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In U.S. and Germany, Community Transmission Is Now Suspected

Three cases have emerged that suggest the possible beginning of a worrisome trend.

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Coronavirus Risk in the U.S. Is ‘Very Low,’ Trump Says

President Trump and C.D.C. officials held a news conference on the threat to the American public from the new coronavirus.

Because of all we’ve done, the risk to the American people remains very low. We have the greatest experts in the world, really in the world, right here — the people that are called upon by other countries when things like this happen. We — we’re ready to adapt and we’re ready to do whatever we have to as the disease spreads, if it spreads. The level that we’ve had in our country is very low. And those people are getting better — or, we think that in almost all cases ... We have in quarantine those infected and those at risk. We have a lot of great quarantine facilities. We’re rapidly developing a vaccine — and they can speak to you, the professionals can speak to you about that. The vaccine is coming along well, and in speaking to the doctors, we think this is something that we can develop fairly rapidly, a vaccine, for the future. We’re very, very ready for this, for anything, whether it’s going to be a breakout of larger proportions or whether or not we’re — you know, we’re at that very low level. And we want to keep it that way.

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President Trump and C.D.C. officials held a news conference on the threat to the American public from the new coronavirus.CreditCredit...Gabriella Demczuk for The New York Times

President Trump named Vice President Mike Pence his point person to coordinate the government’s response to the coronavirus, expressing confidence that the United States would prevent a widespread domestic outbreak.

Mr. Trump’s announcement, at a White House news conference, came after two days of contradictory messages from government officials about the dangers posed to Americans by the virus, which first emerged in China and has infected more than 81,000 people globally, killing nearly 3,000. He also expressed confidence that scientists would develop a vaccine, but he provided no details.

“We’re very, very ready for this,” he said.

Earlier in the day, the president condemned the news media, accusing journalists of making the situation “look as bad as possible” even as government health experts warned that the coronavirus threat in the United States was only beginning. Alex M. Azar II, the health and human services secretary, confirmed another American case of the virus on Wednesday, bringing to 60 the total number of infections in the United States.

A person in California who was not exposed to anyone known to have been infected with the coronavirus, and who had not traveled to countries where it is circulating, has tested positive for the infection, the Centers for Disease Control and Prevention said Wednesday night. The case may be the first instance of community transmission in the United States

“The case was detected through the U.S. public health system and picked up by astute clinicians,” a C.D.C. statement said.

It brings the number of infections in the country to 60, including the 45 cases among Americans repatriated from Wuhan, China — the epicenter of the outbreak — and the Diamond Princess cruise ship, which was overwhelmed by the virus after it docked in Japan.

The potential transmission in the new case is a source of concern.

“That would suggest there are other undetected cases out there, and we have already started some low-grade transmission,” said Dr. William Schaffner, an infectious disease specialist at Vanderbilt University.

The Daily Poster

Listen to ‘The Daily’: The Coronavirus Goes Global

The illness is on every continent except Antarctica, with more new cases now being reported outside China than within. But how threatening is the outbreak, really?
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Listen to ‘The Daily’: The Coronavirus Goes Global

The illness is on every continent except Antarctica, with more new cases now being reported outside China than within. But how threatening is the outbreak, really?

archived recording

Across the world, there are rising concerns of a potential coronavirus pandemic after a major jump in cases outside of China.

michael barbaro

From The New York Times, I’m Michael Barbaro. This is “The Daily.”

archived recording

30 countries and territories, nearly 80,000 cases.

michael barbaro

Today:

archived recording 1

South Korea, which has now 750 cases or more.

archived recording 2

And in Iran, where there have been close to 100 cases and the death toll is 15.

michael barbaro

What began as a public health crisis in China is well on its way to becoming a pandemic.

archived recording 1

It’s still unclear how the virus made it into Italy.

archived recording 2

Four new cases are here on a French territory.

archived recording 3

Japan.

archived recording 4

Canada.

archived recording 5

Afghanistan.

archived recording 6

Austria, Switzerland, and Croatia all confirming their first cases.

michael barbaro

Now.

archived recording

And the C.D.C. in the last hour, warning Americans to prepare for the possibility of an outbreak.

michael barbaro

As officials warn of a coming outbreak in the US —

archived recording

C.D.C.‘s Dr. Nancy Messonnier said it’s not a question of if the novel coronavirus will spread through the United States, but when.

michael barbaro

My colleague Donald G. McNeil Jr. on how bad the coronavirus might get.

archived recording 1

Outbreak could go any direction.

archived recording 2

I do think that we are heading towards a pandemic.

michael barbaro

It’s Thursday, February 27.

Donald, I have the sense that you have covered a lot of epidemics in your career. And if this isn’t too strange a question, how many epidemics have you covered?

donald g. mcneil jr.

SARS, MERS, bird flu, 2009 swine flu, Zika. Dengue and chikungunya didn’t really become epidemics. And also I’ve covered H.I.V., although that started long before my time as a health reporter. And seasonal flu. Have I forgotten anything? That’s enough, right?

michael barbaro

That seems like enough. That seems like a lot of epidemics.

donald g. mcneil jr.

Yeah, and this.

michael barbaro

And by “this,” you mean —

donald g. mcneil jr.

COVID-19, coronavirus infectious disease 2019.

michael barbaro

Well, that’s the reason we want to talk to you, Donald, is because you have this history and this experience when it comes to epidemics. And at this moment, there is a lot of news about this new virus, the coronavirus, but not a lot of understanding about it. So given your history, how do you rank this epidemic in terms of previous epidemics, in terms of — let me use some unscientific words here — bigness, scariness, awfulness?

donald g. mcneil jr.

I spend a lot of time thinking about whether I’m being too alarmist or whether I’m being not alarmist enough. And this is alarmist, but I think right now, it’s justified. This one reminds me of what I have read about the 1918 Spanish influenza. And the reason I say that is because, right now, the only measure we have for the death rate from this flu is a study that the Chinese did of the first 45,000 cases. And of those, 80 percent were mild. 20 percent were various degrees of seriousness, up to critical and on a respirator and in organ failure. And 2.3 percent died. Now, 2.5 percent mortality is about the mortality rate of the 1918 flu.

michael barbaro

Which was a very big deal.

donald g. mcneil jr.

It was a very big deal epidemic. Now, it’s not the Black Death. In the Black Death, a third of the world died. But in 1918, not everybody died, but everybody knew somebody who died. I mean, my oldest friend’s grandmother died. She was a young woman with two kids. She died. Another guy I talked to said, oh, yeah, my grandmother’s sister died in that one.

michael barbaro

I thought you were here to bring calm, Donald.

donald g. mcneil jr.

I’m trying to bring a sense that if things don’t change, a lot of us might die. If you have 300 relatively close friends and acquaintances, six of them would die in a 2.5 percent mortality situation.

michael barbaro

OK, you’re painting a pretty scary portrait here. What makes this virus something so lethal and fearsome? What is it specifically about this virus?

donald g. mcneil jr.

There are six kinds of coronaviruses we know about before. Two of them, SARS and MERS, kill a lot of people.

michael barbaro

Those are both coronaviruses.

donald g. mcneil jr.

Yeah. SARS kills about 10 percent of the people who get it. SARS is gone. MERS kills about 30 percent of people who get it.

michael barbaro

Wow. Those are high death rates.

donald g. mcneil jr.

Absolutely. But there are four other coronaviruses that cause about a quarter of all the common colds this year. And you’ve had all of them. I’ve had all of them. Everybody’s had all of them.

michael barbaro

So we’ve had coronaviruses and just maybe not called them coronaviruses.

donald g. mcneil jr.

Yes, you called them, “I had a cold.” There are many causes of the common cold, but some of the most popular ones are four different coronaviruses. This doesn’t give you a common cold. It attaches deep in your lungs. So you don’t get runny nose as much as you get fevers and cough. And then ultimately, if it keeps getting bad, you get pneumonia. And that’s what kills a lot of people.

michael barbaro

The final stage of this.

donald g. mcneil jr.

And it’s a viral pneumonia. So giving antibiotics does not help.

michael barbaro

So what you just said makes me think that in the grand scheme, this coronavirus is not as bad as a SARS or a MERS. So help me understand why, even though it’s seemingly statistically not as bad as those, it is something quite worrisome?

donald g. mcneil jr.

SARS and MERS, if you get them, are very likely to kill you. But you’re very unlikely to get them because they don’t transmit very easily. If you don’t hang around camels or emergency rooms in Saudi Arabia, you’re unlikely to get MERS. This coronavirus is very transmissible — not as transmissible as measles. About as transmissible as flu, maybe a little bit less. But it’s quite transmissible. We saw that on the Diamond Princess. Here you had a boat with three or four people who might have had the virus on it, then suddenly they were — what was it — 600 people who had the virus on it. That’s a transmissible virus.

michael barbaro

And why is it so transmissible? What is it about the virus? Do we know?

donald g. mcneil jr.

We don’t know. We know that it attaches to some receptors deep in the lung called the ACE-2 receptors, but then so do other viruses. We don’t know why this one jumps easily. Something in the genome does it, but we haven’t pinpointed that genetic change yet.

michael barbaro

So we don’t know why it’s so transmissible, but we do know that it’s passing from person to person quickly. So how exactly do you contract it? How does it transmit?

donald g. mcneil jr.

It’s transmitted mostly by coughing. And we think it’s transmitted by fomites, which is to say touching surfaces. So if you’re in this room and you’ve got it, you’ve coughed all over this table. And I come in later and I don’t know you were here. And I, you know, I’ve got my hands on the table, and then I pick up my finger and I put it in my eye or my nose. I might get it. And that’s scary. Now there’s a whole question of is it got aerosol transmission, which means it drifts through the air and might go through the ventilation system into another room. That might be part of it. And there might also be some fecal transmission. But those are unimportant. The main thing is coughing and surfaces.

michael barbaro

That’s how it gets transmitted.

donald g. mcneil jr.

We’re still in the early days of knowing about this virus, but that’s the prevailing theory, that those are the number one and two drivers.

michael barbaro

My sense is that when it comes to infections, this is not a virus that discriminates. That young people get it. Middle-aged people get it. Old people get it. But do we have a sense of who is most likely to contract this coronavirus?

donald g. mcneil jr.

Yeah.

michael barbaro

It sounds like because it’s so transmissible, almost everybody might be able to get it.

donald g. mcneil jr.

Oddly enough, children are very unlikely to get this virus.

michael barbaro

Huh. Why is that?

donald g. mcneil jr.

Well, nobody knows. The theory I’ve seen that makes sense is that kids have enormous numbers of these mild coronaviruses, because that’s the typical cold virus. Kids are the ones who get colds. You go to kindergarten, you come back with a cold. So they may have some immunity from having somewhat similar but mild viruses circulating in the child population. Whereas all of us who had those viruses as kids, our immunity to those has waned. And now we have a new coronavirus.

michael barbaro

Our immune system is just not as prepared.

donald g. mcneil jr.

Yeah, we’re susceptible to it. The people who are getting sick and hospitalized is basically people from 30 on up. Most of the people in the hospitals are between 30 and 79, the Chinese said. Now, the people who die is basically the older you are, the more likely you are to die. So far, the large numbers of deaths have been elderly Chinese men. That’s because the virus has been in China. But there’s also a phenomenon in China that something like 50 to 80 percent of all men smoke, and only 2 to 3 percent of all women smoke. And once you’re a smoker and you’re over 50, your lungs are kind of half shot, you know? You’ve got emphysema or C.O.P.D., maybe a mild case. But if you get a dangerous lung infection on top of that, you’re much less likely to recover. Also once you’re over 65, you have an immune system that starts weakening slowly, so you’re less able to bounce back from that kind of thing. So we see the death rates are like people in their 80s and then people in their 70s and then people in their 60s. But we’ve seen people in their 30s die from this. We’ve seen some of the doctors, you know, including the famous doctor Li Wenliang, who tried to raise the alarm. He was 33 or 34, and he died.

michael barbaro

And how do you explain that?

donald g. mcneil jr.

He might have been unlucky, and he might have gotten a big blast of virus from a lot of patients. Even with viruses, the dose, to some extent, makes the poison. If you get a big load of virus in one blast, your body’s overwhelmed more quickly by it. And that may have happened to him.

michael barbaro

You’ve been talking about this death rate of around 2 or 2.5 percent from this coronavirus. And you mentioned earlier that that is a lot like the Spanish flu of 1918. For those of us who didn’t live in the early twentieth century, can you put this into a more modern context? How does this compare with the annual flu? How does this compare with something maybe a little more knowable for us?

donald g. mcneil jr.

OK, this is not like the annual flu. The annual flu, in a bad year, has a death rate of around 0.1 percent. So we’re talking about 20 times as bad.

michael barbaro

That’s very meaningful.

donald g. mcneil jr.

When people were going around saying, oh, not to worry about this. You should get a flu shot because the flu is a bigger threat. Yes. At this moment, the flu is a bigger threat, definitely, in the United States. But don’t think you have nothing to worry about. One thing that might happen is it might not get here in a big wave until the fall. That happened in 1918. There was a spring wave that was scary, and then the virus mostly disappeared in the summer, because a lot of viruses don’t like hot weather. But then when it came back in the fall and winter, that was the real killer wave. And that’s when a lot of people died. But we conventionally say that if the 1918 flu came back today, it wouldn’t be as deadly.

michael barbaro

Because it’s not 1918.

donald g. mcneil jr.

Because in 1918, we didn’t have antibiotics, and a lot of people died of secondary bacterial pneumonias. We didn’t have mechanical ventilators to put people on. We didn’t have the steroids that cuts down on lung inflammation. We have a lot of things in modern medical care that we didn’t have then. But what’s disturbing about what you see happening in China is that a lot of people are going into hospitals and they are getting antibiotics, and they are getting Tamiflu, and they are getting antivirals, and they are getting steroids, and they are getting put on ventilators. And they still die. And that’s unexpected, and it’s quite spooky.

[music]

michael barbaro

We’ll be right back.

archived recording 1

Back now with scientists around the world working day and night to contain the coronavirus.

archived recording 2

Chinese now sharing information with the World Health Organization in the hope that it will lead to treatments for the coronavirus, but —

archived recording 3

There has been an effort to secure funding with Congress, some $2.5 billion used for vaccine development, treatment, as well as —

archived recording 4

Top health authorities have played down the rising hopes about a vaccine, as well as a treatment for the coronavirus.

[music]

michael barbaro

Donald, I want to move into diagnosis and treatment. Right now — correct me if I’m wrong — there is no treatment.

donald g. mcneil jr.

Correct. Right now, there is no treatment. I mean, there’s treatment in that you hospitalize somebody. You put them on oxygen. Then you give them antibiotics so they don’t get a secondary bacterial pneumonia or things like that. But there’s nothing that actually cures this virus.

michael barbaro

Or prevents it.

donald g. mcneil jr.

Correct. Nothing that prevents this virus.

michael barbaro

So what are the most promising possibilities out there to do either of those things? And what’s the timeframe we’re looking at to do that?

donald g. mcneil jr.

There are several anti-viral drugs that are being tested. Some have been used against H.I.V. Some have been tried against Ebola and didn’t work. There’s an anti-malaria drug they’re trying as ways of stopping this. They’re doing tests on them in China now. And we may know the results of that trial within the next two or three weeks.

michael barbaro

So far, then, none of the experimental treatments for this are known to work.

donald g. mcneil jr.

They’re still in the testing phase.

michael barbaro

Got it. Do we know anything?

donald g. mcneil jr.

Frankly, I think if there was something that was a miracle drug, it would have leaked right now. They — ethically, if it was a miracle, they’d have to stop the trial early and just give everybody that drug.

michael barbaro

OK, what about a vaccine, something that would prevent this virus?

donald g. mcneil jr.

A vaccine is going to take pretty close to a year to produce.

michael barbaro

A year.

donald g. mcneil jr.

A year.

michael barbaro

That’s a really long time.

donald g. mcneil jr.

Yeah, so we’re not — if this virus arrives here, we will not have a vaccine. And the reason is, you have to do the safety and efficacy trials. And those have to be done in animals, and then they have to be done in people. And first you have to do them in a small number of people, and then you do them in a large number of people. Because when you don’t do that, you may find — and this has happened — that the vaccine makes the problem worse.

michael barbaro

What do you mean?

donald g. mcneil jr.

Well, there have been vaccines that have caused horrible side effects in the past. And there also have been vaccines that actually make you more susceptible to the disease. There was a dengue vaccine that appeared to make children more susceptible to dengue. There was an H.I.V. vaccine trial that had to be stopped because it made people more likely to catch H.I.V.

michael barbaro

OK, so during this year when a vaccine would be under development, but not yet available, paint a portrait of what is likely to happen. Now I know, based on my many years as a Times reporter, science and health reporters here do not like to speculate. But I am going to, with your permission, ask you to speculate a little bit about what that year looks like, the worst-case scenario and the best-case scenario.

donald g. mcneil jr.

I don’t know what’s going to happen. But keep in mind, the 1918 flu was really the 1918-1919 flu. It started in the spring, faded in the summer, came back like a monster in the fall. That would be a worst-case kind of scenario. That we don’t have a vaccine yet by the fall, and the disease hits us hard then.

michael barbaro

In that scenario, could almost every person in the country who is not a child get the virus?

donald g. mcneil jr.

Some big chunk of the country — 30, 40, 50 percent — are likely to get a new virus when it blows through. And if you don’t get it in the first wave, you might get it in the second wave.

michael barbaro

And 2 percent lethality rate of 50 percent of the country. I don’t want to do that math. It’s really, really awful.

donald g. mcneil jr.

It’s a lot of people. It means, you know, you don’t die. 80 percent of people have mild cases. But you know somebody who dies.

michael barbaro

That’s pretty horrible.

donald g. mcneil jr.

Yeah. Right now, it’s a smaller threat than the flu for us in the United States right now, but it could be a lot worse. And take that threat seriously. And that’s what the C.D.C. is saying, too. Prepare. It’s not just prepare as in stock up on food and buy masks. It’s more like, mentally prepare yourself for what would happen if you and all of your friends had to stay home for a month, or not be able to ride the subways, or supermarkets ran low on food. Or, you know, your medicine — your insulin or your H.I.V. meds or your heart meds or whatever it is you take — wasn’t available because the supply lines from China have been cut off. So we’ve got to mentally prepare ourselves for something like that.

michael barbaro

OK. Now, the best-case scenario.

donald g. mcneil jr.

The best-case scenario is one of these drugs works, and basically everybody gets sick next year, but everybody who is hospitalized gets a drug that keeps them from dying and keeps them from going into deep, deep, deep respiratory distress. And we have the equivalent of a bad flu season. And then everybody says, oh, the media, they blew it out of proportion again. You know, it’s all ridiculous. And, you know, I get blamed. So, too bad. It’s happened before.

michael barbaro

So at this point, American health officials are saying it’s just a matter of time — and they’re not saying how much time — before this virus reaches the U.S. in a pretty meaningful way and starts to spread. So how prepared is this country?

donald g. mcneil jr.

Not prepared enough. And it’s hard to know exactly how prepared we need to be.

michael barbaro

Why do you say not enough?

donald g. mcneil jr.

Well, in any bad flu season, hospitals put people on all their ventilators. We have a National Strategic Stockpile, which has a lot of stuff in it — masks, gowns, gloves, drugs, even some ventilators. But you can’t stockpile enough ventilators to put — a ventilator is like a cost of a car. It’s $25,000 to $50,000. Hospitals can’t go out and order an extra hundred of those. And if they did order an extra hundred of those —

michael barbaro

It would take awhile.

donald g. mcneil jr.

It would take awhile. And also you need at least three people to staff that ventilator with the patient on it around the clock. And that’s a lot of trained respiratory technicians and things. So if we get hit with a gigantic epidemic of a lot of people with pneumonia needing to be on breathing machines, we’re not prepared for that.

michael barbaro

What about preparations beyond ventilators?

donald g. mcneil jr.

What happened in China, with the shutdown of Wuhan and Hubei province during Tet, during New Year, was the equivalent of shutting down Chicago and most of that surrounding part of the Midwest at Christmas time and telling people, you are now going to stay in Chicago. You can’t leave. You can’t see your families. All the flights are canceled. All the trains are canceled. All the highways are closed. You’re going to stay in there. And you’re locked in with a deadly disease. We can do it.

michael barbaro

Would we do that?

donald g. mcneil jr.

We can do it, but we’re not used to being controlled from the top down the way people have been in China. So I don’t know what’s going to happen in the United States. We’re not mentally prepared to fight a sort of people’s war against an epidemic, which is what happened in China.

[music]

michael barbaro

Before I let you go, I feel like I have to ask you, given your experience covering these kinds of epidemics, what kind of preparations are you personally making?

donald g. mcneil jr.

I have food in the basement anyway. I always have about a month’s worth of food in the basement, because that’s the kind of person I am. I’ll probably order some more of my heart — you know, blood pressure medicine, you know, so that I have another 90-day supply. I shouldn’t stockpile masks. I’m against it. I did go out and buy a box of 10 masks back in January. I feel a little ashamed I did that, because really those masks are more important on health care workers than they are on me. Otherwise, I’m not sure there’s much you can do. You know, I take some comfort in the fact that 80 percent of the people have a mild disease, and that might be me and everybody I love, too. We might all get lucky. But not everybody we know is going to get lucky if this turns into something like 1918.

[music]

michael barbaro

Well thank you, Donald.

donald g. mcneil jr.

You’re welcome.

michael barbaro

On Wednesday, U.S. health officials reported the first American infected with the coronavirus who had not traveled to countries in which the disease was circulating. Such an infection may represent a case of community transmission, which would be a turning point for the virus in the U.S.

[music]

archived recording (donald trump)

I have just received another briefing from a great group of talented people on the virus that is going around to various parts of the world. We —

michael barbaro

On Wednesday night, President Trump addressed the nation about the virus from the White House, heralding his administration’s handling of the situation so far, describing the risk to Americans as low and appointing his Vice President, Mike Pence, to oversee the response effort.

archived recording (donald trump)

We — we’re ready to adapt, and we’re ready to do whatever we have to as the disease spreads, if it spreads.

michael barbaro

Asked whether the U.S. would undertake the kind of sweeping measures used to contain the virus in China, the president said that nothing was off the table.

archived recording

Mr. President, have you been presented any plans that would involve quarantining cities like we saw in China? And what would have to happen for you to take a step?

archived recording (donald trump)

We do have plans of a much — on a much larger scale, should we need that. We’re working with states. We’re working with virtually every state. And we do have plans on a larger scale if we need it. We don’t think we’re going to need it, but, you know, you always have to be prepared.

michael barbaro

As of Wednesday, more new cases of infection were reported outside of China than inside of it. The total number of cases has now surpassed 80,000, and nearly 3,000 have died.

[music]

We’ll be right back.

Here’s what else you need to know today.

archived recording

[CROWD SHOUTING]

michael barbaro

At least 25 people have died in some of India’s worst Hindu-Muslim violence in years.

archived recording

[CROWD SHOUTING]

michael barbaro

The violence began with a speech from a local Hindu official calling for the forceful removal of Muslims, who were protesting India’s new citizenship law, which is widely seen as discriminating against Muslims. Within hours of that speech, violence had broken out, much of it directed at Muslims. The latest case of what many inside and outside of India see as the rising danger of Hindu nationalism.

[music]

That’s it for “The Daily.” I’m Michael Barbaro. See you tomorrow.

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A street corner in Milan, in the Lombardy region of Italy. Lombardy has been hit particularly hard by the virus.Credit...Andrea Mantovani for The New York Times

New coronavirus clusters across Europe and the Middle East. More infections in Iran stoking fears about an uncontrolled spread. Global market jitters. A toxic political climate in Washington complicating the public health challenge.

That worrying drumbeat frayed nerves across the world on Wednesday even as the pace of the outbreak seemed to be slowing in China, where most cases have been.

[Read: 10 Chinese readers share their stories of the coronavirus crisis.]

For the first time, more new cases were reported outside China than inside, according to the World Health Organization. Chinese officials on Tuesday reported 411 new infections; in the rest of the world, the number was 427. The total number of cases globally has now topped 81,000 and nearly 3,000 have died.

South Korea, with nearly 1,600 cases, has seen the largest outbreak outside China.

In the European Union, new cases were recorded in Austria, Croatia, France, Germany, Greece and Spain. Most were tied to Italy, where the authorities have been struggling to contain an outbreak that has infected at least 400 people, most of them in the north near Milan.

Hotels in Austria, France and the Canary Islands of Spain were locked down this week after guests tested positive for the virus or were suspected of having it.

As the American health authorities braced for an outbreak in the United States, the Trump administration came under criticism from both Democratic and Republican lawmakers for contradictory statements on the severity of the crisis, a lack of transparency and seemingly lax preparations.

The fast-growing coronavirus outbreak forced South Korea and the United States on Thursday to postpone “until further notice” their joint spring military exercise, originally scheduled to take place next month.

The decision came as South Korea reported 334 new cases of the coronavirus on Thursday, bringing the total number there to 1,595, the largest outbreak outside of China. Nearly 84 percent of the patients were from Daegu, a city in southeast South Korea, and in nearby towns.

On Wednesday, the United States military reported the first case of a soldier being infected. The soldier was stationed at a base near Daegu.

South Korea has placed itself on the highest possible alert to deal with the outbreak, suspending nonessential military training and placing more than 9,500 troops under quarantine. It has also banned most of its enlisted soldiers from taking a leave.

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Worshipers at the Grand Mosque in Mecca, Saudi Arabia, in January.Credit...Amr Nabil/Associated Press

Saudi Arabia on Wednesday temporarily barred Muslim pilgrims from entering the country to visit the holy cities of Mecca and Medina, as it tries to slow the spread of the coronavirus, a stark illustration of the fear the epidemic has stirred.

The Saudi royal family derives much of its stature in the Islamic world from its status as guardians of the holy sites, and it very rarely closes them off. The Saudi response contrasts with that of Iran, which has kept its pilgrimage sites open, despite a significant coronavirus outbreak there, and evidence that people who visited Iran have spread the virus to many other countries.

Each year, millions of Muslims make a pilgrimage to Mecca, or Umrah, which can take place at any time of year; the Hajj, the pilgrimage to Mecca that all Muslims are expected to make at least once, takes place in a specific part of the lunar year, which this year falls in midsummer.

Many Muslims also visit the mosque in Medina that was established by the prophet Mohammed.

The government is “suspending entry into the kingdom for the purpose of Umrah and visiting the Prophet’s Mosque temporarily,” the government-run Saudi Press Agency said.

Syracuse University moved on Wednesday to shut down a study abroad program in Florence, Italy, as the coronavirus continues to spread, bringing to at least six the number of universities and colleges that have taken such steps.

“Yesterday, on very short notice, we made the difficult decision to suspend our academic program in Florence, Italy, based on Italy’s very aggressive stance toward virus containment and travel restrictions,” Kent Syverud, the Syracuse chancellor said in a statement.

New York University’s president, Andrew Hamilton, said in a statement on Wednesday that “out of an abundance of caution,” classes in Florence were being canceled for the rest of the week and students there were to “promptly travel home or to another appropriate location.”

Other colleges that have suspended study abroad programs include Elon University, Fairfield University, Florida International University and the University of Tennessee.

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The Albert Einstein Hospital, where Brazil’s first coronavirus case was detected, in Sao Paulo.Credit...Sebastiao Moreira/EPA, via Shutterstock

Brazil’s health ministry said on Wednesday that a 61-year-old man who had recently traveled to São Paulo from Italy had contracted the coronavirus.

The first known case in Latin America, it comes as Brazil is in the midst of Carnival, a hugely popular festival that draws large crowds into close quarters for raucous street celebrations.

Officials were scrambling to track down other passengers on the flight the man took to Brazil and to find others who had come into contact with him in recent days.

The patient, who lives in São Paulo, had recently traveled for work to northern Italy, where an outbreak has infected at least 325 people. He sought medical help after experiencing a fever, cough and sore throat, according to health officials.

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Despite an increase in coronavirus cases, Iran has yet to shut down popular pilgrimage sites like the holy city of Qom.Credit...Anadolu Agency, via Getty Images

Iran’s leaders continued to downplay the seriousness of the outbreak there on Wednesday, even as the number of cases in Iran or linked to it kept climbing quickly.

The health ministry reported 139 cases and 19 deaths, up from 95 and 15 on Tuesday, and the government ordered a weeklong closure of schools and cultural sites in 10 provinces. Experts say Iran’s high apparent death rate suggests that it has far more infections than it has discovered or acknowledged.

[Update: Japan shocks parents by moving to close all schools in response to coronavirus.]

But President Hassan Rouhani said the virus was coming under control, and he predicted a return to normalcy by Saturday, Iranian state media reported. He added that Iran’s enemies were using the epidemic to further isolate the country.

Bahrain on Wednesday raised its case total to 26, and said all three new patients had just arrived from Iran — as had some of the previous ones. Bahrain is one of several countries reporting infections in people who had recently traveled to Iran.

Pakistan’s health minister, Dr. Zafar Mirza, on Wednesday confirmed the first two cases of the coronavirus in that country, and said that one of them was a 22-year-old student who had recently returned from Iran. Pakistan closed its border with Iran on Sunday.

Georgia reported its first case on Wednesday, also a traveler returning from Iran, who had entered the country through Azerbaijan.

And in Iraq, movie theaters, coffee shops and other public gathering places were ordered to close until March 7. The Education Ministry said that schools and universities, which have been on a winter break, would also remain closed until then.

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Wash Your Hands. No, Like This.

Scientists say that a common technique for applying hand sanitizer, one recommended by the Centers for Disease Control and Prevention, is inferior to an alternative method with twice as many steps.

<i>The best way to clean your skin</i> <i>is still the old-fashioned use</i> <i>of soap, hot water and plenty of elbow grease.</i> What if we told you that you’ve probably been cleaning your hands wrong and that science tells you so? It turns out there’s not one but two common internationally accepted ways to clean your hands: One from our very own C.D.C., and another by the World Health Organization. So which of these two methods is better? Researchers now know. They enlisted doctors and nurses in a Glasgow hospital in an experiment. And what they found in a study published this month was that the W.H.O.’s method was microbiologically more effective than the C.D.C.’s. So the W.H.O. won. But here’s the rub. The C.D.C.’s method for cleaning hands goes something like this: The W.H.O.’s method is like so: Rub palms together. Rub each palm front to back over the back of the other hand, interlacing fingers. Twist palms with fingers interlaced. Interlock your fingers and twist again, this time backs of fingers against palms. Clasp your left thumb in your right hand and move thumb in circular motion. Still with us? Press your right fingers together and rub them in a circular motion on your left palm. Then switch. All right — you’re done! Don’t take it hard if it doesn’t seem worth it. Although the W.H.O. method got cleaner hands, only about two-thirds of the study’s doctors and nurses completed the whole thing, which took about 42 seconds to do. The simpler C.D.C. method? Only 35. And this is important. Because, you see, in hospitals ... <i>(Training video)</i> <i>♪ Hand hygiene is dope. ♪</i> <i>♪ Now sing the alphabet</i> <i>from A to Z, ♪</i> <i>♪ get between all the nooks and tiny crannies ♪ </i> <i>♪ </i> According to the C.D.C., some two million patients get hospital-related infections a year. And the C.D.C. estimates that doctors and nurses clean their hands correctly only half the time they should. So follow-through might be just as important as “microbiological effectiveness.” While this study focused only on alcohol-based hand sanitizers, its author says that the W.H.O. way applies equally well to washing your hands with plain old soap and water — something you can practice at home. <i>♪ Wait! Don’t go near that patient ♪</i> <i>♪ What’s the matter with you? You didn’t clean your hands, ♪</i> <i>♪ and they’re covered with goo ♪</i> <i>Wash your hands all the time, in front of everyone ♪</i> <i>♪ That goes for everybody, yo, get it done ♪</i> <i>♪ Clean your hands. If you just wiped a rear or did enemas ♪</i> <i>♪ ’til clear, clean your hands, Clean your hands ♪</i>

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Scientists say that a common technique for applying hand sanitizer, one recommended by the Centers for Disease Control and Prevention, is inferior to an alternative method with twice as many steps.CreditCredit...Yousur Al-Hlou/The New York Times

If the coronavirus appears in your community, what can you do to protect yourself and your family?

Much of the advice from experts involves common sense, not very different from what you would do to dodge the flu or any other respiratory virus.

Because Americans often disregard colds and flus, continuing about their ordinary business, there are people with symptoms in public places. Without apology, you should put distance between you and them. Six feet would be good, but even a little distancing is helpful.

And do your colleagues a favor if you aren’t feeling well: Stay home from work.

Another obvious way to reduce the odds of infection: wash your hands often. “It’s not super sexy, but it works,” said Dr. Trish Perl, an infectious disease specialist at the University of Texas Southwestern Medical Center.

During the SARS epidemic — also caused by a coronavirus, but one that was much deadlier — hand-washing reduced the risk of transmission by 30 to 50 percent, she said.

If it is not feasible to wash your hands with water, you can use a hand sanitizer, but check the label to be sure it contains at least 60 percent alcohol.

The trademark of coronavirus outbreaks abroad is those ubiquitous face masks. But if you are healthy, the Centers for Disease Control and Prevention and infectious disease specialists do not recommend face masks. Most surgical masks are too loose to prevent inhalation of the virus.

If you are infected, however, a mask can help prevent the spread of a virus.

The most effective are so-called N95 masks, which block 95 percent of very small particles.

Health officials in Nassau County, N.Y., said on Wednesday that they were monitoring 83 people in voluntary isolation for potential coronavirus exposure, but that there were no confirmed cases in the county or the state.

Many of the people had recently been in China, while others had been in contact with such people, the county health commissioner, Dr. Lawrence Eisenstein, said in a news conference.

About 175 people in Nassau County, which borders New York City, have been asked to self-quarantine for some period of time since the authorities started taking that precaution several weeks ago, he said.

People in other parts of the country have also agreed to isolate themselves after traveling from places with coronavirus outbreaks.

“As of today, there are 83 people who are on our list of being removed from contacting other people,” Dr. Eisenstein said. Officials are in communication with them every day, he said, and all have complied with the quarantine request.

Five of the people have tested negative for the virus, and a sixth person’s test results are pending.

Andy Simone, the county’s director for emergency preparedness, said that hospitals were prepared in the event that someone tests positive. But she added, “There is no fear right now, we do not have a case in Nassau County.”

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Medical staff transporting a patient infected with the coronavirus into the University Hospital in Duesseldorf, Germany, on Wednesday.Credit...Guido Kirchner/DPA, via Associated Press

Germany’s health minister, Jens Spahn, said Wednesday that new cases were confirmed in the country that cannot be traced to the virus’s original source in China.

This raised the troubling possibility that the virus might have been transmitted within the country itself.

The disease is moving to a new phase in Germany, Mr. Spahn said at a news conference. “The infection chains are partially no longer trackable,” he said.

About 20 cases of the coronavirus have been identified in the country, he said, but until now health officials had been able to trace those who became infected back to the virus’s origins in central China or to hot spots in Italy.

The authorities in Germany’s most populous state, North Rhine-Westphalia, were trying on Wednesday to retrace the steps of a couple who contracted the coronavirus from a source they could not immediately identify.

The couple had spent the previous two weeks — the estimated incubation period for the virus — “taking part in normal, public life,” said Karl-Josef Laumann, the state health minister.

That included attending a large carnival party and taking a brief trip to the Netherlands, he said. Dutch authorities and the hotel where the couple stayed have been informed.

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A trading room in the stock exchange in Seoul, South Korea, on Tuesday.Credit...Jean Chung for The New York Times

Nervousness about the spread of the coronavirus gripped Wall Street again on Wednesday, with an early rise in stock prices giving way to a third day of selling. The S & P 500 was down 0.4 percent at the end of trading, bringing its losses for the week to more than 6 percent.

The day began with the S & P 500 increasing by more than 1.5 percent before giving up those gains. Market observers attributed the change in sentiment to comments from Germany’s health minister that the outbreak had entered a more serious phase, because the coronavirus had been transmitted there.

Bonds rallied, pushing the yield on the 10-year Treasury note to a record low for a second day. The price of oil also fell.

Major markets around the world continued to drop, with investors reacting to reports of the coronavirus spreading across the globe. European markets fell more by than 1 percent on Wednesday, and Asian markets ended the trading day lower.

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Milan Central Train Station. Many of the cases of the coronavirus in Europe have been tied to northern Italy.Credit...Andrea Mantovani for The New York Times

The coronavirus epidemic poses a new and serious threat to Europe’s already diminished system of free movement across borders.

For generations, Europe Union leaders have pursued — and, to a great degree, realized — a vision of a continent where not only would trade be seamless, so would travel.

Eventually, 26 European countries — including four that are not in the bloc — signed on, allowing people to travel from country to country in what is known as the Schengen area without showing passports, or even being stopped at border crossings.

But the idea has never been universally loved; right-wing and nationalist politicians in particular have opposed it. Ireland joined the European Union in 1973, but has never joined Schengen; neither did Britain, a member of the bloc for 47 years until it left in January.

Opposition to free movement surged with the migrant crisis of 2015. Many countries erected what were supposed to be temporary border controls, but five years later, some are still in place.

As coronavirus outbreaks grow and multiply, calls for closing borders have grown louder. So far no country has taken that drastic step, but privately European officials have warned that could change quickly.

On Wednesday, the European Union’s top official for communicable diseases said that Europe needed to prepare more broadly for the kind of crisis that has hit northern Italy.

“Our current assessment is that we will likely see a similar situation in other countries in Europe, and that the picture may vary from country to country,” said the official, Andrea Ammon, director of the European Center for Disease Prevention and Control.

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Looking out from balconies of the H10 Costa Adeje Palace hotel on the Spanish resort island of Tenerife on Tuesday.Credit...Associated Press

Two European hotels were on lockdown on Wednesday as coronavirus infections spread on the Continent, and a third was quarantined for several hours.

The authorities in Innsbruck, an Austrian ski town in the Alps, sealed off the 108-room Grand Hotel after an Italian employee there tested positive for the virus. The cordon was the second at a European hotel in two days, after Spain on Tuesday cordoned off the H10 Costa Adeje Palace on the resort island of Tenerife after a guest, also from Italy, tested positive.

Each of the infected Italians had recently visited the Lombardy region of the country.

Spain, Austria, Croatia, Switzerland and France all reported cases linked to Lombardy on Tuesday.

In central France, the Ibis Center hotel in Beaune was closed after a client from Hong Kong died during the night. The health authorities ordered that all 30 members of the guest’s group remain in isolation while tests were conducted.

[Read: For a Hong Kong restaurateur in the time of coronavirus, resilience is on the menu.]

But the tests results on Wednesday afternoon did not show coronavirus, and the lockdown was lifted.

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New York still has no confirmed cases of coronavirus, but it has set in motion preparations and financing in the expectation that some New Yorkers will test positive.Credit...Kevin Hagen for The New York Times

Gov. Andrew M. Cuomo of New York said Wednesday that the state would set aside $40 million in the expectation that the coronavirus would eventually spread to New York. He also said the state had begun planning for possible quarantines at homes, hotels and hospitals.

While there have been no confirmed cases of the virus in New York, the governor and the state health commissioner, Dr. Howard Zucker, warned that its spread to the state was inevitable.

“It is highly probable that we will have people in New York State who test positive,” said Mr. Cuomo, noting that New York City is “the front door internationally” for many travelers. “No one should be surprised when we have positive cases.”

The governor also said he would ask federal health authorities for permission to test patient samples in a laboratory in New York, rather than waiting several days for results from the C.D.C. in Atlanta.

State officials have already been taking precautions against the disease, asking about 700 recent visitors to China to voluntarily quarantine themselves, even as Customs and Border Protection agents continue to screen passengers at area airports.

Reporting was contributed by Russell Goldman, Choe Sang-Hun, Roni Caryn Rabin, Keith Bradsher, Austin Ramzy, Elaine Yu, Ben Dooley, Alexandra Stevenson, Ed Shanahan, Kevin Granville, Marc Santora, Melissa Eddy, Christopher F. Schuetze, Matina Stevis-Gridneff, Alan Yuhas, Andrew Kramer, Anton Troianovski, Richard Pérez-Peña, Alan Finder, Gina Kolata, Ernesto Londoño, Noah Weiland, Maggie Haberman Emily Cochrane, Alissa J. Rubin and Falih Hassan.

A correction was made on 
Feb. 26, 2020

An earlier version of this article incorrectly referred to Switzerland's relationship to the European Union. Although Switzerland is within Europe's Schengen zone of passport-free travel, it is not an E.U. member.

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