We have to just accept that if we want to do what’s best for the American public.”
Vanessa Swales contributed reporting.
For weeks, the World Health Organization resisted declaring the coronavirus outbreak a pandemic, fearing that doing so would incite panic across the globe.
But facing the cameras on Wednesday, the agency’s director general, Dr. Tedros Adhanom Ghebreyesus, did just that, asking for global unity to “change the course of this pandemic.”
It was a symbolic moment that underscored the standing of the W.H.O. as the world’s leading public health agency. But it also reflected the W.H.O.’s underlying weakness as an organization that by international treaty is supposed to lead and coordinate the global fight against coronavirus — yet that has, in many ways, been marginalized.
Global solidarity has been noticeably absent in the fight to stop an outbreak that has already killed more than 4,300 people and spread to more than 110 countries. No one seems to be in charge. There doesn’t seem to be a plan.
The coronavirus has touched a diverse collection of countries and cultures, but a number of shared experiences have emerged — from grieving the dead to writing songs.CreditCredit…Carlos Lemos/EPA, via Shutterstock
Fifteen years ago, the World Health Organization undertook a major revision of the International Health Regulations, the global framework for responding to outbreaks. The revision was intended to correct flaws in the global response to the 2003 SARS outbreak, which killed hundreds of people and pushed advanced health care systems to the breaking point.
The basic idea was that the W.H.O. would serve as a central coordinating body. Countries would notify the agency about outbreaks and share information to help scientists address an epidemic at the global level. The W.H.O. would coordinate efforts on containment, declare emergencies and make recommendations. The revised regulation is legally binding and has been signed by 196 countries, including the United States.
But dozens of countries are flouting the international regulations and snubbing their obligations. Some have failed to report outbreaks to the organization, as required. Others have instituted international travel restrictions, against the advice of the W.H.O., and without notifying global health officials.
“One of the biggest challenges we face is that too many affected countries are still not sharing data with W.H.O.,” Dr. Tedros said last month. He has also blamed some countries — he has refused to specify which ones — for failing to take the outbreak seriously enough.
As part of the United Nations, the W.H.O. is broadly influential yet hampered by budget and political pressures. It lacks meaningful enforcement authority, creating a telling power imbalance. It is often accused of kowtowing to its donors — from powerful players like the United States and China to private funders like the Gates Foundation.
These contradictions contributed to the agency’s much-criticized response to the Ebola outbreak in West Africa and led some scholars to question the need for such a weak institution. But Rebecca Katz, a scholar at Georgetown University, said such criticism misses a fundamental point.
“If there wasn’t a W.H.O., you’d have to invent it,” said Dr. Katz, who has studied health regulations for more than a decade. “They are in a bit of a tough spot because you know you have international law but then you also know that every nation is sovereign,” she said.
This time, some former critics credit the W.H.O. for doing a better job, declaring a global emergency much quicker than it did during the SARS and Ebola outbreaks, consistently sharing information with the public and convening more than 300 scientists and research funders to help develop tests, vaccines and medicines.
Even so, the agency is also marginalized in many ways.
The most obvious examples are the global flouting of international travel restrictions. More than 70 countries have instituted the restrictions, according to the W.H.O., including the United States, where President Trump announced on Wednesday night restrictions to travel from the European continent.
Yet in four advisories it has issued since early January, the W.H.O. has consistently advised against them, cautioning that limits on international movement during public health emergencies are unlikely to stop the pathogen’s spread.
The rules do not apply to domestic travel restrictions or to decisions made by private airlines, but the W.H.O. has repeatedly warned that international bans can block needed resources, or delay aid and technical support. Such restrictions are justified only at the beginning of an outbreak to buy nations time to prepare, the agency said. Beyond that, they are more likely to cause significant economic and social harm.
Meanwhile, only 45 of the more than 70 countries that have adopted international travel restrictions have fulfilled the requirement to report their actions to the agency, a spokesman said.
Restricting travel “is a good political placebo. It’s going to make people feel safe,” said Clare Wenham at the London School of Economics, a scholar who has studied the health regulations for more than a decade. “Why are we not learning that this doesn’t work?” Dr. Wenham asked about travel restrictions.
W.H.O. itself has sent out mixed signals in recent weeks. In a report it issued this week, the agency said that some travel restrictions “may have delayed the importation of new cases.” But W.H.O. did not change its fundamental opposition to international restrictions or revise its travel advisory.
Then there is the unwillingness of some countries to lift a ban on the export of protective equipment, complicating the broader fight against the disease. France and Germany have put limits on exports of such gear.
“We can understand that governments have a primary responsibility to their own health workers,” said Michael Ryan, who heads the W.H.O.’s health emergencies program.
He urged nations to stop hoarding gear and called for solidarity across the globe.
“The life of a health worker in one country is certainly as valued as the life of a health worker in another,” Dr. Ryan said on Monday.
The national governments that signed onto the international regulation also left themselves a loophole, which they are exploiting now.
The loophole was the product of hours of negotiations in Geneva, where the revisions were finalized in 2005, according to Gian Luca Burci, who served as the agency’s legal counsel for 11 years. Mr. Burci said negotiators stayed up until 5 a.m. before agreeing on a trade-off that balanced “public health considerations and the retention of the ultimate political power.”
Countries were reluctant to cede total control to an international agency. They drafted a provision that gave them the right to take health measures that they believed would have similar or better results than W.H.O. recommendations — on the premise that these measures were scientifically grounded and for the common good.
“States gave themselves a ‘get-out-of-jail-free’ card,” Mr. Burci said.
Under the rules, countries are obligated to report to the health agency within 48 hours any measures that they take beyond the collective guidelines, as well as report the rationale behind their actions. Many countries have failed to do so during the coronavirus outbreak, and the W.H.O. can do little about it.
In some cases, W.H.O. officials learned of travel shutdowns only after they happened, from reports in the media.
“What do we really mean if nobody is following W.H.O.’s recommendation with impunity,” Mr. Burci asked.
Because they have no power to enforce international regulations, W.H.O. officials have to walk a diplomatic tightrope. In a statement, a W.H.O. spokesman said that the agency “cannot compel countries to change measures they have implemented.”
Last month, Dr. Tedros sent two letters, which have not been made public, reminding nations about their obligations. His staff has collated media reports on the flurry of travel restrictions and is chasing after countries to obtain their rationale.
Agency officials have resisted naming and shaming countries that breach the rules and have largely dodged media questions on the subject.
“The W.H.O. doesn’t interact in public debate or criticize our member states in public,” Dr. Ryan said on Wednesday when asked which countries had failed to rise to the occasion.
“You know who you are,” Dr. Ryan said.
Part of that hesitation comes down to money, said Ashish Jha, a director of Harvard Global Health Institute. The organization has said that it needs $675 million to fund its response to the coronavirus outbreaks. As of this week, nations have pledged to donate about $300 million.
“W.H.O. is at the mercy of its member states,” Dr. Jha said. “Countries don’t have to listen.”
Even as the agency struggles to nudge member states to comply with the regulations, the coronavirus pandemic poses major questions for the future. One pressing question is on how the world will cope if an outbreak develops in countries with underdeveloped health care systems.
Two-thirds of the world’s countries lack the necessary laboratories and surveillance systems to detect outbreaks and comply with international regulations. The Group of 7 has pledged to help poorer nations but has not always followed through.
The world is not ready for “a fast-moving, virulent respiratory pathogen pandemic,” a W.H.O. report said last year.
Dr. Katz, the Georgetown scholar, said stronger international regulations would help prepare for such an outbreak.
“This is what we have. This is the agreement we have. This is the organization we have,” she said.
The spread of the coronavirus is now a pandemic, officials at the World Health Organization said on Wednesday.
“We have rung the alarm bell loud and clear,” said Tedros Adhanom Ghebreyesus, the W.H.O.’s director-general.
Dr. Tedros called for countries to learn from one another’s successes, act in unison and help protect one another against a common threat.
“Find, isolate, test and treat every case, and trace every contact,” Dr. Tedros said. “Ready your hospitals. Protect and train your health care workers.”
“Let’s all look out for each other, because we’re in this together to do the right things with calm and to protect the citizens of the world.”
Although this is the first pandemic caused by a coronavirus, “we also believe that this is the first pandemic that is able to be controlled,” Dr. Tedros added.
He pointed several times to the success of China, which has cut new infections from over 3,500 a day in late January to a mere 24 in the most recent daily count. The world is watching to see whether China can keep its numbers down as it gradually releases millions of city dwellers from quarantine and lets them go back to work.
South Korea and Singapore have also begun to see cases drop. But the rest of the world is seeing alarmingly rapid rises.
The W.H.O. is emphatically not suggesting that the world should give up on containment, Dr. Tedros said.
“We are suggesting a blended strategy,” he said, referring to a blend of containment and mitigation. “We should double down. We should be more aggressive.”
China, South Korea and Singapore have shown that aggressive contact tracing and rapid isolation of the sick can work. Unlike Western nations, all three rejected the idea of home quarantine, because cases rapidly spread in families.
Some alarmed public health experts have described Beijing’s approach as draconian or brutal, but the W.H.O. has referred to it simply as aggressive.
Wuhan and surrounding cities, the outbreak’s epicenter, have been shut down since late January, and travel elsewhere is strictly limited.
Everyone must wear a mask outdoors and submit to constant temperature checks, which are administered at the doors to every office building, store and restaurant, as well as bus, train and subway stations — even at the entries to apartment houses and residential neighborhoods.
People who think they are infected are screened at special “fever clinics,” not at doctors’ offices. They get temperature checks, flu tests, white blood cell counts, CT lung scans and laboratory tests for the virus, according to Dr. Bruce Aylward, leader of the W.H.O. observer mission that visited China in February.
Anyone who appears to have the new virus, instead of flu or bacterial pneumonia, is held until the lab results are in or while testing is repeated. Some are held at repurposed hotels.
If they are found to be infected, they may not return home — almost 80 percent of infections were within families, studies in China found.
If infected persons are seriously ill or elderly, they are hospitalized. Those with milder cases recuperate in isolation centers with hundreds of beds and nursing care. The centers are segregated by sex and age; even children who are infected must go.
No visitors are allowed, but there activities like dance classes to fight the boredom and keep people active.
As difficult and aggressive as they are, such measures “reduce the number of cases that are wheeled through the doors of hospitals,” said Dr. Michael Ryan, head of the agency’s emergencies program.
The largest number of deaths in China occurred in Wuhan, because its hospitals were overwhelmed in early January, when the authorities were suppressing news of the danger.
The fact that 90 percent of the world’s cases are in four countries — China, Italy, Iran and South Korea — indicates that the pandemic can still be contained if countries act fast, Dr. Tedros said.
There are only about 1,100 confirmed cases in the United States, but experts fear that is only a fraction of the real prevalence, because testing for the coronavirus has been unavailable or haphazard in the United States.
The number of cases in the world doubles every six days, epidemiologists have estimated.
The epidemic is thought to have begun with a single infection of a person in Wuhan, presumably by a butchered animal, in mid-November last year. Without any containment measures, it would now be at about one million cases; by the end of April, there would have been over 250 million.
Exactly how many cases were prevented by China’s crackdown is unknown, said Dr. Aylward, “but it’s in the hundreds of thousands.”
The goal of an aggressive containment response, W.H.O. officials explained, is to hold down the number of deaths and critical illnesses until a vaccine can be rolled out, possibly by early next year.
Although declaring a pandemic is largely symbolic, given that the virus has been spreading around the world for weeks, health officials hope the action will raise public awareness of the approaching danger.
Many countries have been slow to prepare, and the W.H.O.’s appeals for funds to help the poorest countries get ready have largely gone unanswered as the world’s wealthiest countries struggle to protect themselves.
Declaring a pandemic does not change what the W.H.O. will do, Dr. Ryan said. It is an effort “to galvanize the world to fight.”
A lot of thought was given to finally using the word, he said, because of the fear that it would cause countries to give up the fight as hopeless.
As of Wednesday, the virus had infected more than 120,000 people in 114 countries, killing about 4,300 of them.
For many days, when pressed on whether the disease is a pandemic, W.H.O. officials have drawn a distinction between “uncontrolled spread” and “uncontrollable spread.” They argued that China’s thus far successful effort to drive new cases down proved that the global outbreak could be controlled in places even without a vaccine.
Although Dr. Tedros said some countries were not moving fast enough or taking the threat seriously enough, Dr. Ryan declined to name them.
“The W.H.O. does not criticize its member states in public,” he said. “You know who you are.”
Declaring a pandemic has no legal meaning and does not impose any new measures.
On Jan. 30, the W.H.O. declared the virus a public health emergency and said that distinction was more important than whether to call it a pandemic.
Agency officials have often declared themselves frustrated by pressure — which often comes from journalists — to say exactly when a pandemic is officially underway.
After the 2009 pandemic of H1N1 swine flu from Mexico to the Americas to Europe and beyond, the W.H.O. gave up its old definition of a pandemic: “sustained human-to-human transmission of a novel pathogen in two or more W.H.O. regions.”
Journalists quibbled with a W.H.O. media representative over the judgment that the spread in both North America and South America did not qualify as pandemic. (They comprise a single W.H.O. region.) And reporters wondered how many cases in Britain constituted “sustained transmission.”
In February, W.H.O. media representatives said they had given up declaring pandemics so as not to reopen a never-ending discussion.
But the usefulness of the term for raising alarm apparently proved irresistible.
The W.H.O. has sought $675 million for the fight against the coronavirus. It has received only $100 million in pledges and $51 million in cash, according to its website.
Dr. Ryan urged countries to hire thousands more contact-tracers, who find everyone known to have come in contact with an infected person and isolate anyone who may be infected. At the height of its outbreak, the city of Wuhan, China, where the pandemic began, had 18,000 contact-tracers working in teams of five.
Many were government employees who had been reassigned from various government departments and retrained on the job, according to Dr. Bruce Aylward, a W.H.O. assistant director-general who led the agency’s mission to China in February.
BEIJING — As new cases of the coronavirus spiked on two continents, the World Health Organization warned on Monday that the world was not ready for a major outbreak, even as it praised China’s aggressive efforts to wrest the epidemic under control.
After two weeks on the ground in China, a team sent by the W.H.O. concluded that the draconian measures China imposed a month ago may have saved hundreds of thousands of people from infection. Such measures — sealing off cities, shutting down businesses and schools, ordering people to remain indoors — have provoked anger in China and could be difficult to replicate in democratic countries with a greater emphasis on protecting civil liberties.
“There’s no question that China’s bold approach to the rapid spread of this new respiratory pathogen has changed the course of what was a rapidly escalating and continues to be a deadly epidemic,” said Bruce Aylward, a Canadian doctor and epidemiologist who has overseen international campaigns to fight Ebola and polio and who led the W.H.O. delegation.
The epidemic has already killed more than 2,600 people in China, mostly in Hubei Province, where the outbreak began in December, and infected more than 77,000 people. But the number of new infections in China has been steadily dropping, giving officials in the country confidence that the extraordinary measures have been effective in blunting the virus’s spread.
There are concerns, however, that as people begin returning to work in China, the virus could flare up again.
At the same time, new cases are escalating outside China. In Italy, where there has been an eruption of more than 150 cases, the authorities have locked down at least 10 towns, closed schools in major cities and canceled sporting events — all moves that are echoes of China’s tactics, if not quite as draconian.
In Iran, the outbreak has killed at least 12 people as of Monday, the largest number of coronavirus-linked deaths outside China.
South Korea on Monday reported 231 additional cases, bringing the nation’s total to 833 cases and seven deaths. By Tuesday, another 60 infections had been recorded, bringing the total to just under 900.
Dr. Aylward said responding swiftly and aggressively to contain outbreaks and treat those infected was paramount.
“We have all got to look at our systems because none of them work fast enough,” Dr. Aylward said.
The virus that has crippled China for more than a month now threatens to become a pandemic that could touch virtually every part of the globe. Stock markets in Asia, Europe and North America plunged on Monday as investors worried that the economic disruption the outbreak has already caused in China is all but certain to have wider impact.
The S & P 500 dropped nearly 3 percent in early trading on Monday, after European markets recorded their worst day since 2016, and major benchmarks in Asia closed sharply lower. The Dow Jones industrial average fell more than 900 points in the first hours of trading.
China, which was the source of the outbreak, might also offer solutions, according to Chinese officials and the W.H.O.’s assessment, despite the confusion and obfuscation that slowed the government’s initial efforts to respond to what was then a mysterious new illness appearing in hospitals in Wuhan, the epicenter, in December.
Since late January, the Chinese government has put at least 760 million people — more than half of its population — under residential lockdowns of varying strictness, from checkpoints at building entrances to hard limits on going outdoors, according to a New York Times analysis of government announcements in provinces and major cities.
While China’s reporting has been at times confused — with changes to its method of counting causing huge swings in daily tolls — the overall trend since the middle of this month has indicated a slowing in the rate of infections.
On Sunday, 24 Chinese provinces reported no new cases. Six of them lowered their emergency response measures. In Hubei Province there were 398 new cases, the second consecutive day in which the number of new cases declined.
“The decline we are seeing is real,” Dr. Aylward said.
Even so, the death toll continues to rise, with 150 deaths reported on Sunday, the highest in nearly three weeks. In total, 2,663 people in China have been killed by the virus, according to official figures released Tuesday morning.
Liang Wannian, a senior official with China’s National Health Commission, said China was not ready to declare victory yet.
“The situation is still very grim,” he said at a news conference. “We haven’t stopped the epidemic in Wuhan yet.”
Many health experts agree it is premature to celebrate given the highly contagious nature of the virus and the potential for a new surge in cases when millions of people go back to work in China or when travel restrictions are lifted.
But they generally agreed with the W.H.O.’s assessment on China’s measures.
“The containment definitely worked in China,” said Leo Poon, the head of the public health laboratory sciences division at the University of Hong Kong. “The question now is whether similar policies can be applied in other countries.”
Clarence Tam, an assistant professor of infectious diseases at the School of Public Health at the National University of Singapore, said it was difficult to interpret the case numbers from China, particularly from Hubei. That is because the total number of infections jumped when the authorities expanded the methods used to diagnose them twice in two weeks.
“Trying to look at the case numbers is very difficult,” Dr. Tam said. “We don’t really know what is influencing those case numbers.’’
Adding to the confusion, Chinese media outlets reported on Monday that Wuhan would begin easing a sweeping lockdown, by allowing some people to leave. But just hours after news of the change emerged, the authorities backtracked, saying the announcement had been made in error.
What is unclear to many public health experts is whether a shortage of testing kits is causing a large number of cases to remain undetected. Hospitals in China remain overstretched and many patients say they have been turned away. Health care workers are still coming down with the virus despite official pledges to protect them. Mr. Liang, the health official, said more than 3,000 health care workers have been infected.
Another problem is that China does not disclose how many people are being tested. If the proportion of people being tested is really declining, it would suggest there is a downturn in the rate of transmission. “But we don’t have that yet,” Dr. Tam said.
“From my perspective, it’s ‘watch and wait and see,’ ” he said. “It looks positive but it’s difficult to interpret what those numbers mean at the moment.”
In a speech on Sunday, China’s leader, Xi Jinping, called the epidemic the country’s most serious public health crisis and said it was “the most difficult to prevent and control” since the founding of the People’s Republic.
The epidemic has already severely disrupted life and commerce — as well as the Communist Party’s annual legislative conferences that had been scheduled to begin in Beijing in early March. The Standing Committee of the National People’s Congress announced on Monday that it had postponed the conferences indefinitely.
Mr. Xi said controlling the outbreak in Wuhan and Hubei as well as preventing the epidemic from spreading to Beijing, the capital, were the country’s top two strategic goals. He pledged more pro-growth policies to help overcome the epidemic.
David Heymann, an epidemiologist at the London School of Hygiene and Tropical Medicine, said the case numbers from China suggest that there “may be a decrease in transmission.”
China was following its playbook from the severe acute respiratory syndrome outbreak of 2002-2003, said Dr. Heymann, a former chief of communicable diseases at the W.H.O., when it was “able to stop outbreaks outside the epicenter in Guangdong Province by meticulous outbreak containment and control.”
The real test could be yet to come. As China moves to restart its economy, the coronavirus could flare up again.
“There is an acute recognition here that just as we — the Chinese — forced the tail of this outbreak down, it could come back up again as people start to move again, the shops start to open, the restaurants open, the schools open,” Dr. Aylward said. “It’s a risk.”
Steven Lee Myers reported from Beijing and Sui-Lee Wee from Singapore. Amber Wang and Claire Fu contributed research in Beijing.
LONDON — In Iran, a spike in coronavirus infections has prompted fears of a contagion throughout the Middle East. In Italy, one of Europe’s largest economies, officials are struggling frantically to prevent the epidemic from paralyzing the commercial center of Milan. And in New York, London, and Tokyo, financial markets plummeted on fears that the virus will cripple the global economy.
From Asia to Europe to North America, the lethal spread of the coronavirus accelerated on Monday, putting a heavy strain on a world already fractured by trade wars, populist politics and sectarian conflict.
An equal-opportunity epidemic, the virus is afflicting open and closed societies, autocracies and democracies, developed countries and war zones alike. That makes the task of containing it even more daunting.
The emergence of Italy, Iran, and South Korea as new hubs of the outbreak underscored the lack of a coordinated global strategy to combat the coronavirus, which has infected nearly 80,000 people in 37 countries, causing at least 2,600 deaths. The number of infected people in the United States reached 53 on Monday, up from 34 on Friday, according to the Centers for Disease Control and Prevention.
A delegation of the World Health Organization, sent to China to assess the epidemic, warned Monday the world was not ready for a major outbreak. Infectious disease experts said a unified response is critical to mitigating the damage and slowing an outbreak that they say can no longer be stopped.
“Six new countries have reported cases this morning,” said Michael T. Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “This is an inflection point in this experience. The world needs to say, ‘What can we do together to combat this?’”
For weeks, most of the world’s focus has been on China, which has placed tens of millions of people under strict lockdowns to try to staunch the spread of new cases. But on Monday, the newer outbreaks in South Korea, Italy and Iran were testing very different political systems, with very different health systems.
In Iran, authorities shut down schools, universities and cultural centers across 14 provinces to try to curb the outbreak. Iranian officials said 61 people had been infected, with 12 others dying. But their credibility was ridiculed by critics, who claimed the death toll was much higher, with memories still fresh across Iran of an attempt to cover up the downing of a commercial airliner last month by the country’s military forces.
The dearth of reliable information alarmed Iran’s neighbors, several of which share long, poorly patrolled borders with the country. Pakistan and Turkey temporarily closed their borders with Iran on Sunday. Afghanistan, which reported its first coronavirus case on Monday, banned all travel to the country, except for “essential humanitarian needs.”
Yet already coronavirus cases, some linked to Iran, were emerging elsewhere in the region: in Iraq, Lebanon, Israel, Egypt, Kuwait and Oman. Several of those countries are autocracies, which could lead to the same suppression of information that critics say is hampering the response in Iran.
“Countries will start underreporting cases, so they don’t seem to be suggesting a terrible tragedy has hit them or they don’t want to be accused of unsettling the rest of the world,” Dr. Osterholm said.
At some point, he said, the virus would spread so far and become such a common worldwide problem that its point of origin would no longer be relevant.
For now, though, Chinese people traveling abroad were still encountering suspicion and even hostility. In South Korea, popular with Chinese tourists, some shops have begun posting signs saying, “No Chinese.”
On Monday, South Korea, the hardest hit country outside China, reported 231 more cases, bringing its total to 833 cases and seven deaths. By Tuesday, another 60 infections had been recorded, bringing the total to just under 900. The South Korean president, Moon Jae-in, put the country on the highest possible alert, opening the way for the government to lock down cities and take other sweeping measures.
In Italy, authorities quarantined more than 50,000 people in 11 towns clustered in the northern Lombardy region, partly in an effort to prevent the virus from spreading to Milan, where an outbreak could cripple the Italian economy. Italy has reported at least six deaths.
In Brussels, officials with the European Union said they were in constant contact with the Italian government, while powerful neighbors such as Germany and France have mostly committed to keeping their borders open. European officials said they were not advising members to introduce border controls in the Schengen zone, which allows travelers to pass across borders without passport checks.
“Any decisions made need to be based on risk assessment and scientific advice, and need to be proportionate,” said Stella Kyriakides, the European Union’s commissioner for health and food safety. “We stress that, for the moment, W.H.O. has not advised changing or imposing restrictions on either travel or trade.”
Still, there is a heightened vigilance. On Sunday, Austria held up a train at the Italian border amid suspicion that two of the 300 passengers from Venice had the virus. The train was allowed to cross into Austria after the passengers tested negative.
On Monday, authorities in Lyon, France, stopped a bus from Milan and confined the passengers inside after suspicion of a case onboard, the newspaper Le Parisien reported. Passengers on an Alitalia flight from Rome to Mauritius decided to return home after being told they would have to go into quarantine.
At this stage in the crisis, experts said, closing borders was a largely futile exercise. In many cases, the virus has been carried into a country before the border was sealed. And detection is harder because the virus is now being transmitted from people with minimal or even no flulike symptoms.
“People always find a way to move,” said Professor Devi Sridhar, director of the global health governance program at Edinburgh University. “Even before the lockdowns in China, three million people moved.”
Dr. Sridhar said the emphasis should now be on vaccination campaigns and equipping medical centers with adequate respiratory facilities. She also said hospitals needed to take measures to stop being spreading grounds for the virus.
Europe, she said, was in a better position to combat the coronavirus than other parts of the world because it has reliable reporting systems and a fairly high level of trust between the public and health authorities.
In Britain, which has 13 confirmed cases, a spokesman for Prime Minister Boris Johnson issued a statement on Monday saying the country was well prepared for any additional infections.
“We are using tried and tested procedures to prevent further spread and the N.H.S. is extremely well prepared and used to managing infections,” the statement said, referring to the National Health Service.
Yet even in Europe, there are troubling signs of a lack of coordination. When the Italians went into crisis mode over the weekend, officials in Brussels struggled to convince other European Union member states to share information swiftly and coordinate on how to respond to the outbreak.
Such weaknesses sound eerily similar to China, which drew harsh criticism for its secretive approach and slow initial response after the outbreak first emerged in Hubei Province.
China’s president, Xi Jinping, acknowledged that it was the country’s most serious public health crisis, and “the most difficult to prevent and control,” since the founding of the People’s Republic. Underscoring the point, the country’s leaders on Monday were forced to postpone their biggest political conclave of the year, the National People’s Congress.
Yet health experts said that once China woke up to the threat, it acted decisively.
The W.H.O. team in China concluded that the draconian measures imposed by the government there may have saved hundreds of thousands of people from infection.
“There’s no question that China’s bold approach to the rapid spread of this new respiratory pathogen has changed the course of what was a rapidly escalating and continues to be a deadly epidemic,” said Bruce Aylward, a Canadian doctor and epidemiologist who led the W.H.O. delegation.
But with the virus spreading rapidly, Dr. Aylward warned that other countries would need to respond swiftly and aggressively, too. “We have all got to look at our systems because none of them work fast enough,” he said.
Steven Lee Myers and Sui-Lee Wee contributed reporting from Beijing, and Matina Stevis-Gridneff from Brussels.
Religious pilgrims, migrant workers, businessmen, soldiers and clerics all flow constantly across Iran’s frontiers, often crossing into countries with few border controls, weak and ineffective governments and fragile health systems.
Now, as it struggles to contain the spread of the coronavirus, Iran is also emerging as the second focal point after China for the spread of the disease. Cases in Iraq, Afghanistan, Bahrain, Kuwait, Oman, Lebanon, the United Arab Emirates — even one in Canada — have all been traced to Iran, sending tremors of fear rippling out from Kabul to Beirut.
The Middle East is in many ways the perfect place to spawn a pandemic, experts say, with the constant circulation of both Muslim pilgrims and itinerant workers who might carry the virus. Iran’s economy has been strangled by sanctions, its people have lost trust in their government and its leaders are isolated from much of the world, providing little clarity about the extent of the epidemic.
Civil wars or years of unrest have shattered the health systems of several neighboring countries, like Syria, Iraq, Afghanistan and Yemen. And most of the region is governed largely by authoritarians with poor track records at providing public transparency, accountability and health services.
“It is a recipe for a massive viral outbreak,” said Peter Piot, director of the London School of Hygiene and Tropical Medicine and the former founding executive director of the Joint United Nations Program on H.I.V./AIDS.
Millions of Muslim pilgrims travel each year from around the region to visit Shiite holy sites in Iran and Iraq. In January alone, 30,000 people returned to Afghanistan from Iran, and hundreds of others continue to make the pilgrimage to Qom, the site of the outbreak, every week, Afghan officials say.
Iraq closed its border with Iran on Saturday, but millions cross it every year. So scores of infected people could potentially have brought the virus to Iraq, depending on how long it has been present in Iran. And as of midday on Monday in Najaf, flights to and from Iran were still taking off and landing.
Governors of Iraqi provinces bordering Iran were taking the potential for contagion seriously and at least two were personally inspecting the border crossings to ensure that they were being policed and that Iranians were barred from crossing into Iraq.
Qutaybah al-Jubouri, the head of the Iraqi Parliament’s Health Affairs Committee, called the coronavirus “a plague” and said his committee was demanding a far more complete closure of all “land, sea and air” borders with Iran “until the disease is completely controlled.”
Iran’s health ministry sent a letter to the governor of Qom on Thursday and asked Shiite religious leaders to limit the number of pilgrims at the Shrine to Fatima Masumeh and other religious sites in the city, but as of early Tuesday, throngs of people still gathered around the shrine, touching it and taking part in communal prayers.
Iran is in many ways a case study in the risks of the disease spreading. The country reported its first case of the coronavirus less than a week ago, in Qom. On Monday health officials reported that four people had died there in the last day, bringing the total to 12. At least 61 others had been infected in Iran, the officials said, with new cases being reported in Isfahan, Hamedan and other cities, as well as in Qom.
Now the slow drip of news about the spread of the virus is compounding Tehran’s already acute credibility problems, less than two months after officials were forced to admit lying about their knowledge of the accidental downing of a Ukrainian passenger jet by air defense systems. Many Iranians on Monday were openly skeptical about the official accounts of the spread of the virus.
A member of Parliament representing Qom claimed on Monday that at least 50 people had already died there, including 34 in quarantine, and that the first case had been reported more than two weeks before officials acknowledged any infections.
“Every day 10 people are dying in Qom,” the lawmaker, Ahmad Amiri Farahani, asserted in a speech to Parliament, demanding a quarantine on his city.
Health ministry officials vehemently disputed his claims. “I will resign if the numbers are even half or a quarter of this,” said Ahmad Harirchi, adviser to the health minister.
Adding to the public anxiety, the Iranian news media reported that Dr. Mohamad Reza Ghadir, the head of a medical university in Qom and the top official in charge of managing the outbreak there, was among those placed in quarantine.
On Monday, Dr. Ghadir said on Iran’s state television network that the health ministry had ordered city officials “not to publish any statistics” related to the outbreak in Qom. The situation there was “very dire and disease has spread across the city, ” he said.
Iranians, distrusting the authorities, were ignoring official urgings to stay away from hospitals for fear of spreading the disease, instead crowding into emergency rooms to get themselves tested. Imam Khomeini Hospital in Tehran put up a triage tent outside to handle the overflow.
In an interview with BBC Persian from Tehran, Dr. Babak Gharaye Moghadam urged citizens to “please, please listen” to the advice of health officials and not to turn to social media feeds on their cellphones for guidance.
The price of hospital masks was spiking across the region, including in Iran, Iraq, Lebanon and Afghanistan, where some were selling for as much as 30 times the usual cost.
Experts worry that few Middle Eastern countries are ready to respond effectively to the threat posed by the virus.
“How ready are these countries?” asked Dr. Montaser Bilbisi, an American-trained infectious disease specialist practicing in Amman, Jordan. “In all honesty, I have not seen the level of readiness that I have seen in China or elsewhere, and even some of the personal protective equipment is lacking.”
In Jordan, for example, he said that he had not yet seen a fully protective hazardous materials suit. “So health care workers would be at very high risk for infection.”
In Afghanistan, officials said the first confirmed case of the virus was a 35-year-old man from the western province of Herat who had recently traveled to Qom. Health officials declared a state of emergency in Herat. The government on Sunday had already suspended all air and ground travel to and from Iran.
But the border is difficult to seal. Thousands cross every week for religious pilgrimages, trade, jobs and study — about 30,000 in January alone, the International Organization of Migration, an intergovernmental agency, reported.
“In the past two weeks, more than a 1,000 people have visited or traveled to Qom from Herat, which means they come into closer contact with the virus,” the Afghan heath minister, Ferozuddin Feroz, said on Monday at a news conference in Kabul.
As officials offered reassurances that they were ordering more hospital masks, residents were panicking about what other precautions to take.
The son of a professor at a university in Herat, who returned three days ago from Iran, called a reporter for The New York Times on Monday asking what the procedure for quarantine was.
“My father doesn’t show any signs of corona, but he and our family are worried,” the son, Mohamad Iman, said. “He’s locked himself up in a room where he just reads books. He has asked us to leave him some food and water at the door, but to stay away.”
Saudi Arabia was the epicenter of a similar outbreak seven years ago, known as the Middle East Respiratory Syndrome, or MERS, that was transmitted from camels to humans.
But even after seven years, Saudi Arabia, one of the richest countries in the world, has struggled to adapt state-of-the-art hygiene procedures to limit the spread of the virus within hospitals. A MERS outbreak last spring infected at least 61 people, killing eight of them.
“Many hospitals in Saudi Arabia have improved but some could still do better at prevention,” said Dr. David L. Heymann, former chairman of Britain’s Health Protection Agency.
In Iraq, the country with the most extensive border with Iran, only one case has been detected so far: that of a 22-year-old Iranian religious student in Najaf, Suhail Mohammad Ali.
In the first comprehensive steps to combat the spread of the virus, the education department in Najaf on Monday postponed spring exams and the sacred Imam Ali Shrine was closed.
The central government’s health department recommended avoiding crowded places, kissing or shaking hands.
In Beirut, Lebanon, a 41-year-old woman who had traveled to Qom on a religious pilgrimage landed in Beirut on Thursday night and was found on Friday to have the virus. It was not until Monday, though, that the government issued an emergency plan, suggesting that travel to the affected areas be restricted and that arriving passengers be isolated at the airport if they showed symptoms.
But no definite restrictions were ordered; not all passengers landing in Beirut in recent days have been screened; and another two planes from Qom were allowed to land in Beirut on Monday. Passengers on the plane carrying the infected Lebanese woman from Qom were told to quarantine themselves at home.
The country’s health minister, Dr. Hamad Hasan, on Monday urged the Lebanese to stay calm. But Rabih Shaer, founder of a Lebanese nonprofit that campaigns against corruption, called the government’s sluggish response “irresponsible and criminal.”
“Already the Lebanese population lost trust that this political class can face all the problems,” he said. “And now, until today, they still haven’t taken the right measures. There’s no transparency, there’s no accountability.”
Dr. Nada Melhem, a virologist at the American University of Beirut who has been consulting with the Health Ministry, acknowledged that, “the level of panic in Lebanon is really high.”
“But with systematic follow-up, we will be able to contain it,” she added. “Are we going to have some gaps? We will definitely have some, but I hope we can limit them as much as we can.”
Reporting was contributed by Alissa Rubin from Baghdad, Vivian Yee from Beirut, Lebanon, Asadullah Timory from Herat, Afghanistan, and Fatima Faizi from Kabul, Afghanistan.
SEOUL, South Korea — The coronavirus spread to more countries and the numbers of new cases and deaths outside of China climbed, with special concern focused on South Korea, where infections doubled in a single day — raising fears that another Asian country was losing control of the escalating epidemic.
By Saturday, the virus had been identified in two new countries, Lebanon and Israel, bringing the spread to 28 countries, with about 1,500 confirmed cases outside of China, where it originated. The death toll in Iran rose to six, the highest outside of China, and the number of confirmed cases there reached 28, though experts suggest that the real number is likely to be far higher.
South Korea’s prime minister, Chung Sye-kyun, called the situation in his country “grave” and urged citizens to cooperate with the government and avoid large political gatherings, which have continued in the capital, Seoul, despite a city ban.
“The government will sternly deal with acts that interfere with quarantine efforts, illegal hoarding of hygiene goods and acts that spark uneasiness through massive rallies,” Mr. Chung warned in a nationally televised address.
The spike of cases in Korea and the rising death toll in Iran raised fears that the window to avert a global pandemic was narrowing. The World Health Organization warned African leaders of the urgency of preparing for the virus, and identified 13 African countries as priorities because of their direct links to China and the high volume of travel between the countries.
The number of confirmed infections in South Korea, after more than doubling on Saturday, rose to 556 on Sunday morning. More than half were among members of a secretive religious sect, the Shincheonji Church of Jesus, and their relatives and other contacts. Most of the cases are centered in and near Daegu, the country’s fourth largest city, which has been placed under a state of emergency.
Between Daegu, a city of 2.4 million people, and a nearby province where the sect’s members often do volunteer work, 465 people have tested positive.
In the neighborhood of the sect’s church in the city, banks, coffee shops, restaurants and convenience stores have all shut down, rendering it a ghost town. Across the city, department stores, shopping alleys and traditional outdoor marketplaces have all been drained of shoppers.
The only busy sites were government-run health centers, where citizens lined up to find out whether they were infected.
The scare deepened across South Korea as the number of patients soared and two more deaths from the virus were reported.
A 40-year-old worker at an auto-parts factory in Gyeongju, a city near Daegu, was found dead at his home on Friday evening. He was posthumously confirmed on Saturday to have been infected with the coronavirus. A 56-year-old patient from a hospital in Chengdo, another town near Daegu, died on Sunday, health officials said.
On Friday, the first reported case in Busan, South Korea’s second largest city, caused public libraries, horse racetracks and facilities for senior citizens to close. Many churches offered services only online. Others stayed open, but skipped hymns or “Amens” to limit the possibility of congregants’ exposure.
The cities of Chuncheon and Ulsan reported their first cases on Saturday, and the national news agency Yonhap reported that people there were emptying shelves of rice, instant noodle, eggs and other essential food items.
The number of coronavirus cases in South Korea also set off alarms in Israel, after nine South Korean visitors tested positive for the virus upon returning home. They had spent a week touring popular, often-crowded Israeli religious sites. On Saturday, Israel tightened its border and barred South Korean travelers.
Discussions whether to allow other flights from South Korea to Tel Aviv were planned for Sunday, Kan radio said. Health officials were working with the tourism ministry and travel agencies to book flights back to South Korea for the 1,700 South Korean tourists in Israel.
In the United States, State Department officials said that thousands of Russia-linked social media accounts were spreading disinformation about the coronavirus, including a conspiracy theory that the United States was behind the outbreak.
Two senior American officials said that the repatriation this week of 14 American citizens from the cruise ship Diamond Princess who had tested positive for the coronavirus had infuriated President Trump. Mr. Trump is a self-declared “germaphobe.”
William Walters, a top medical official at the State Department, told reporters that the decision to fly the 14 back had been made by the State Department in consultation with Robert Kadlec, an assistant secretary at the Department of Health and Human Services.
The evacuation of more than 300 Americans was already underway last Sunday when Japanese officials informed American counterparts of the laboratory test results, he said.
The decision to fly back the infected passengers was made over the objections of officials at the Centers for Disease Control and Protection.
The C.D.C. also had advised American passengers of the Westerdam cruise ship, where a passenger was found to have the coronavirus, that they were not required to self-quarantine and were no longer subject to travel restrictions. No other infections were found among passengers on the ship, the C.D.C. confirmed.
An American woman, 83, who had disembarked from the Westerdam in Cambodia along with thousands of others passengers and crew members, had tested positive for the coronavirus after arriving at the airport in Kuala Lumpur, Malaysia on Feb. 15.
The woman’s diagnosis had raised concerns and worries that another vector of transmission was going global and Cambodia has called the Malaysian diagnosis flawed.
By Saturday, the patient had been cleared of the coronavirus and was being monitored in the hospital with a “slight cough” after an antiretroviral treatment, said Noor Hisham, the Malaysian health director general.
Cambodia’s prime minister, Hun Sen, said the woman never had coronavirus. The prime minister is a close ally of China and he has cast doubts on the seriousness of the coronavirus outbreak.
The rise in Iran’s death toll came days after the country had insisted that it had no coronavirus cases. Kianush Jahanpur, the head of public relations at the country’s health ministry, wrote in a tweet that most of the infections came from Qom, 80 miles south of the capital, Tehran. Cases were also reported in Tehran and the northern city of Rasht.
On Saturday, state media reported that universities would be closed in 10 provinces for a week and movies, concerts and other cultural events were canceled countrywide for a week.
Dr. Tedros Adhanom Ghebreyesus, the World Health Organization’s director, said the organization was “especially concerned” about the cases in Iran.
The spread of the virus is a concern as Iran holds parliamentary elections this weekend. Many voters in Qom lined up in front of the voting stations wearing masks according to videos from Iranian news agencies.
With confirmed cases rising in Asia and in the Middle East, the W.H.O. confirmed on Saturday that its experts were being allowed into Wuhan, the city at the center of the coronavirus epidemic, for the first time.
Choe Sang-Hun reported from Seoul and Derrick Bryson Taylor from New York. Reporting was contributed by Hannah Beech from Bangkok, Farnaz Fassihi from New York, David M. Halbfinger from Jerusalem, Elian Peltier from London and Edward Wong from Washington.
The coronavirus outbreak that has sickened almost 75,000 in China and killed more than 2,000 worldwide, has upended travel and commerce across the world. In light of the spread of the disease, which has been named COVID-19, would-be travelers to Asia and even parts of the world with few or no cases are wondering what to do.
The Times asked readers for their most pressing questions and got a flurry of queries: Should I cancel my trip to Asia, despite the financial penalties? Or go ahead? What about going to other parts of the world? How hard is it to disinfect an airplane, anyway, and is a mask enough to protect from the virus?
For anyone planning to travel, the website of the World Health Organization is a good starting point. (W.H.O. has been issuing daily updates about the spread of COVID-19 and the status of cases.) The Centers for Disease Control and Prevention, which has advised Americans to cancel all nonessential travel to China, also offers information and guides for travelers. The Times has a map of the number of cases reported in each country.
In addition to those agencies, travelers should consult the websites of their home country and their intended destination to see what policies have been put in place.
“You should also be double careful to do the things we say everyone should always do like hand washing with soap and water, especially after touching surfaces or coming in contact with someone who has been coughing,” said David Eisenman, director of University of California, Los Angeles’s Center for Public Health and Disasters, and professor of community health sciences at the university’s Fielding School of Public Health. “You should be avoiding close contact with others if you’re sick and you should have your flu shot.”
Here are some of the most common questions and the current advice from health and travel experts. Questions have been combined and condensed for clarity.
I have a trip planned that is not to Asia. Is it safe to go?
Readers asked about destinations thousands of miles from Wuhan, China, where the coronavirus outbreak started, including Ireland, Argentina and Vancouver (the last city made one traveler nervous because of its close ties to China).
Dr. Eisenman and other doctors said that from a medical standpoint, there isn’t any current reason to skip a trip to a country where few or no cases of the coronavirus have been reported.
“You have to evaluate your trip week to week, if not day to day,” said Bernard Camins, medical director for infection prevention at the Mount Sinai Health System. “But if you’re looking at a place where there are no cases, there’s no question you should continue on your trip.” (Dr. Camins has trips to Europe planned for this spring and is not canceling.)
The question becomes more difficult the closer to the heart of the outbreak you are planning to travel, Dr. Camins said. In places like Singapore and Thailand, there have been cases, but there is no evidence that there is a lot of person-to-person transmission and the virus doesn’t seem to be out of control, he said. “The chances of you running into a person with it there is low, unless you’re a health care professional and you’re going to work in a hospital,” he said.
He added: “The golden rule for travel right now should be this: If you’re the one who is sick, stay home, do not travel, wear a mask, even for the flu.”
Steve Kuriga, an independent travel adviser at Cadence, a San Diego agency affiliated with the Virtuoso network said, “It’s a personal decision, but unless you’re going through an infected area I don’t see any reason to put off your travels.”
Mr. Kuriga added that he has clients who are looking at South America as an alternative to Asia for an upcoming trip because no cases of COVID-19 have been reported there.
I have a trip planned to Vietnam in April, what is the situation in that country?
There have been 16 confirmed infections, no deaths, 14 recoveries and 1,538 quarantined cases in Vietnam. The country’s prime minister officially declared COVID-19 an epidemic in Vietnam on Feb. 1, and authorities closed land borders with China, indefinitely stopped flights to and from China, and instituted a 14-day quarantine for anyone coming from affected areas in China. The government is also encouraging people to avoid public gatherings at the moment.
Although some cities that have registered infections have closed tourist attractions and heritage sites, the majority are still open to the public. Many festivals and events are going on as planned, but others have been postponed. For a detailed list, consult Vietnam’s tourism site, which has detailed information about traveling to the country.
What about Cambodia?
Until recently, Cambodia said it had only one case of the coronavirus and Prime Minister Hun Sen made a point of not wearing a surgical mask in public. But then a passenger on the Westerdam, a Holland America Line boat that had been blocked from docking in five countries over fear of the virus, was diagnosed with COVID-19 disease after disembarking from the ship in Sihanoukville, throwing into question how well the virus was being contained.
The U.S. State Department has a Level 1 warning about traveling to Cambodia, which means that in its assessment there is currently no danger in traveling to the country. You can keep up-to-date with the department’s advisories at its website.
Can I go to Japan?
Japan has reported more than 700 cases of coronavirus, with 621 of them coming from the Diamond Princess cruise ship, which has been quarantined in Yokohama; two passengers on the ship have died. Japanese authorities allowed a number of people from the ship to leave, a decision that some health experts have questioned.
The C.D.C. has a Level 1 watch for coronavirus in Japan, which advises travelers to “practice usual precautions.”
Since Feb. 13, non-Japanese nationals who have visited Hubei and Zhejiang provinces in China within 14 days of arrival in Japan, or who have a Chinese passport issued in those provinces, are not allowed to land in Japan except under special circumstances.
Japan’s National Tourism Organization is advising travelers that medical expenses may be high in the event that you become sick or injured and need to go to the hospital in Japan. “Please do not forget to take out the necessary travel insurance,” the tourist board said in a statement on its website. It is also encouraging tourists to take the same precautions people take during flu season when traveling.
What’s happening in South Korea?
South Korea has 104 infections, 53 of which were added on Thursday, nearly doubling the number from the day before. The mayor of the city of Daegu asked residents to stay indoors after several people associated with a church contracted COVID-19. On Thursday, authorities announced the first death in the country, and the United States Army Garrison Daegu restricted access to its base, according to a statement.
Currently, the C.D.C. has no advisory for South Korea, according to its site.
I am scheduled for a layover at Singapore’s Changi Airport. Is that a problem?
As of Wednesday, Singapore had 84 cases of coronavirus, but transiting through the airport is unlikely to bring travelers in contact with any of the sick. Earlier this month the airport implemented rules to help keep the virus at bay. Anyone who has traveled to mainland China within 14 days of arriving at Changi is not allowed to enter Singapore or to travel through it. Additionally, Singapore’s Immigration and Checkpoints Authority suspended the issuance of new visas to people with Chinese passports. The airport also said it increased the frequency with which the airport is being cleaned and is using more disinfectants in the cleaning process.
Mr. Kuriga said that in his estimation, “Right now it’s safe to travel through there, but like with everything else, keep checking.”
Do airlines sanitize planes between flights? Are they instituting any new policies?
Planes are small spaces with a lot of people on them, and can be involved in transmitting diseases. While it’s not clear if most airlines are changing their cleaning procedures because of the coronavirus, we do know how they typically clean airplane cabins.
“At Southwest, aircraft undergo regular cleanings in between flights, and a comprehensive cleaning when the aircraft is parked overnight,” a spokesman for the airline said. When the plane is cleaned, surfaces — including tray tables, seats and carpets — are cleaned.
Curtis Blessing, a spokesman for American Airlines said planes are cleaned on a regular basis and the depth of the cleaning varies, depending on turn times and type of flight, but bathrooms are cleaned, floors are spot cleaned and visible trash is removed from seat pockets on all flights.
“When ground time allows, galleys are cleaned, as are tray tables,” Mr. Blessing said. “Transcontinental, Hawaii and international flights see an even deeper level of cleaning that includes cleaning of lavatories, tray tables and galley areas, as well as any surface areas throughout the aircraft. Floors are also vacuumed.”
Delta is supplying kits with hand sanitizer, gloves and surgical masks to passengers on all flights to and from Asia. A Delta spokeswoman said the airline’s planes are “thoroughly cleaned for the safety of our customers and crew.”
A spokesman for Alaska Air said that bathrooms on the airline’s planes are cleaned between every flight, and tray tables are cleaned when a layover is longer than an hour. A thorough cleaning of the plane happens whenever a plane stays at an airport overnight.
“Our existing cleaning and disinfecting chemicals are effective against viruses, and nothing about the novel coronavirus indicates that it’s resistant to these efforts,” he said.
What about a cruise ship?
Cruise lines have learned how to combat the norovirus after more than two decades of outbreaks, but some passengers still get sick.
Ross Klein, a sociologist at Memorial University of Newfoundland who studies the cruise industry, said, “The cruise ships are well trained in ‘killing’ a virus and are quite proficient if they follow what they know and the protocols they have for norovirus.”
Those protocols don’t seem to have been followed on the Diamond Princess, the cruise boat that was quarantined in Yokohama, Japan, for two weeks and had 621 sick passengers, he said. The quarantine has been criticized by experts for failing to keep COVID-19 from spreading between passengers and crew members, and two passengers on the ship have died. “But that doesn’t mean the ship can’t be sanitized before taking on new passengers,” Mr. Klein said. “It is no more difficult than a land-based hotel.”
Is a mask sufficient to protect me on an airplane?
W.H.O. says that if you are healthy, you only need to wear a mask if you are taking care of someone with a suspected coronavirus infection. The organization also suggests wearing the mask if you are the person sneezing or coughing.
“Masks are only effective when used in combination with frequent hand cleaning with alcohol-based hand rub or soap and water,” the organization says in its guide about how to best choose a mask, use it and dispose of it.
The type of mask also makes a difference. An N95 mask reduces a wearer’s exposure to airborne particles, from small particle aerosols to large droplets, according to the C.D.C., which has a guide for understanding the differences between a regular surgical mask and an N95 respirator.
My flight has been canceled, but my travel insurance won’t pay. How, in the middle of a medical crisis, could that not be considered a qualifying event for travel insurance?
Bizarre as it may sound, standard travel insurance doesn’t cover losses caused by a global health crisis — even one that’s been declared “a public health emergency of international concern” by W.H.O. and for which the C.D.C. has issued a Level 3 travel notice recommending that travelers avoid all nonessential travel to China.
When it comes to travel insurance, so-called Cancel For Any Reason upgrades are the best course here. But they’re also very expensive and tend to cover only 50 to 75 percent of your trip, said Stan Sandberg, an industry expert and co-founder of TravelInsurance.com, a site that allows travelers to compare and buy travel insurance online.
“It’s important to note that with Cancel For Any Reason coverage, the insurance policy must be purchased within a set amount of days — usually 21 days or fewer, depending on the plan — after making the first payment for the trip, and the entire prepaid and nonrefundable cost of the trip must be insured. The trip must also be canceled more than 48 hours before the departure date,” Mr. Sandberg said.
At Berkshire Hathaway Travel Protection, for example, CFAR coverage costs an additional 40 percent of your total travel insurance premium.
The risk-reward ratio will vary by traveler. In addition to ratings and reviews of specific policies, TravelInsurance.com’s information about the claims process — and their respective outcomes — may be helpful in determining whether or not CFAR coverage is worth the outlay.
My credit card provides travel insurance. Will that actually do anything for me?
The short answer: Not really.
Trip cancellation and interruption insurance, designed to reimburse certain nonrefundable expenses when a trip is canceled or delayed, is a perk of many travel-focused credits cards, including the American Express Platinum and Delta SkyMiles Reserve, as well as both Chase Sapphire cards (Preferred and Reserve).
But what’s actually covered varies, and health crises are particularly unforgiving to consumers. Chase Sapphire cards, for example, will only reimburse you if you’re quarantined “due to health reasons by a competent governmental authority having jurisdiction” — but not a “disinclination to travel due to an epidemic or pandemic.” In other words, if you choose not to travel — even to quite reasonably avoid a region affected by the coronavirus — trip cancellation and interruption insurance won’t help. American Express doesn’t have explicit epidemic inclusions (or exclusions), but cardholders might have luck claiming reimbursement by getting a doctor’s note stating that “a covered trip is medically inadvisable.”
What if I’m immune-compromised and have a doctor’s note to that effect. Still no refunds?
Older adults and people with underlying health conditions may be at increased risk for severe disease. According to medical experts, many of those who have died in the coronavirus outbreak had pre-existing conditions that weakened their ability to fight it. Travelers with an immune-suppressed system should talk to their health care providers before traveling.
Mr. Kuriga, the travel adviser in San Diego, said that it’s a good idea to reach out to a travel agent or the travel company you booked a trip with because some companies might be flexible in their cancellation and refund policies.
“Not all companies are coming up with broad policies,” he said. “Some companies are dealing with it on a case-by-case basis.”
I am planning to go to Japan. If I decide to travel anyway, what is the best way to arrange for medical assistance if I need it?
The simplest precaution is to purchase medical travel insurance, in particular, a primary-coverage plan that substitutes for your existing United States health insurance while you’re abroad. Look for hefty emergency medical coverage (at least $50,000, according to most experts) and emergency medical transportation coverage (upward of $100,000, depending on how remote your destination is). Deductibles, waivers for pre-existing conditions, and pricing vary by a number of factors; you can comparison-shop on TravelInsurance.com, Squaremouth, and a host of other sites.
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A 29-year-old respiratory doctor in Wuhan, the city at the center of the new coronavirus outbreak in China, died on Thursday night after being infected by the virus, according to an announcement from the hospital where he worked. It was the latest in a string of deaths among health care providers working to contain the outbreak.
The doctor, Peng Yinhua, was also among the youngest of the publicly announced victims of the virus, which has largely killed older men with underlying health conditions.
On Chinese social media, users expressed shock at Dr. Peng’s age. They also cited state media reports that Dr. Peng had planned to get married on Feb. 1, but that he had postponed the wedding because of the epidemic.
Last month, the death of another young Wuhan doctor, Li Wenliang, provoked an outpouring of anger and grief on social media. Dr. Li, 34, had been reprimanded by the local authorities for trying to warn his medical school classmates about the virus before officials had acknowledged an outbreak. When Dr. Li died of the virus, he became a potent symbol of perceived government mismanagement and concealment.
After Dr. Peng’s death, some users seemed to nod to Dr. Li as well. “We send away another hero,” one person wrote on Weibo, a Chinese Twitter-like platform.
“Exactly how many more medical staff have to die?” another wrote.
Earlier this week, another high-profile doctor, Liu Zhiming, died. Dr. Liu was the director of the Wuchang Hospital in Wuhan.
Cases in South Korea surge as officials focus on a church.
South Korea said on Friday that the number of confirmed cases of coronavirus infections rose to 156, a near tripling over three days.
Among the 52 new cases reported on Friday, 41 are in Daegu, a city of about two and half million people in the southeastern part of the country, and the surrounding region, South Korean disease control officials said in a statement. Among those, 39 of the new cases were connected to a church called Shincheonji.
Officials said a 61-year-old woman who had attended services at the church over the past two Sundays had been identified as a potential source of the spread of the virus.
The new figures give South Korea the world’s second largest number of confirmed cases if those from the Diamond Princess cruise ship are not included in Japan’s total. The vast majority of cases are in mainland China, which has reported more than 75,000 cases. Japan has 94 cases, which does not include the more than 600 people who had been on board the Diamond Princess cruise ship.
South Korea reported on Thursday what officials said could be its first death from the coronavirus. A 63-year-old patient with symptoms of pneumonia died on Wednesday at the Daenam Hospital in Cheongdo.
The company that makes iPhones said it would be cautious in resuming work at its Chinese factories.
With much of China still on lockdown, businesses are struggling to get up and running. Foxconn, the Taiwan company that manufactures Apple’s iPhones and other gadgets, indicated just how difficult that will be.
The company on Thursday said its revenues would take a hit from the spread of the coronavirus, and that it would be “cautious” in resuming work at its factories in China. Plants outside of the country, in places like Vietnam and Mexico, were at full capacity, the company said.
The warning comes as Chinese leaders try to balance restarting the economy with controlling the spread of the coronavirus. Following repeated extensions of the Lunar New Year holiday, many migrant workers remain at home, facing mandatory quarantines and lockdowns. A number of businesses and officials have issued warnings that such policies need to be relaxed to avoid a new economic crisis.
Even if factories get all their workers back, other policies are likely to make life difficult. Some local governments require new preventive measures, like requiring workers to wear masks, or housing each worker in a single dorm room. In other cases, cities have invoked mandatory two-week quarantines on all returning workers.
Concerns about production at Foxconn, the world’s largest contract manufacturer of electronics, underscore the broader impact the epidemic could have on global supply chains. A huge portion of the world’s electronics come out of China’s factories. A longer suspension of production could hit overall supply.
Beijing stepped up its war of words over critical coverage in foreign media outlets.
The Chinese Embassy in Nepal has attacked a Nepalese newspaper for publishing a column criticizing Beijing’s handling of the coronavirus outbreak and an illustration of Mao Zedong wearing a face mask.
The Embassy said in a statement this week that the Kathmandu Post had “deliberately smeared” the government and people of China, and “viciously attacked” the nation’s political system.
The statement, which singled out the paper’s top editor, was the latest example of the Chinese government’s increasingly muscular brand of diplomacy and its efforts to publicly quash criticism of its policies, even abroad. This week, Beijing also announced it would expel three Wall Street Journal reporters in retaliation for a headline on an opinion piece.
The column in question in the Kathmandu Post is a syndicated opinion piece, entitled “China’s secrecy has made coronavirus crisis much worse” and originally published in The Korea Herald, that was reprinted in the Post on Tuesday. The paper accompanied the column with an illustration of a Chinese bank note digitally altered to depict Mao wearing a surgical face mask.
The Chinese Embassy’s rebuke singled out Anup Kaphle, the Kathmandu Post’s editor-in-chief, for scorn, saying that he was “a parrot of some anti-China forces.” It warned that the Chinese government could take further action.
One of Asia’s poorest and least-developed democracies, Nepal has grown closer to China as it seeks to reduce its dependence on India. Chinese investors have pumped millions of dollars into the country.
In an editorial on Wednesday, the newspaper alluded to China’s growing economic influence on Nepal and accused the embassy of violating diplomatic norms by using threatening language against the outlet and disparaging its top editor.
“The Chinese embassy’s statement, ultimately, is not just about the Post, or its Editor-in-Chief,” the editorial said. “It is a rebuke to not bite the hand that feeds.”
China’s deaths and infections rise after officials change their methodology again.
Chinese officials announced on Friday that 889 new cases of the coronavirus had been reported in the previous 24 hours, raising the overall total above 75,000.
The death toll went up by 118, to 2,236.
All but three of the new deaths were in China’s central Hubei Province, the focus of the outbreak. Hubei was also the source of nearly three quarters of the new confirmed cases of infection.
The new count came one day after Chinese health authorities said they were using new criteria to count cases of the coronavirus. The move appeared to undo a change they made last week.
That earlier change allowed health officials in Hubei to count cases diagnosed in clinical settings, including with the use of CT scans showing lung infections, not just those confirmed using specialized kits to test for the virus.
On Thursday, officials said Hubei would now resume using the same criteria as the rest of the country. Cases will be considered confirmed only if the virus is found.
Trials for two coronavirus drug therapies to begin.
The World Health Organization said on Thursday that two new drug therapy trials to help fight the coronavirus are set to begin in China and that early results may be available within three weeks.
One trial involves an experimental antiviral drug made by Gilead. It has not yet been licensed for use.
The drug was tested against the Ebola virus in Congo, where it was not very effective. But when it was given to the first American known to be infected with the coronavirus, an unidentified man in Washington State, he recovered.
The second trial involves a combination of two anti-H.I.V. drugs that is sold as Kaletra in the United States and available in generic versions.
If either therapy helps prevent severe pneumonia, sepsis or organ failure in coronavirus patients, death rates may fall. Two other drugs — favipiravir and chloroquine — have also been discussed as potential treatments.
Reporting was contributed by Paul Mozur, Donald G. McNeil Jr., Choe Sang-Hun, Roni Caryn Rabin, Carlos Tejada, Elaine Yu and Tiffany May.
In nearly 20 years with the Centers for Disease Control and Prevention, Rear Adm. Nancy Knight, director of the agency’s global health protection division, has led the development, coordination and implementation of public health policies and programs in countries including Nigeria, Kenya and South Africa. Before joining the C.D.C., Dr. Knight was a Peace Corps volunteer in Lesotho and trained as a family physician.
In 2008, Dr. Knight helped start in Nigeria the C.D.C.’s Field Epidemiology Training Program, training “disease detectives” to identify diseases and how to respond to them. When Ebola came to Lagos, she returned to Nigeria and worked with the government and the “detectives” to deal with the disease.
“Those people we trained were instrumental in fighting Ebola because they were leading the effort on the ground, looking at daily cases and running that response within those communities,” she said.
Dr. Knight talked about the coronavirus, what travelers can do to avoid it and how the C.D.C. works with governments and other groups around the world to help countries stay prepared for the possibility of an outbreak of a contagious disease, and to tackle those diseases when they occur.
What does your department do at the C.D.C.?
My division and the work that we do focus on working with countries to achieve global health security and keep people safe from outbreaks.
How do you do that?
We do this through collaborations with partners, particularly governments in countries where we are working. We work together to strengthen core public health systems and find ways to prevent and respond when there are outbreaks.
Through the decisions of Global Health Protection and other experts, we work with countries on some critical aspects of their public health systems. The four aspects that we really focus on are: developing strong disease surveillance systems; making sure there are adequate laboratory networks; making sure there are people with expertise in epidemiology — we call them disease detectives; and ensuring that there are strong emergency response structures.
We have such an interconnected world today, and it’s shocking how quickly people and things can move from country to country. In as little as 36 hours an individual can move from a small village on any continent to any country in the world. With that comes a risk of movement of diseases within our borders and across them.
It is. There’s always going to be fear of diseases, especially when it’s a new disease we’ve never heard of before or one we know about, but it helps to be able to detect them quickly. We want to be equipped to know what it is, stop it, mitigate it and keep it from spreading as quickly as possible.
Another thing that can be kind of frightening is not only the health impact and the lives that can be affected or the people who die, but there’s also a big economic concern. These diseases can affect human health, animal heath, economies. They can affect relations with neighboring countries, trade and tourism.
Are there any examples of that economic fallout?
More than 11,000 people died of Ebola — that’s a huge toll on human life, and the cost on the global economy was more than $53 billion. Severe acute respiratory syndrome — SARS — costs countries $40 to 45 billion.
How many people are involved in containing a disease once we know it’s out there?
Thousands and thousands. It’s a worldwide issue. After the SARS outbreak in 2003, countries around the world recognized that not everyone was prepared to address an outbreak like that when it occurs, so the World Health Organization and countries in it put into place the international health regulations. But a majority of countries were not prepared to respond. They knew what they agreed to, but they were missing the road map.
The global health agenda was established, so many countries that wanted help figuring out how to know their gaps in an objective way could get that information.
People are concerned about the coronavirus. How do decision makers go from one level of seriousness to the next when a virus is spreading?
The C.D.C has three levels when a health threat occurs: Watch, alert and warning. Level One is watch. It’s when you should practice usual precautions for this destination, as described in the Travel Health Notice and/or on the destination page. This includes being up-to-date on all recommended vaccines. Level Two is alert, when you should practice enhanced precautions for this destination. Level three is warning, when we say people should avoid nonessential travel to this destination. At Level Three the outbreak is of high risk to travelers and no precautions are available to protect against the identified increased risk.
Travelers should remember that there is limited access to adequate medical care in affected areas, and older adults and people with underlying health conditions may be at increased risk for severe disease. Travelers with an immune-suppressed system should consult with their health care providers for additional guidance before travel.
Currently, there is no vaccine available to protect against 2019-nCoV. There is no specific antiviral treatment recommended for 2019-nCoV infection. People infected should receive supportive care to help relieve symptoms. If you were in Wuhan and feel sick with fever, cough or difficulty breathing within 14 days after you left Wuhan, you should seek medical care right away. Before you go to a doctor’s office or emergency room, call ahead and tell them about your recent travel and your symptoms.
This interview was edited and condensed for clarity.
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LONDON — A Chinese tourist has died in France of the coronavirus, the French health minister said on Saturday, becoming the outbreak’s first fatality in Europe and outside Asia.
France’s health minister, Agnès Buzyn, said the tourist, who was 80 years old and from the Chinese province of Hubei, the center of the outbreak, died at the Bichat-Claude Bernard Hospital in Paris on Friday after weeks of hospitalization. His daughter, who also has the virus, is receiving treatment and is expected to be discharged soon, Ms. Buzyn said.
The man and his daughter were among 12 confirmed cases in France. Of those cases, seven remain hospitalized and four have been discharged, according to health authorities.
The man’s death comes as officials in Europe grapple with preparing for the spread of the disease on the Continent, where there have been 44 cases, according to data from the World Health Organization.
By Saturday, the number of confirmed coronavirus cases around the globe had risen to more than 66,000, with at least 1,523 deaths, almost all in mainland China. Hong Kong, Japan and the Philippines have each recorded a single death.
Though the effects of the outbreak have so far been minimal in Europe, with confirmed cases in Germany, France and Britain, the outbreak was beginning to have a slowing effect on Europe’s economies.
The death in France was announced days after the World Health Organization warned that the virus’s spread could accelerate outside China.
Germany reported two more cases just days ago, raising the total there to at least 16. And the British health authorities declared the new coronavirus “an imminent threat,” although all but one of the nine patients who tested positive there have been discharged.
A British businessman who is believed to have been the initial source of at least five cases in Britain and five more in France said on Tuesday that he had contracted the virus at a conference in Singapore last month. He later traveled to a chalet in Les Contamines-Montjoie, where he came into contact with five Britons who later tested positive for the virus. Then he returned to Britain.
The businessman, Steve Walsh, said he had fully recovered.
Ms. Buzyn, the French health minister, did not identify the patient who died on Friday, but said he had arrived in France on Jan. 16 and been hospitalized since Jan. 25.
“His condition had quickly worsened and he had been in critical condition for several days,” Ms. Buzyn said in a televised statement.
Ms. Buzyn announced on Saturday that the 12th confirmed case in France was a British national who had also stayed at the chalet.
The director general of the World Health Organization, Tedros Adhanom Ghebreyesus, has warned that the new coronavirus could pose a “very grave threat” to the world and should be viewed as “Public Enemy No. 1,” he said.
“The detection of a small number of cases may indicate more widespread transmission in other countries,” Dr. Tedros wrote on Twitter just days ago. “In short, we may only be seeing the tip of the iceberg.”
The coronavirus, which surfaced in a Chinese seafood and poultry market late last year, has spread to 24 countries, killing more than 1,000 and sickening tens of thousands of people in a matter of weeks. The World Health Organization has declared the situation a global health emergency.
Here’s a timeline of what we know so far about the outbreak.
Chinese authorities were treating dozens of cases of pneumonia of unknown cause.
On Dec. 31, the government in Wuhan, China, confirmed that health authorities were treating dozens of cases. Days later, researchers in China identified a new virus behind an illness that had infected dozens of people in Asia. At the time, there was no evidence that the virus was readily spread by humans. Health officials in China were monitoring it to ensure that the outbreak would not develop into something more severe.
China reported its first death.
On Jan. 11, Chinese state media reported the first known death from the disease caused by the virus, which had infected dozens of people in China. The 61-year-old man who died was a regular customer at the market in Wuhan, where the illness is thought to have originated, and he had previously been found to have abdominal tumors and chronic liver disease. The report of his death came just before one of China’s biggest holidays, when hundreds of millions of people travel across the country.
Other countries, including the United States, confirmed cases.
The first confirmed cases of the coronavirus outside mainland China occurred in Japan, South Korea and Thailand, according to the World Health Organization’s first situation report published on Jan. 20. The first confirmed case in the United States came the next day in Washington State, where a man in his 30s developed symptoms after returning from a trip to Wuhan.
Wuhan, a city of more than 11 million, was cut off by Chinese authorities.
After Chinese officials urged people not to travel to or from Wuhan, severe travel restrictions were put in place. On Jan. 23, the authorities closed off Wuhan by canceling planes and trains leaving the city, and suspending buses, subways and ferries within it. At this point, at least 17 people had died and more than 570 others had been infected, including in Taiwan, Japan, Thailand, South Korea and the United States.
The World Health Organization declared a global health emergency.
Amid thousands of new cases in China, a “public health emergency of international concern” was officially declared on Jan. 30 by the World Health Organization. The country’s Foreign Ministry spokeswoman said that China would continue to work with the W.H.O. and other countries to protect public health, and the U.S. State Department warned travelers to avoid China.
Airlines suspended service to China, while the Trump administration restricted entry into the U.S.
On Jan. 31, Delta Air Lines, American Airlines and United Airlines said they would suspend service, for at least two months, between the United States and mainland China. The Trump administration said it would suspend entry into the United States by any foreign nationals who had traveled to China in the last 14 days, excluding the immediate family members of American citizens or permanent residents. By this date, 213 people had died and nearly 9,800 had been infected worldwide.
The first coronavirus death was reported outside China.
A 44-year-old man in the Philippines died after being infected by the coronavirus, officials said on Feb. 2. The man’s death was the first reported outside China. By this point, the number of deaths had risen to more than 360.
Hundreds, mostly Americans, were evacuated from Hubei Province.
About 350 people, mostly Americans, who were evacuated from Hubei Province in China, arrived in California on Feb. 5. The group would be held at Travis Air Force Base in Fairfield, Calif., and at Marine Corps Air Station Miramar in San Diego for 14 days, which is the maximum time it takes a person to become sick after being exposed to the coronavirus. By Feb. 13, the number of coronavirus cases in the United States had risen to 15 in seven states.
A cruise ship in Japan quarantined thousands.
On Feb. 5, after a two-week trip to Southeast Asia, more than 3,600 passengers began their 14-day quarantine aboard the Diamond Princess cruise ship in Yokohama, Japan. Officials began screening passengers, and the number of people who tested positive became the largest number of coronavirus cases outside of China. By Feb. 13, the number stood at 218.
A Chinese doctor, who tried to warn others, died from the coronavirus.
When Dr. Li Wenliang, a Chinese doctor, died on Feb. 7 after contracting the coronavirus, he was hailed as a hero by many for his attempt to ring early alarms that a cluster of infections could spin out of control.
In early January, the authorities tried to silence him when he was called in by both medical officials and the police, and he was forced to sign a statement denouncing his warning as an unfounded and illegal rumor. Dr. Li’s death provoked anger and frustration at how the Chinese government mishandled the situation by not sharing information earlier and by silencing whistle-blowers.
The death toll in China surpassed the number SARS killed worldwide.
On Feb. 10, the death toll in China rose to 908, surpassing the global number of dead from the SARS epidemic in 2002-3, which killed 774. At this point, the number of confirmed cases of infection in the country had risen to 40,171.
The death toll in China topped 1,000.
Chinese officials said the death toll had reached 1,016 while the number of infections had grown to 42,638 on Feb. 11. A U.S. citizen died in Wuhan, officials said on Feb. 8; it was the first known American death.
The Communist Party fired top officials of Hubei Province and Wuhan.
China’s ruling Community Party ousted Jiang Chaoliang, the party secretary of Hubei Province, and Ma Guoqiang, the top official in Wuhan, on Feb. 13 amid widespread public outrage over the handling of the outbreak.
There were more than 14,000 new cases in Hubei Province.
Officials on Feb. 13 added more than 14,840 new cases to the total number of infected in Hubei Province. That set a daily record, coming after officials in Hubei seemed to be including infections diagnosed by using lung scans of symptomatic patients.
The news seemed to be positive: The number of new coronavirus cases reported in China over the past week suggested that the outbreak might be slowing — that containment efforts were working.
But on Thursday, officials added more than 14,840 new cases to the tally of the infected in Hubei Province alone, bringing the total number to 48,206, the largest one-day increase so far recorded. The death toll in the province rose to 1,310, including 242 new deaths.
The sharp rise in reported cases illustrates how hard it has been for scientists to grasp the extent and severity of the coronavirus outbreak in China, particularly inside the epicenter, where thousands of sick people remain untested for the illness.
Confronted by so many people with symptoms and no easy way to test them, authorities appear to have changed the way the illness is identified.
Hospitals in Wuhan, China — the largest city in Hubei Province and the center of the epidemic — have struggled to diagnose infections with scarce and complicated tests that detect the virus’s genetic signature directly. Other countries, too, have had such issues.
Instead, officials in Hubei now seem to be including infections diagnosed by using lung scans of symptomatic patients. This shortcut will help get more patients into needed care, provincial officials said. Adding them to the count could make it easier for the authorities to decide how to allocate resources and assess treatment options.
But the change also shows the enormous number of people in Hubei who are sick and have not been counted in the outbreak’s official tally. It also raises the question whether the province, already struggling, is equipped to deal with the new patients.
The few experts to learn of the new numbers on Wednesday night were startled. Lung scans are an imperfect means to diagnose patients. Even patients with ordinary seasonal flu may develop pneumonia visible on a lung scan.
“We’re in unknown territory,” said Dr. William Schaffner, an infectious disease specialist at Vanderbilt University in Nashville.
In China, health officials have been under exceptional strain. Hospitals are overwhelmed, and huge new shelters are being erected to warehouse patients. Medical resources are in short supply. It’s never been clear who is being tested.
Health workers have gone door to door in Wuhan to check people for symptoms. The prospect of forced isolation may be deterring some people with respiratory illnesses from presenting themselves at health facilities to seek health care, some experts say, making the dimensions of the epidemic even less clear.
“You have to be sick, the authorities need to find you, or you find them, and they need to test you,” said Dr. Arthur Reingold, an epidemiologist at the University of California, Berkeley.
The push to prioritize lung scans seems to have begun with a social media campaign by a physician in Wuhan, who last week called for using the scans to simplify the screening of patients and to accelerate their hospitalization and treatment.
Lung scans produce immediate results, she said, and Wuhan was running short of testing kits.
Even before today’s news, experts complained that epidemiological information from China has been incomplete, threatening containment efforts.
The new coronavirus is highly transmissible and will be difficult to squelch. A single infected “super-spreader” can infect dozens of others. Outbreaks can seem to recede, only to rebound in short order, as the weather or conditions change.
Recent clusters of coronavirus cases suggest the new coronavirus not only spreads quickly, but also in ways that are not entirely understood.
In Hong Kong, people living 10 floors apart were infected, and an unsealed pipe was blamed. A British citizen apparently infected 10 people, including some at a ski chalet, before he even knew he was sick.
In Tianjin, China, at least 33 of 102 confirmed patients had a connection of some sort with a large department store.
“This outbreak could still go in any direction,” Dr. Tedros Adhanom Ghebreyesus, director general of the World Health Organization, said on Wednesday.
A change in diagnosis may make it still harder to track the virus, said Dr. Peter Rabinowitz, co-director of the University of Washington MetaCenter for Pandemic Preparedness and Global Health Security.
“It makes it really confusing right now if they’re changing the whole way they screen and detect,” he said. Now estimating the scale of the epidemic “is a moving target.”
It is not uncommon for scientists to refine diagnostic criteria as their understanding of a new disease changes. But when the criteria are changed, experts said, it makes little sense to continue to make week-over-week comparisons.
“It sounds simplistic, but it’s so very important — what numbers are you counting?” said Dr. Schaffner, the infectious disease specialist.
Scientists have been wary of the notion that the epidemic has peaked for other reasons, as well.
Unlike MERS and SARS, both diseases caused by coronaviruses, the virus spreading from China appears to be highly contagious, though it is probably less often fatal.
It is harder for public health officials to track a rapidly moving epidemic. Scientists often describe these epidemics as a sort of iceberg — their girth and true shape hidden below the surface.
Chaos makes it still more difficult to discern those dimensions. But an accurate grasp of the situation within China is necessary for the safety of the rest of the world, noted Dr. Tedros of the W.H.O.
The country is so central to the world economy that it can easily “seed” epidemics everywhere, he said.
“Our greatest fear remains the damage this coronavirus could do in a country like D.R.C.,” Dr. Tedros said, referring to the Democratic Republic of Congo, which has been struggling with outbreaks of Ebola and measles.
“It’s a huge task to manage a response effectively,” said Dr. Christine Kreuder Johnson, a professor of epidemiology at the University of California, Davis. “This would be true for any country.”
“We’re in the dark in terms of knowing what to expect next.”
Reporting was contributed by Vivian Wang.
HONG KONG — The news was abrupt and, to some, surprising: Overnight, a Chinese province near Russia, had cut its count of confirmed coronavirus cases by more than a dozen.
The revision stemmed from what appeared to be a bureaucratic decision, buried in a series of dense documents from the national government. Health officials said that they would reclassify patients who had tested positive for the new coronavirus but did not have symptoms, and take them out of the total count of confirmed cases.
The documents offered little detail or explanation, and skepticism was immediate. A Hong Kong newspaper called the decision a “disguise.” World Health Organization officials seemed caught off guard when asked about the move at a news conference this week.
The change in counting cases is only one factor that has made it difficult for experts to determine the true scale of the epidemic. In fact, the shifting landscape of how infections are defined and confirmed has led to significant variations in the estimates for the extent of outbreak.
Early on Thursday, provincial officials in Hubei province, the center of the outbreak, announced that nearly 15,000 new cases and 242 new deaths were recorded in a single day, largely because the authorities expanded their diagnostic tools for counting new infections.
Until now, only infections confirmed by specialized testing kits were considered accurate. But those kits have been in such short supply — and so many sick people have gone untested — that the authorities in Hubei Province have started counting patients whose illness have been screened and identified by doctors.
The result was a sudden — and large — spike in the overall tally for the coronavirus: more than 1,300 people killed and well over 50,000 infected.
The surge in cases in Hubei, the result of a local change in how cases are counted, underscored how elusive the exact scale of the epidemic is.
The change in how cases are counted — both inside and outside the epicenter of the outbreak — reflects a two-headed problem in the global fight against the disease. On the one hand, health officials need to stay flexible in dealing with new outbreaks.
One the other hand, mistrust of the Chinese government — especially when it comes to being transparent about the threat and extent of the virus — remains pervasive.
“It’s pretty clear that there is an issue with trust about whatever the Chinese government comes out with at the moment,” said Kerry Brown, a former diplomat and director of the Lau China Institute at King’s College, London.
“That may be terribly unfair,” Mr. Brown said. But, he added, “to redefine things — even legitimately — at a moment like this is always going to be a presentational challenge, because people are going to be very sensitive, and they’re going to suspect there’s another agenda.”
The new numbers out of Hubei came only a day after China reported that new infections had hit the lowest point in a single day since Jan. 30. Experts cautioned then that it was premature to draw any conclusions from the drop.
Coronavirus Map: Tracking the Spread of the Outbreak
The virus has sickened more than 60,300 people in China and 24 other countries.
The shifting case counts are not the only example of conflicting or spotty information. Researchers have given differing estimates on when the outbreak might peak, ranging from a date already past to several months in the future. The Chinese authorities have closely guarded the demographic details about the fatalities, creating uncertainty about who is most susceptible.
Scientists have even debated just how much of a danger asymptomatic transmission poses. Chinese health officials were among the first to raise the prospect of asymptomatic transmission, even as health experts in other countries were skeptical of early reports that the virus could be passed on by such patients. But in recent days, Chinese officials have also played down the asymptomatic transmission risk.
The uneven information comes as China’s leader, Xi Jinping, said that the containment efforts were working.
“After hard work, the epidemic situation has seen positive change, and the prevention and control work has achieved positive results,” he said during a meeting of the Communist Party leadership in Beijing on Wednesday, according to a summary of his remarks by state-run media. “This is hard-won, and all parties have contributed.”
The changes to the classification of asymptomatic coronavirus cases emerged on Jan. 29, in a set of guidance from China’s National Health Commission. The agency said that it would no longer count patients who had tested positive for the coronavirus but did not display symptoms as “confirmed cases.” Instead, those patients would be counted separately, as “positive diagnosis” patients, and would become confirmed only if they began showing symptoms.
Chinese health officials have given little public justification for the labeling change. The National Health Commission did not immediately return a request for comment.
The changes have prompted debate among some public health experts.
“Adapting definitions during an outbreak is not unusual, with increasing insights and also with prioritizing where efforts need to go,” said Dr. Marion Koopmans, the head of the viroscience department at Erasmus University Medical Center in the Netherlands.
Still, even experts who said that the effect of discounting certain cases would be small said that it would be useful to epidemiologists — and the public — to have a complete count of all cases, including asymptomatic ones.
Dr. Malik Peiris, the chair of virology at the University of Hong Kong, said in an email that mild or asymptomatic infections could form an “invisible iceberg” that made a given virus’s fatality rate much lower than it initially appeared.
Determining the true denominator of the number of people infected — whether symptomatic or not — would, he said, “be most informative to, hopefully, calm current panic in China and the world.”
In a sign of just how much the changes could further muddle public understanding of the virus, even the W.H.O., which has praised the Chinese government for its cooperation in fighting the outbreak, expressed confusion.
Dr. Chen Bingzhong, a former senior government health official in Beijing who has been vocal in calling for more transparency about public health crises, said a full tally of the number of cases would keep the authorities accountable.
He added that a positive test result should be disclosed as such, regardless of symptoms.
“Testing positive means it is the new coronavirus,” he said. “If you don’t recognize it, you are covering the truth.”
Jin Wu contributed reporting from Hong Kong, and Yiwei Wang contributed research from Beijing.