Health officials confronted tough questions and doubts Thursday about testing to intercept the fast-spreading virus, with scrutiny focused on a four-day delay in screening an infected California woman despite her doctors' early calls to do so.
The questions are global: not just who, when and how to test for the illness, but how to make sure that working test kits get out to the labs that need them. All those issues apparently came in to play in the treatment of the woman in northern California, a case officials say may be the first community-spread instance of the disease in the U.S.
"This was a clear gap in our preparedness, and the virus went right through the gap," said Dr. Ali Khan, dean of the University of Nebraska College of Public Health.
In the wake of the latest California case, U.S. health officials on Thursday expanded their criteria for who should get tested, and took steps to increase testing.
The debate over testing has taken on added urgency as the number of cases worldwide climbed past 82,000, including 2,800 reported deaths. The rapid spread pushed officials in Saudi Arabia to cut travel to Islam's holiest sites, triggered tougher penalties in South Korea for people who break quarantines and ratcheted up pressure on investors as U.S. stock markets extended their week-long plunge. The Dow Jones Industrial Average sank nearly 1,200 points Thursday, its worst one-day drop since 2011.
With the illness rippling across 47 nations in every continent but Antarctica, public health officials emphasized the need for rapid intervention.
"Aggressive early measures can prevent transmission before the virus gets a foothold," World Health Organization chief Tedros Adhanom Ghebreyesus said. He cited a study in China of more than 320,000 test samples that enabled health officials to zero in on the 0.14 percent that screened positive for COVID-19, the disease caused by the virus.
But catching the disease early will require countries to invest in rapid diagnostics, said Dr. Gagandeep Kang, a microbiologist who heads the Translational Health Science And Technology Institute in India.
Test kits used by the World Health Organization cost less than $5 each, said Michael Ryan, the group's emergencies programs director. But that figure does not include the expense of medical staff and validation screening, and making such investments effective goes well beyond the expense involved.
"As we can see from the new sparks on Italy, Iran, Korea, is that early identification of cases is crucial. There, the first persons with infection were missed," said Marion Koopmans of the Erasmus Medical Center in the Netherlands.
Doctors at the University of California Davis Medical Center were mindful of the need for early identification on Feb. 19 when the hospital admitted a female patient on a ventilator who showed symptoms of a viral infection. They asked she be tested for the new coronavirus, according to an email hospital officials sent to their employees, but a test was not administered because she did not fit federal test criteria. The test was not done until four days later, on Feb. 23, and the results did not come back until Wednesday, a full week after she was admitted, the hospital said.
The federal agency in charge of testing, the U.S. Centers for Disease Control and Prevention, took issue with that account late Thursday. The agency said it was still investigating, but that a preliminary review showed it had not been informed of the case until Feb. 23, when it requested specimens for testing. It said criteria in place at the time could have allowed the woman to be tested earlier.
The case highlights the fact that most testing in U.S. up to now has been limited to those who, in addition to showing symptoms, have a history of travel to countries affected by the disease or contact with those who have done so, said Lauren Sauer, director of operations at Johns Hopkins University's Office of Critical Event Preparedness and Response.
"In the U.S., people are sticking pretty closely to that definition," Sauer said. But the increasing cases on other continents "are demonstrating we need to do a better job than just where the outbreak originated."
On Thursday, the CDC updated its testing criteria on its website — a move that had been in the works for days, according to a federal official familiar with the change.
The CDC will continue to advise testing people who have traveled to certain outbreak areas and have fever and certain other symptoms. But now testing is also appropriate if such symptoms exist and flu and other respiratory illnesses have been ruled out and no source of exposure has been identified.
As part of that, CDC has expanded the list of countries that are red flags for testing to include not only China but Iran, Italy, South Korea and Japan.
Last month, the CDC said it had developed a test kit that could be sent to state and big city public health labs, so they could broaden testing to more people. Early this month, the agency got authorization to begin distribution of the kit to government public health labs in the 50 states and some cities and counties.
But most of the kits proved to be faulty, providing inconclusive results to test samples that should have tested positive. The problem was blamed on one of three reagents used in the testing. CDC said it was trying to manufacture new reagents, but gave no firm timetable for when that would occur.
Only about a half dozen state and local public health labs had fully functional kits as of early this week.
As weeks passed, the problem became more and more frustrating, said Scott Becker, the chief executive of the Association of Public Health Laboratories.
On Monday, Becker's organization sent a letter to the U.S. Food and Drug Administration, basically asking permission for state labs to develop their own tests. On Wednesday, FDA officials responded that labs would be allowed to rely on the two other reagents, meaning that as many as 40 state and local labs could be up and running with their tests in the next few days, Becker said.
The California case, and remarks by Italian officials that they were rethinking how to classify people who test positive for the illness but show no symptoms, highlighted the questions that surround large-scale screening for the disease.
The test being used by U.S. health officials takes just four to six hours to perform once it's in a lab. But up to now, those tests have been sent to federal testing centers, often significantly extending the time to get results.
"Testing protocols have been a point of frustration," California Gov. Gavin Newsom said Thursday. He said federal officials had assured their state counterparts that capacity to test will be growing "exponentially" in the next few days, but he wasn't more specific.
Federal official likely limited testing early on because of concerns about a deluge of false positives, which could panic communities and become counterproductive, said Khan, a former top disease investigator for the CDC.
But he suggested that a tiered testing system might be the answer, in which a positive test would have to be verified by another lab before a case is diagnosed and counted.
The challenge is complicated by a slowness to distribute test kits.
Newsom said Thursday the state had just 200 testing kits on hand and "that's simply inadequate." He said he spoke to CDC officials and they assured him they were working to make testing more broadly available in California.
In Italy, where an outbreak has depressed tourism and fueled panic, officials said Thursday they would change their reporting and testing practices in ways that could lower the country's reported caseload.
Italian authorities plan from now on to distinguish between people who test positive for the virus and patients showing symptoms, since the majority of the people in Italy with confirmed infections aren't actually sick. They said they would follow urging by the WHO and hold off on certifying cases screened only at a regional level, until they can be confirmed by national officials.
"The cases that emerge from the regions are still considered suspect and unconfirmed," said Walter Ricciardi, a WHO adviser to the Italian government.
But U.S. experts said the crisis requires more rapid testing, and a willingness by officials to revise their criteria. Sauer pointed to a case in Canada, where officials zeroed in on a traveler from Iran with COVID-19 soon after that country announced its first cases.
"Let our really smart doctors do what they do really well," Khan said. "If they are really suspicious that a pneumonia or influenza-like illness does not quite look like an influenza-like illness, allow them to test!"
President Donald Trump on Thursday cited low unemployment rates for African Americans and passage of a criminal justice bill providing earlier release for thousands of federal drug offenders as examples of how he's helping the black community.
Trump met with African American supporters Thursday as part of the White House commemoration of Black History Month.
"I will not stop. I will not give up until we have delivered equal and abundant opportunity to every neighborhood across our land," Trump said at a reception.
Before the reception, he met with black supporters who complained that Trump was not being given enough credit, or that he had been portrayed unfairly as racist.
"You attack him, you attack all of us," said Bruce LeVell of Georgia.
Trump's reelection campaign has stepped up its outreach to black Americans as it tries to claw away support from the traditionally Democratic voting bloc ahead of November's general election.
Approval of Trump among black Americans has been consistent at about 1 in 10 over the course of his presidency. A Pew Research Center analysis of people who participated in its polls and were confirmed to have voted showed Trump won just 6% of black voters in 2016.
But the campaign claims it is seeing an uptick of support among black men in particular — and notes that even a small shift in the electorate could decide close races.
Vice President Mike Pence sought to project calm Thursday in his new role as chief coordinator of the government's response to the coronavirus as the Trump administration rushed to contain mounting public concerns and some of the worst stock market declines in more than a decade.
Pence convened his first meeting of President Donald Trump's coronavirus task force one day after the president made him the government's point-person for the epidemic. Pence also tapped a seasoned medical professional to be his chief adviser and said Trump had "tasked us to take every step necessary" to protect the American people."
The meeting came amid confusion over who was leading the inter-agency coordinating process to confront the virus. Health and Human Services Secretary Alex Azar stood alongside Trump on Wednesday when the president announced he was putting Pence "in charge" of the government's virus response.
At the end of the White House briefing, Azar said he was "delighted" to have the vice president's help but also said he wanted to "clarify" that "I'm still chairman of the task force."
Pence explained things differently Thursday. "I'm leading the task force," he said after being asked to clarify, though he noted that Azar continues to hold the title of chairman.
Trump, himself, later defended his administration's handling of the coronavirus during an Oval Office meeting with black supporters and again suggested part of the market slide was due to nervousness about the Democrats seeking to replace him.
"If any of these people ever did happen to assume the presidency you would have a crash like you've never seen before. And I think the market is also putting that into the equation."
Until now, acting White House Chief of Staff Mick Mulvaney was responsible for coordinating the response across the government outside of the health care agencies. Facing lawmakers' questions Thursday about the new organizational chart, Azar said Pence would now fill that role.
Administration aides insisted there was no daylight between the two men, noting that Pence had scheduled the first meeting under his leadership to be held at HHS instead of at the White House.
On Capitol Hill, Azar told lawmakers Thursday that he was involved in discussions about Trump's decision to designate Pence. He said he welcomed the heft that the vice president's office brings.
"I'll be honest with you. When I heard the idea that the vice president would be willing to help add the force of his office to this effort, I said, quote, 'That's genius,'" Azar told Rep. Bill Pascrell, D-N.J.
Earlier Thursday, Pence told the Conservative Political Action Conference in Maryland that "we will continue to bring the full resources of the federal government to bear to protect the American people." Pence said Trump and the administration would work with leaders in both political parties and at the state and local levels.
The White House had wavered on whether to name a "czar" to coordinate the virus response. Trump said Pence would not be a "czar," but he wanted "everybody to report to Mike" and that Pence would report to him. Trump said the scope of the threat had extended beyond the purview of HHS to other Cabinet departments.
Pence sought Thursday to instill confidence in a jittery public and shaken financial markets by naming Debbie Birx, a medical doctor and the administration's global AIDS coordinator, to serve as his chief adviser on the virus. He also added Treasury Secretary Steven Mnuchin and Larry Kudlow, director of the National Economic Council, to the task force out of recognition that the situation was quickly becoming an economic threat, too.
The Dow Jones Industrial Average sank nearly 1,200 points Thursday, deepening a week-long global market rout caused by worries that the coronavirus will wreak economic havoc around the world. Stocks are headed for their worst week since October 2008, during the global financial crisis.
Pence said he'd had conversations Wednesday night and Thursday with House and Senate leaders of both parties to discuss funding for the virus response. The administration has requested an additional $2.5 billion, while Senate Democratic leader Chuck Schumer of New York countered with an $8.5 billion proposal.
Pence described the conversations as "productive" and "very positive" and said he would look to the task force for guidance on additional funding.
Speaker Nancy Pelosi, D-Calif., said she told Pence when they spoke Thursday about her concerns about his leadership based on his record on health issues when he was Indiana's governor, including his reluctance to authorize a needle exchange program following an HIV outbreak in the southern part of the state.
The White House and Pence's team moved Thursday to control the flow of information from federal agencies about the virus response, ordering that public communications be cleared by their offices. A person familiar with the matter, who spoke on the condition of anonymity to discuss the internal guidance, said the decision was made to ensure the whole-of-government response was on message.
Ron Klain, who coordinated the U.S. response to the Ebola threat during the Obama administration, had a sharp retort to Trump's comment Wednesday that "because of all we've done, the risk to the American people remains very low."
Klain tweeted Thursday: "Oh look: it's the "Mission Accomplished" tweet for #coronavirus." That was a reference to President George W. Bush's premature claim in 2003 that major combat operations in Iraq had ended when the war, in fact, continued for years.
Saudi Arabia cut travel to Islam's holiest sites, South Korea toughened penalties for those breaking quarantines and airports across Latin America looked for signs of sick passengers as a new virus troubled places around the globe.
With the number of sick and dead rising, the crisis gave way to political and diplomatic rows, concern that bordered on panic in some quarters, and a sense that no part of the world was immune.
"Viruses don't know borders and they don't stop at them," said Roberto Speranza, the health minister in Italy, where northern towns were on army-guarded lockdowns and supermarket shelves were bare.
As outbreaks grew sharply Europe and the Middle East, air routes were halted and border control toughened. But for an illness transmitted so easily, with its tentacles reaching into so many parts of the world, leaders seemed willing to try anything to keep their people — and economies — safe.
Japanese Prime Minister Shinzo Abe called for schools across the country to close for weeks, a decision that impacted 12.8 million students.
"The most important thing is to prevent infections," said Norinobu Sawada, vice principal of Koizumi primary school, "so there aren't many other options."
In South Korea, the hardest-hit country outside China, four Busan markets known for colorful silks and a dizzying array of other wares were shuttered while the country's military sent hundreds of its doctors and soldiers to aid in treatment and quarantines.
The global count of those sickened by the virus exceeds 82,000, with China still by far the hardest-hit country. Recent days have seen sharp spikes in South Korea, Italy and Iran.
South Korea reported 256 additional cases Friday, raising its total to 2,022, with most occurring in the region around the city of Daegu. Many cases there have connections to a church and health workers are testing thousands of its members.
China's National Health Commission reported 327 new cases and 44 deaths over the previous 24 hours, most of them in Wuhan, the city where the COVID-19 illness emerged in December. Mainland China's total cases are now 78,824 with 2,788 deaths.
Even the furthest reaches of the globe were touched by the epidemic, with a woman testing positive in Tromsoe, the fjord-dotted Norwegian city with panoramas of snow-capped mountains. Health officials said the woman had traveled to China.
In Iran, the front line of Mideast infections, officials loosened rules barring the import of many foreign-made items to allow in sanitizers, face masks and other necessities, and removed overhead handles on Tehran's subways to eliminate another source of germs. Peru put specialists on round-the-clock shifts at its biggest airport, Argentina took the temperature of some new arrivals and El Salvador added bans for travelers from Italy and South Korea.
The holy city of Mecca, which able-bodied Muslims are called to visit at least once in their lives, and the Prophet Muhammad's mosque in Medina were cut off to potentially millions of pilgrims, with Saudi Arabia making the extraordinary decision to stop the spread of the virus.
With the monarchy offering no firm date for the lifting of the restrictions, it posed the possibility of affecting those planning to make their hajj, a ritual beginning at the end of July this year.
"We ask God Almighty to spare all humanity from all harm," the country said in announcing the decision.
Disease has been a constant concern surrounding the hajj, with cholera outbreaks in the 19th century killing tens of thousands making the trip. More recently, another coronavirus that caused Middle East respiratory syndrome, or MERS, prompted increased public health measures, but no outbreak resulted.
It wasn't just governments that were taking action: Cologne Cathedral, one of Germany's main religious sites, was emptying its basins of 'holy water' to prevent the spread of infection. And Facebook canceled its annual conference for developers.
COVID-19's global creep had some countries warning people to obey containment measures.
Singapore charged a former Wuhan resident who has the virus and his wife for allegedly lying about their whereabouts as officials tried to stem further infections. In Colombia, which has yet to report any cases, officials reminded residents they could be jailed for up to eight years if they violate containment measures. And in South Korea, the National Assembly passed a law strengthening the punishment for those violating self-isolation, more than tripling the fine and adding the possibility of a year in prison.
"It came later than it should have," said Lee Hae-shik, spokesman for the ruling Democratic Party, calling for further non-partisan cooperation to address the outbreak.
Countries' efforts to contain the virus opened up diplomatic scuffles. South Korea fought prohibitions keeping its citizens out of 40 countries, calling them excessive and unnecessary. China warned Russia to stop discriminatory measures against its people, including monitoring on public transit. Iran used the crisis to rail against the U.S., which it accused of "a conspiracy" that was sowing fear.
President Donald Trump's choice of Vice President Mike Pence to oversee the nation's response to the new coronavirus threat is bringing renewed scrutiny to the former governor's handling of an HIV outbreak in southern Indiana when he was governor.
Pence reluctantly agreed to authorize a needle exchange program in Scott County in March 2015 after the epidemic centered there saw the number of people infected with HIV skyrocket, with nearly 200 people eventually testing positive for the virus that year.
Despite his own misgivings — Pence worried about how the exchanges would affect "anti-drug policy" and had misgivings about providing clean needles to addicts — he initially issued an executive order allowing one in Scott County before later signing a law allowing the state government to approve them for counties on a case-by-case basis.
Greg Millett, director of public policy at amfAR, the Foundation for AIDS Research, said Indiana's HIV outbreak would have been "entirely preventable" if Pence had acted earlier in response to data that was available to Indiana public health officials and clearly showed an outbreak was imminent.
The outbreak primarily infected intravenous users of the painkiller Opana in an impoverished, rural area with few health resources. The needle exchange Pence finally approved for Scott County successfully curbed the epidemic's spread by providing clean needles to IV drug users to reduce needle-sharing that spreads HIV, hepatitis C and other diseases.
Millett said Scott County had averaged five new HIV cases annually between 2004 and 2013, but between November 2014 and Jan. 11, 2015, it suddenly saw 13 new cases in just over two months.
Quick implementation of a needle exchange program could have stopped that escalation, but new cases continued to surge without one, he said.
"This would have been entirely preventable if Indiana had acted fast with a syringe exchange," he said. "To have some 200 people become infected over such a short time period was unprecedented."
Millett, who worked as an epidemiologist with the Centers for Disease Control and Prevention between 1999 and 2013, doing HIV research, said the CDC later determined that Indiana's outbreak resulted in infections that will amount to $100 million in health care costs — expenses he said could have been reduced or avoided by a quicker response.
Despite his reservations about Pence, Millett said he's encouraged by the vice president's announcement Thursday that Debbie Birx, the administration's global AIDS coordinator, will serve under the vice president as the White House coronavirus response coordinator. Millett called Birx an effective and respected public health leader.
"She'll bring in people who are experts in infectious diseases who can mount an effective response," he said.
But Steven Thrasher, a Northwestern University journalism professor who has studied Indiana's outbreak as part of his research into HIV and LGBTQ health issues, said Pence's response as Indiana governor raises real questions about whether he's the best person to helm the response to the virus.
Thrasher said that while HIV cases were mounting in Scott County — which lies about 30 miles (48 kilometers) north of Louisville, Kentucky — Pence told local officials wondering whether he would approve a needle exchange "that he was going to pray on it."
"His background shows that he brings religion, a lack of science and a budgetary mindset to public health matters. In a time of emergency, those are not the safest ways to be approaching what could become an epidemic," Thrasher said.
Pence's state health commissioner at the time of the HIV outbreak, Jerome Adams, is now U.S. surgeon general and is widely credited with helping persuade Pence to accept the needle exchange program that now operates in nine of Indiana's 92 counties.
Pence's office, when asked for comment, referred a reporter to Adams. He defended Pence's actions Thursday, saying the then-governor worked closely with him in responding to the outbreak, including implementing the syringe exchange program "that helped change the scope of the unprecedented crisis."
"As a result, our efforts became a model for how other states and localities respond to similar crises," Adams said in a statement.
Joey Fox, who was legislative director for the Indiana State Department of Health during the HIV outbreak, said Thursday that the criticism of Pence is unfair because Indiana's response to the HIV outbreak went far beyond just authorizing a needle exchange program.
Fox said the state's response included bringing HIV testing to the small city of Austin — the community at the heart of the outbreak — at a "one-stop-shop" office where the county's needle exchange was initially based. At that office, people could get tested, enroll in Medicaid to begin HIV medical treatment, get state identification cards and birth certificates and receive other services.
"It's unfair to criticize the governor," Fox said. "He was personally engaged with the public health and the public safety of Scott County, and the Indiana government was engaged from day one on the HIV outbreak.
"Before Mike Pence syringe exchanges were illegal in Indiana. When he left office there were programs around the state."
Democratic Sen. Patty Murray of Washington urged Trump on Thursday to reconsider the choice of Pence, citing his "lack of public health experience and record of putting ideology over science" and his "leadership failure during the Indiana HIV outbreak."
House Speaker Nancy Pelosi told reporters she spoke to Pence on Thursday morning and "expressed to him the concern that I had of his being in this position." Pelosi said that while she wants to work with the White House, she told Pence she was wary of his leadership after his track record in Indiana.
Indiana's needle exchange debate in 2015 was complicated by opposition from law enforcement groups who worried that such programs would enable drug abuse.
Scott County's current health administrator said the county's exchange — through which participants swap used needles for clean ones to stem the spread of diseases through needle-sharing — had a dramatic impact on the outbreak.
Since the county's needle exchange began in early 2015, the number of new HIV cases tied to the outbreak has declined each year, said Michelle Matern, administrator for Scott County's health department.
"I think the data speaks for itself, that it's decreasing the transmission of infectious diseases," she said.
In 2015, there were 187 new HIV cases linked to the same HIV strain involved in the outbreak. Cases plunged to 27 in 2016, 12 in 2017 and 10 in 2018, with a preliminary count of seven new cases last year, Matern said.
Health advocates have long criticized Indiana's Republican-dominated government for paying scant attention to public health, with the state ranking 47th in public health funding, according to a 2019 study by the United Health Foundation.