Holland scrambled to her feet, shaken and grateful she hadn’t been injured: Her puffy down coat had cushioned her fall onto the hardwood floor. Then she realized the pain that had dominated her life for the previous six years had suddenly diminished.

“I thought, ‘This is weird,’ ” said Holland, 71, a retired administrative assistant who lives in Maryland.

For years, Holland’s doctors had disagreed about what was wrong with her hip. She had undergone a slew of scans, plus painful biopsies of her hip bones. Her doctors had prescribed cortisone injections and months of physical therapy to treat what most concluded was osteoarthritis.

But when she sought an explanation for the reason that her March 2017 fall had relieved pain so severe it disrupted her sleep, an X-ray suggested an alarming possibility: a cancer recurrence.

The cause proved to be far less ominous. Holland would learn that the problem had been clearly visible years earlier on an MRI, but its identity and significance were missed.

“I’m a happy camper,” Holland said of the surgery that corrected her problem. “I had thought I was going to be crippled for the rest of my life.”

– —

In 2009, Holland, then 61, was diagnosed with early-stage breast cancer. She underwent a lumpectomy followed by radiation, which appeared successful in eradicating the cancer.

The pain in her upper left leg and hip joint started two years later. Both her oncologist and internist worried it might mean that her cancer had returned and spread to her bones. They ordered a variety of tests, including CT and bone scans, followed by biopsies of her hip bones.

After the tests found nothing significant, Holland began months of physical therapy for a condition her internist decided was trochanteric bursitis, inflammation of the fluid-filled sac near the hip joint. The condition, a common cause of hip pain, often improves with rest, physical therapy and sometimes anti-inflammatory drugs. Holland tried all three; none seemed to help.

Her internist then administered two cortisone shots. Each worked for about two months. Holland, a former gymnast and gymnastics coach who teaches water exercise classes, felt increasingly hobbled by worsening pain that radiated down her leg.

In November 2013, she underwent an MRI scan of her hip. The report noted the presence of “calcified/ossified bodies” in her left hip, which had been detected on an earlier CT scan. The radiologist also noted fluid surrounding her left hip joint, which was “suspicious for an underlying synovitis,” inflammation of the tissue that lines joints and can result from certain diseases including rheumatoid arthritis.

The radiologist concluded that the most likely cause of Holland’s hip pain was not bursitis but rather degenerative osteoarthritis, a common problem in which the protective cartilage around bones wears down over time.

A month before the MRI, Holland had undergone a long-planned partial replacement of her right knee to repair an injury she had suffered years earlier. She had hoped the knee operation might lessen her hip pain.

“My knee felt great,” she recalled. “But the hip did not change. That was a real disappointment.”

A doctor repeatedly insisted her head pain was a tension headache. Something more serious was going on.

By 2015, she had developed pain in a second location: her lower back. Holland consulted an orthopedic spine specialist who told her he thought her hip pain was caused by sciatica, an irritation of the sciatic nerve that runs from the hip down the back of the leg. Her lower back pain, he concluded, was the result of mild spondylolisthesis, which can result from the overextension that occurs in gymnastics. He recommended that Holland receive potentially risky corticosteroid injections in her spine to control her hip pain.

Holland never received those epidural nerve block injections; her insurance company wanted her to try physical therapy first. For the next year, she went to PT faithfully. She also received professional massages, which she deemed “a tremendous help” by improving her mobility and decreasing pain.

But Holland said she worried that this was all that could be done. She was taking anti-inflammatory drugs on a daily basis and still had trouble sleeping because of the pain. Her gait was off, and she sometimes walked hunched over.

“It seemed like my orthopedists were guessing: ‘Is it her hip? Her back? Her knee?’ ” she recalled.

– – –

A week after she fell, Holland returned to the first orthopedist, who had performed her knee operation, and told him about her inexplicable improvement.

She hoped the episode might provide clues about what to do next.

The doctor ordered X-rays and told her she appeared to have a large “loose body near her sciatic nerve.”

He referred her to a third orthopedist for possible removal of the unidentified object, which was the size of a robin’s egg.

The specialist told her he wouldn’t operate. “He said, ‘I don’t know what it is,’ ” Holland remembered. If it was a malignant tumor, he said, surgery could cause it to spread.

Instead, he sent her to a fourth specialist, orthopedic oncologist Felasfa Wodajo of Virginia Cancer Specialists. (Orthopedic oncologists treat both benign and malignant diseases of the musculoskeletal system.)

“She’s very memorable,” Wodajo said. He described Holland as “a great historian” of her case who came armed with scans and medical records.

To Wodajo, Holland’s symptoms and test results did not suggest osteoarthritis. Her joints showed no sign of the degeneration commonly seen in arthritis and she seemed much too active.

Most telling was Holland’s recent X-ray, which showed several dozen small white flecks that resembled pieces of popcorn scattered around her hip joint, along with the large nodule in her left buttock. Wodajo said he immediately knew what was wrong.

“If you’ve never seen it before, I’m not sure it would jump out at you,” he said. But as an orthopedic oncologist, he sees the uncommon condition three or four times a year. Wodajo told Holland her hip pain was caused by primary synovial chondromatosis.

Holland said she remembers asking two questions: Is it cancerous, and can you fix it? His answer to the first question was no and the second was yes. Holland said she promptly burst into tears.

Synovial chondromatosis is a disorder of unknown cause that can result in severe disability. Most commonly seen in men in their 50s, it is not inherited. It occurs when the synovium grows abnormally, generating small nodules composed of cartilage, some no larger than a grain of rice. These pellet-like bodies can become loose inside joints, where they can roll around, damaging the cartilage that covers the joint. In Holland’s case, her fall had dislodged a large calcified body that was pressing on her sciatic nerve.

Those “calcified/ossified bodies” the radiologist flagged in Holland’s 2013 MRI were hallmarks of the condition.

“On that MRI it’s glaringly obvious,” Wodajo said. Because the radiologist did not specialize in orthopedic cases, he noted, it appears their significance was missed.

First he was hoarse. Then he couldn’t chew.

Holland’s history of cancer may have complicated her diagnosis, Wodajo said, because doctors were focused on determining whether her cancer had returned.

“That’s very common,” he said, referring to “people with a history of cancer who turn out to have something unrelated.”

Treatment of synovial chondromatosis, which often recurs, involves surgery that is typically performed arthroscopically through a small incision. But in Holland’s case, that was not possible: Her disease was too extensive.

“I told her we’d have to dislocate her hip, which is not a trivial thing,” Wodajo recalled.

Holland underwent surgery in July 2017. She spent one night in the hospital, less time than initially expected, and then recuperated at home. A week later, she was largely pain-free.

So far, the disorder has not recurred.

Holland regards Wodajo as her “hero” and says she wishes she hadn’t wasted years marked by anxiety and pain chasing a diagnosis that could have been made much earlier.

She hopes her experience will dissuade doctors from resorting to the catchall arthritis diagnosis “if they don’t know what’s wrong.”

“What if I hadn’t fallen, what would have happened?” she asked. “I think about that all the time.”

The potential for a longer incubation period was linked to a patient in China’s Hubei province, where the virus was first detected in December. A 70-year-old man was infected with coronavirus but did not show symptoms until 27 days later, the local government reported.

South Korea and Japan both reported a sharp spike in cases Saturday, while an additional 109 people died of the virus in China and a sixth person died in Iran. Italian authorities on Saturday said the country was seeing a sudden rise in coronavirus cases, with at least 58 confirmed in the past two days – an outbreak that represents the largest yet across Europe.

Meanwhile, scientists in China reported indications that the virus might be transmissible through urine.

World Health Organization Director General Tedros Adhanom Ghebreyesus said Saturday that WHO experts were due to arrive that day in Wuhan, China, the center of the coronavirus outbreak. The team has visited three Chinese provinces this week, Tedros said in a speech in Geneva.

Outside China, Tedros said the WHO is concerned about the number of cases without a clear epidemiological link, such as recent travel to China or contact with a person known to be infected.

The WHO also has been sending medical supplies to Africa and training the continent’s health-care workers to prepare them for the virus’s possible arrival there, Tedros said. The only confirmed case of the coronavirus in Africa is in Egypt.

“Our biggest concern continues to be the potential for covid-19 to spread in countries with weaker health systems,” Tedros said.

Chinese leader Xi Jinping, who has not visited Wuhan since the outbreak began, was briefed that the situation in the city and in surrounding Hubei province “remains grim and complex,” according to a report by the official Xinhua News Agency published Saturday.

“The nationwide inflection point of the epidemic has not yet arrived,” the report said after a meeting of Communist Party leaders.

China’s National Health Commission reported Saturday that 397 new cases of coronavirus had been diagnosed Friday, taking the total to more than 76,000. The rate of infection outside Hubei appears to have slowed markedly, although there has been a great deal of confusion about the statistics this week as officials have repeatedly changed the criteria for confirming cases.

Among the new cases discovered Friday were a 70-year-old man in Hubei who was confirmed as infected after 27 days in isolation, while a man in Jiangxi province tested positive after 14 days of centralized quarantine and five days of isolation at home. On Thursday, authorities reported that a man in Hubei had tested positive for coronavirus after what appeared to be a 38-day incubation period with no symptoms.

The United States is also struggling with domestic fallout from its responses to the virus. The California city of Costa Mesta has sued the federal government over its plan to transfer quarantined coronavirus patients from the Travis Air Force Base near Sacramento to the former Fairview Developmental Center as early as this weekend. The city said that the area in question is surrounded by residential neighborhoods and that placing patients with a highly contagious disease so close by could pose a risk to public health.

A federal judge granted Costa Mesa’s request Friday, temporarily blocking the transfer of up to 50 patients. The restraining order prohibits state and federal government authorities from transporting anyone infected with coronavirus or who has been exposed to the disease to Costa Mesa before a hearing at 2 p.m. Monday at the Santa Ana federal courthouse, according to the Los Angeles Times.

The State Department, meanwhile, is battling thousands of Russian-linked social-media accounts promoting baseless theories that the United States created the coronavirus outbreak, according to the AFP. The accounts post “almost near identical” messages at similar times in five languages, the report says.

“Russia’s intent is to sow discord and undermine U.S. institutions and alliances from within, including through covert and coercive malign influence campaigns,” Philip Reeker, the acting assistant secretary of state for Europe and Eurasia, told the AFP.

Misinformation about the coronavirus outbreak has proliferated – mostly on social media – since the first cases were reported in December.

– – –

The State Department on Saturday heightened its travel advisories from Level 1 to Level 2 for South Korea and Japan, urging Americans to “exercise increased caution” when traveling to those countries due to the rising number of coronavirus cases there. Older adults and people with chronic conditions, who might be at higher risk of contracting the virus, should consider postponing unnecessary travel to those countries, the department said.

In Seoul, the Korea Centers for Disease Control and Prevention (KCDC) reported Saturday that 229 additional cases of the coronavirus had been detected, taking the total to 433, more than doubling in the space of a day and making South Korea the most affected country outside China.

“Apart from the Diamond Princess cruise ship, [South] Korea now has the most cases outside China, and we’re working closely with the government to fully understand the transmission dynamics that led to this increase,” Tedros said.

The majority of the new cases have been traced to existing clusters at a church in the southern city of Daegu and a hospital in nearby Cheongdo County, according to the KCDC.

More than half of South Korea’s cases are connected to the Daegu branch of the Shincheonji Church of Jesus the Temple of the Tabernacle of the Testimony.

Since members of the church attended a funeral at nearby Cheongdo Daenam hospital, 111 coronavirus cases have been reported there, including two patients who died of the virus.

The mass infection at the hospital is centered on its locked psychiatric ward, where a confined environment could have aggravated transmissions, said Jung Eun-Kyeong, director of the KCDC.

A man in his 40s was found dead at his home in the city of Gyeongju, east of Daegu, after becoming infected with the virus. He is the third person in South Korea to die of the virus.

In Japan, the number of coronavirus cases rose to 121 on Saturday, more than tripling in a week. That number excludes the 634 people on board the Diamond Princess who contracted the virus.

One of the latest cases was a teacher in her 60s at a public junior high school east of Tokyo, who complained of nausea while working. The mayor of Chiba city said the school will be closed until Wednesday, public broadcaster NHK reported.

The teacher had not traveled abroad in the past two weeks and has no record of having been in contact with a known infected person, underlining the fact that the virus is now spreading almost invisibly throughout the country, experts say.

– – –

As numbers suddenly rose in Italy, the government has scrambled to contain the new outbreak, asking some 50,000 people to stay indoors and suspending all public events – including religious ceremonies and school – in 10 small towns to the south of Milan.

Until a few days ago, Italy had seen only three confirmed infections, including a pair of Chinese tourists.

“There is quite an evident contagion, a very strong one,” said Giulio Gallera, health chief of the northern Lombardy region, which has seen the majority of the cases.

Italian officials on Friday attributed the country’s first death to the coronavirus, and on Saturday said that a 77-year-old woman had also tested positive for the virus after being found dead in her home. But Italian authorities said the woman suffered from other health conditions, and were unsure whether it was the virus that had killed her.

The cases in Italy appeared concentrated in the prosperous Lombardy region, which includes the country’s financial hub, Milan, and other areas nearby.

According to Italian media reports, one of the first people to come down with the virus was a 38-year-old who’d had dinner with somebody who had just come back from China. But some three weeks passed between that dinner and the time the man came down with a fever. In between, he ran a half-marathon, played soccer and traveled to several towns, according to La Repubblica, a major Italian daily.

Meanwhile, the number of confirmed cases of the virus in Iran has risen to 28.

The outbreak there has so far been centered on the holy Shiite city of Qom, where on Wednesday authorities suspended schools and religious gatherings as a precaution. On Saturday, Iranian authorities also closed schools in the capital, Tehran, and issued a temporary ban on cinemas and art-related events across the country, state-run Fars News Agency reported.

Other countries in the region have also reacted with alarm, particularly after Lebanon’s first coronavirus case Friday was found to be a woman who had just traveled from Qom.

In the past few days, Iraq and Kuwait suspended direct flights to Iran, while Iraq temporarily halted new visas for Iranian nationals and, along with Turkey, imposed restrictions on travelers who had recently arrived from Iran. Kuwait Airways said Saturday that it would be chartering special flights to evacuate citizens from Mashhad, Iran.

As fears mounted, Israel announced Saturday that nine South Koreans who had recently returned home from a tour in Israel tested positive for the virus. Israeli and Palestinian authorities on Saturday urged anyone who may have interacted with the group visiting from Feb. 8 to 15 to self-quarantine as they work to trace who may have had contact with the tourists, who visited major cities including Jerusalem.

Israel’s ambassador to China, Zvi Heifetz, was among those who self-quarantined, The Jerusalem Post reported, citing Israel’s foreign ministry. Heifetz took the same flight to Seoul as the South Korean tourists and is quarantined in Beijing, the report says.

About 200 students and teachers who came into contact with the South Koreans have also self-quarantined, according to The Times of Israel.

A spokeswoman for Israel’s Population and Immigration Authority said Saturday that all non-Israeli citizens arriving on a direct flight from Seoul to Tel Aviv that evening would be denied entry. Israel’s Health Ministry has ordered Israelis returning from South Korea to self-quarantine.

– – –

Meanwhile, tests are continuing on the crew members on board the Diamond Princess. At least 74 crew members have so far been found to have the virus.

All of the passengers have now been tested and almost all have left the ship, either to go home if they tested negative, to local hospitals or government facilities if they have the virus, or back to their home countries.

Some passengers were asked to stay aboard to serve an additional quarantine if their cabin mate contracted the virus, but they are also disembarking Saturday to serve out the rest of their quarantine in a government facility, local media reported.

More than 200 port calls in Japan by international cruise ships have been canceled this month due to the coronavirus outbreak, a Kyodo News survey showed Saturday, with the lost revenue from passengers coming ashore dealing another blow to Japan’s weakening economy.

– –

The 83-year-old woman who tested positive for the coronavirus when she arrived at Kuala Lumpur airport after disembarking in Cambodia from the MS Westerdam cruise ship has recovered, Malaysia health authorities said Saturday.

The woman “is showing good improvement and signs of recovery, however, she is still being monitored and managed in hospital for a slight cough,” Malaysia’s director general of health, Noor Hisham Abdullah, said in a statement.

The woman repeatedly tested negative while on board the ship and when she disembarked in Sihanoukville, then twice tested positive while transiting in Kuala Lumpur airport on Feb. 15. That set off a global scramble to track the hundreds of other passengers who had also disembarked then boarded planes bound for home.

The woman was taken to a hospital and given antiviral treatment and supplementary oxygen, and she showed improvement after 72 hours of treatment initiation, Abdullah said. Two more tests, conducted 24 hours apart, both came back negative for coronavirus.

But the U.S. Centers for Disease Control and Prevention cast doubt on whether the woman was ever infected, saying she “never had coronavirus to our knowledge.”

Cambodia’s Ministry of Health had previously cleared the 747 crew members who were still on board the Westerdam and the 781 passengers who were still in the country of coronavirus infection.

– – –

Separately, scientists in China are continuing to study how the virus is transmitted.

A research team led by renowned Chinese pulmonologist Zhong Nanshan had isolated live coronavirus strains in urine samples from infected patients, Zhao Jincun, a respiratory expert at the State Key Laboratory, told reporters in Guangdong on Saturday.

The team of scientists had previously said the virus, in addition to being carried in respiratory droplets, appeared to be transmissible through fecal matter, underscoring the need to practice good hand washing as a preventive measure.

Zhao did not directly say that the virus could be transmitted through urine, simply noting that the strains had been isolated and that this had implications for public health control. They are continuing to work on isolating the virus and on a cure, the Guangzhou Daily reported.

But he said people should pay more attention to personal and family hygiene to prevent the spread of the virus and recommended frequently washing hands, closing the toilet lid before flushing and making sure bathroom drains are not blocked.

– – –

Denyer reported from Tokyo, Harlan from Rome, and Berger and Iati from Washington. The Washington Post’s Lyric Li in Beijing, Akiko Kashiwagi in Tokyo, Min Joo Kim in Seoul, Stefano Pitrelli in Rome, Ruth Eglash in Jerusalem, and Yasmeen Abutaleb and Carol Morello in Washington contributed reporting.

Upstairs, Luke Rodda, the chief forensic toxicologist, looked over his morning docket and the terse reports from first responders.

Male, 33, “prior history of fentanyl overdose,” found at bus stop.

Male, 27, “white powder in baggie.”

Male, 51, found by construction worker, syringe next to him.

There had been at least nine apparent drug-related deaths over the previous three days in late January, Rodda said.

“This is our new norm now,” he said.

These individual tragedies are part of a national drug crisis that has shifted west. Drug overdoses are rising in many states west of the Mississippi, and dramatically so in California, even as they are falling across much of the East.

This trend has only recently become clear in government mortality data, including new numbers released Feb. 12. The increase in overdoses in the West is an ominous development that comes after a short period of progress in bringing down the overall drug-overdose death toll.

Drug deaths dropped 4% nationwide from 2017 to 2018, according to final mortality statistics released Jan. 30 by the Centers for Disease Control and Prevention. Secretary of Health and Human Services Alex Azar heralded the new numbers as evidence that the Trump administration’s efforts to combat the overdose epidemic “are beginning to make a significant difference.”

But the provisional CDC statistics released last week, which include estimated underreporting of deaths by medical examiners, show a slight uptick in fatal overdoses nationally over the first half of 2019.

In California, fatal drug overdoses over the previous 12 months increased 13.4% between July 2018 and July 2019, the last month for which the CDC has compiled provisional data – an additional 728 deaths.

In contrast, Illinois’ fatal drug deaths were down 8%, Pennsylvania’s down 10%, Michigan’s down 13% and Maine’s down 20%.

The overdoses in the West are driven largely by opioids, particularly illicit fentanyl, a synthetic drug that is roughly 50 times as powerful as heroin. Fentanyl has finally arrived in force in the western United States. Because fentanyl is so potent, and its dosage so easily miscalibrated, it is killing people who previously had managed their addictions for years.

Historically, the West Coast opioid market has been dominated by black tar heroin, a gunky substance not easily mixed with white powder fentanyl. That’s the orthodox explanation for why fentanyl first became popular in the eastern United States, where white powder heroin has historically been favored and drug dealers could more easily blend fentanyl and heroin.

Fentanyl started becoming more common here around 2015. The medical examiner’s latest, provisional numbers tell an alarming story: Deaths in San Francisco from fentanyl and/or heroin jumped from 79 in 2017 to 134 in 2018, and then more than doubled to 290 in 2019.

People are dying from other drugs as well, with a large spike in deaths linked to the potent stimulant methamphetamine. Efforts to cut off access to meth precursors sold in pharmacies have helped shut down local meth labs like the ones made famous in the TV show “Breaking Bad.” But that opened a new market for the Mexican drug cartels, said Daniel Comeaux, special agent in charge of the Drug Enforcement Administration’s San Francisco division.

“You have no mom and pop labs anymore because so much is coming from the Mexican cartels,” Comeaux said in an interview in his office in the heart of the Tenderloin district. “As much as we’re seizing, they’re producing.”

Comeaux said the DEA remains aggressive in targeting illicit-drug wholesalers.

“Look, we’re putting people in jail,” Comeaux said. The agency last year launched a program to target drug dealing in the Tenderloin district, leading to indictments of more than 100 people.

“If you cause an overdose death, we will put you in jail for 20 years – federally,” Comeaux said.

He acknowledged that there is rampant drug use right outside his office, but said the federal response has made it harder to buy drugs.

“Now you might have to walk three blocks to buy heroin,” he said. “If we didn’t do what we’re doing, you would be able to buy that heroin in one block.”

The drug-using population overlaps to a great degree with the homeless population – another relatively new development, according to Alex Kral, an epidemiologist at RTI International, a nonprofit research firm. Kral said that 15 years ago, he rarely saw people on the street injecting drugs, and estimated that only about a quarter to one-third of homeless people were doing so. Now, he said, upward of 75% of the homeless people in San Francisco are injecting drugs.

And even the most experienced users of heroin can be fooled by fentanyl: “If you’re a new user of fentanyl, you don’t even know necessarily how much to take.”

Kral works on harm reduction – an approach that provides people with tools and support to limit the negative consequences of drug use.

Harm reduction advocates emphasize that the overdose crisis is driven by social factors, including economic inequality, the housing crisis that is tied to a rise in homelessness in San Francisco, systemic racism and the criminalization of drug use.They say the overdose epidemic should be treated as a matter of public health and not as a law enforcement issue.

“The war on drugs has created this problem,” said Eliza Wheeler, a leader in the harm reduction community.

Paul Harkin, director of harm reduction at GLIDE, a multi-service social center, pointed out that testing kits, including chemically treated strips similar to pregnancy tests, could help users know what’s in their drugs and help them avoid overdosing.

“Unfortunately, America is very puritanical. We have to decriminalize in the way Portugal did, and we have to do drug testing so we know what’s in the drug supply,” he said.

That’s particularly a problem with fentanyl, which delivers an immediate, powerful high but can also render the user unconscious and unbreathing almost instantly.

“I’ve never seen so many people die,” said Chris, a young man in a hoodie standing near Eighth and Market streets in an area with open drug use. He did not want to give his full name because of concerns about trouble with law enforcement. He said he takes fentanyl and meth and has been on drugs for 15 years. He spoke in a light pre-dawn rain while, just a few feet away, young people stood at a bus stop waiting to board buses to technology companies in other locations in Silicon Valley.

Chris was engaged in conversation with a man named Brian, 29, who had been sitting unsheltered in the rain, leaning against a fence. Brian said he lives outside and prefers to do so. He said he’s been using meth for 10 years. Neither Chris nor Brian is interested in seeking drug treatment.

“It’s like a 24-hour party out here,” Chris said.

“That’s such a bougie comment,” Brian said.

The use of drugs in public and the burgeoning homeless population are sources of dismay for many of the more affluent residents of the city. Harm reduction activists believe that the law enforcement focus on impoverished and homeless drug users is unfair given that wealthy people often use drugs without repercussions.

“People are interested in open-air drug dealing because it’s visible to people and makes our city look bad,” said Kristen Marshall, a harm reduction worker who distributes naloxone to drug users.

She noted that thousands of overdoses have been reversed by peers on the street who were supplied with naloxone as part of harm reduction efforts. For many years, San Francisco saw a growing population of drug users but had a strikingly low rate of fatal overdoses. But that was before fentanyl showed up.

The statistics of drug use and overdoses do little to capture the gritty reality of life on the downtown streets of San Francisco. The drug use is in plain sight in the Tenderloin and the South of Market neighborhoods. One morning on Market Street recently, a young man in a hoodie was bent over at a bus stop in front of a hotel, injecting himself with a needle. He had slit both pants legs to improve access to his legs. One leg was bleeding. He looked dazed as he stood up, and did not respond when asked his name and whether he needed assistance.

Asked again whether he was OK, he looked puzzled and said, “I feel like there’s something alive in my body and I don’t know what it is.”

Wang will co-chair the meeting with Philippines Foreign Secretary Teodoro Lopez Locsin, the current Asean-China country coordinator.

There will also be a meeting of China-Asean medical experts to be held in parallel with the foreign ministers’ meeting.

“Since the outbreak of the Covid-19 epidemic, the Chinese government, acting with a high sense of responsibility to its people and the international community, has put people’s lives, health and safety on top of its agenda and adopted the most comprehensive and rigorous prevention and control measures, which are gradually paying off,” China’s embassy in Bangkok said in a statement.

“As of February 14, new confirmed cases in China, excluding Hubei province, has declined for the 12th consecutive day, while over 8,000 patients have been cured and the mortality rate is controlled at 2.29 per cent nationwide and 0.55 per cent for areas excluding Hubei. The situation speaks volumes that the epidemic is curable and controllable and that China is confident and capable of defeating the epidemic,” the statement added.

At the 56th Munich Security Conference recently, Wang reminded the delegates that we live in a time when traditional and non-traditional security issues are entwined, and when local issues easily become global and vice versa, and that no country can prosper in isolation. Under the concept of a community of shared future for mankind, China and Asean countries have maintained close communication and carried out rounds of effective cooperation in responding to the Covid-19 epidemic, the embassy said.

“Many Asean countries, including Thailand, have offered us support and assistance through various ways, vividly demonstrating the valuable friendship of good neighbours. That the two sides have decided to hold a special foreign ministers’ meeting within such a short period of time demonstrates our will and determination to overcome difficulties with concerted efforts,” the statement added.

At the Vientiane meeting, Wang will talk about China’s strong measures on countering the epidemic and exchange in-depth views on collaboration with Asean counterparts to advance joint prevention and control, maintain normal economic and social exchange, and explore launching a permanent mechanism on public health cooperation, the embassy said. “By doing so, we will safeguard the health and safety of people in regional countries and contribute to global public health,” the statement added.

“When I was 8 years old, I remember watching a cartoon that explained the immune system to children,” writes Nasif in an email. “I loved it, and I decided then to draw and create my own comics.”

The immune system is the body’s natural defense against viruses, bacteria and other nasty stuff, Nasif says. But viruses are especially good at developing disguises that help them hide from the immune system. Which is why we need vaccines to help our bodies see through the act.

Most vaccines contain a weakened or dead version of the virus they are meant to protect against, though some vaccines carry only the proteins found on the virus’s surface. In either case, once these substances are injected into the body, your immune system grabs them up and learns how to identify them, kind of like a cheat sheet that helps you prepare for a big test.

Then, when the body comes into contact with the real thing – a healthy virus – it knows how to protect against it and can set to work gobbling up the viruses before they can do too much damage.

You may be wondering why you still have to get shots for something such as polio, even though no one you know has gotten it. This is where a term called “herd immunity” comes into the discussion.

“Vaccines act as a firewall that prevents the spread of diseases to others,” Nasif says.

When enough people develop resistances to a disease by getting a vaccine, the chance that a virus can infect someone and then keep spreading drops to near zero. This is how polio went from a disease that was infecting 350,000 people a year in 1988 to one that caused just 33 cases reported worldwide in 2018. Of course, the protection only continues if people continue to give their bodies a cheat code to beat polio – vaccines.

Many people are concerned that a new virus coming from China could become a big problem for people around the world. Nasif says that scientists are working hard to create a vaccine for this coronavirus, which causes a disease called covid-19, but that it takes time to produce a vaccine that will be safe to use in people.

For now, she says the best thing you can do to protect yourself against this or any other viruses, bacteria and other things that cause diseases, is to wash your hands frequently and avoid being close to people who are coughing or sneezing.

Nasif also suggests eating a healthy diet and getting plenty of sleep at night – two ways you can give your immune system a helping hand.

Nasif also suggests eating a healthy diet and getting plenty of sleep at night – two ways you can give your immune system a helping hand.

Their return almost doubles the number of confirmed cases of the coronavirus in the United States to 29. The number of confirmed infections in China now exceeds 72,000, with the death toll rising to 1,868, the majority of both in Hubei province, where the virus emerged in December.

The 14 U.S. passengers tested positive for the virus after leaving the Diamond Princess, a cruise ship carrying 2,666 passengers and 1,045 crew members that had been quarantined for two weeks off the Japanese port of Yokohama.

But by the time their test results arrived, they were on a fleet of buses that took 328 asymptomatic passengers from the ship to two charter planes bound for U.S. military bases in Texas and California, according to a senior U.S. official who spoke on the condition of anonymity to speak freely about the incident.

It was a wrench in a coordinated effort. While the buses sat on the tarmac, health experts considered whether to put the 14 on the flight or divert them to hospitals in Japan, the official said. The State Department had already told passengers that virus-infected people would not board flights.

The planes included a sealed-off section of 18 seats in the back, and part of the plan was to isolate passengers there if they developed symptoms midflight, the official said.

Health authorities deemed them “fit to fly” because they were not showing symptoms, the State Department and the Department of Health and Human Services said in a statement Monday. They were cordoned off from the other passengers during the flight, the statement said.

“These individuals were moved in the most expeditious and safe manner to a specialized containment area on the evacuation aircraft to isolate them in accordance with standard protocols,” according to the statement.

It was unclear whether the other passengers were informed, the official said. The State Department did not respond immediately to a request for comment.

Another 44 Americans from the cruise ship tested positive for the coronavirus Sunday and had been taken to hospitals in Japan.

One flight unloaded bleary-eyed passengers at Travis Air Force Base in Fairfield, California, late Sunday night local time, and the other in Lackland Air Force Base in San Antonio early Monday.

All are due to go into quarantine for 14 days, the maximum incubation period for the virus. Ten passengers who tested positive were moved to a hospital in Omaha, Nebraska, upon arrival, where they are being quarantined, retested and monitored in rooms with separate filtration systems at the University of Nebraska Medical Center. Four others with the virus are in a hospital outside Travis Air Force Base and will be moved to Omaha this week, the official said.

Japan’s Health Ministry on Monday reported 99 new cases of coronavirus among the passengers and crew of the Diamond Princess, increasing the total number of infections from the ship to 454, including the Americans. Of those, 18 are in serious condition, the Yomiuri newspaper reported.

Yosuke Kita, a senior official in the Japanese Health Ministry, said the government would finish testing everyone aboard the Diamond Princess by the end of the day Monday. One of the new cases was a Russian woman, the Russian Embassy in Tokyo said on Twitter, and two were Australians, according to the Australian Broadcasting Corporation.

In addition to the cases on the Diamond Princess, Japan reported a sharp rise in the number of people with coronavirus over the weekend, with 65 people confirmed to have the virus, up from 33 on Thursday. The fact that many of the latest cases cannot be traced directly to China led Health Minister Katsunobu Kato to acknowledge that the virus had entered a “new phase” of local transmission.

The country is shifting to an approach focused on community-based control and treatment, said Shigeru Omi, chief director with the Japan Community Health Care Organization, which runs medical centers across Japan.

Kato said Japan can now administer more than 3,000 tests a day, and designated hospitals will be able to take 1,800 of the most severe cases, “and citizens with very light symptoms will be requested to stay home,” Omi said. People who develop symptoms will be encouraged to contact special call centers, rather than visit hospitals on their own.

Omi said that the “goal of this strategy is to slow the speed of transmission and reduce mortality” – a de facto acknowledgment that it has now become impossible to prevent the virus from spreading further in Japan.

The World Health Organization said new data has yielded better understanding of how the virus circulates and shows a decline in new cases, WHO Director General Tedros Adhanom Ghebreyesus said in a news conference Monday. But he cautioned against that as a sign the virus has reached its apex.

“Trends can change as new populations are affected. It’s too early to tell if this reported decline will continue,” he said. “Every scenario is still on the table.”

Government officials in Malaysia, Cambodia and the United States were scrambling on Monday to track down passengers from another cruise ship – the Westerdam, owned by Holland America Line – who may have been exposed to coronavirus.

Hundreds of passengers have flown home, mostly through Thailand or Malaysia, after the ship docked in the Cambodian port of Sihanoukville and health authorities there deemed it coronavirus-free.

But an 83-year-old American woman who disembarked from the ship at Sihanoukville on Friday took a charter flight to Kuala Lumpur, the capital of Malaysia, along with 145 other passengers. They had all passed health checks by Cambodian authorities and cleared to leave the ship and travel onward.

When the woman arrived in Kuala Lumpur, she reported not feeling well and tested positive for the virus. Malaysian authorities say she is in stable condition.

Her traveling companion tested negative, and none of the other passengers or crew members reported symptoms, Holland America Line said in the statement.

The Westerdam on Monday remained in Sihanoukville, where it had docked last week after spending two weeks at sea. Authorities in Japan, Taiwan, Guam, the Philippines and Thailand had turned it away after seeing what happened with the Diamond Princess, where the number of infections grew rapidly even while the vessel and its passengers quarantined.

The new cases come amid a continuing scramble to contain the virus in China, especially in Wuhan, the capital of Hubei province, where the outbreak began.

China’s National Health Commission said over the weekend that the number of new cases outside Hubei province has declined, as authorities impose severe restrictions on people’s movements in an attempt to stop transmission.

In Beijing, China’s ruling Communist Party signaled that it would almost certainly postpone the annual meeting of its legislature, the National People’s Congress and the other national committee of the Chinese People’s Political Consultative Conference. Together, these meetings are known as the “Two Sessions.”

The move to delay it “underscores the gravity of the coronavirus epidemic,” according to the analysts at the NPC Observer blog. “Officially, the Council is reported to have been mainly concerned with pulling NPC delegates (over a third of whom are local officials) away from their epidemic control efforts,” the analysts said in a blog post, linking to a state media article.

Other analysts point out that it would be bad optics for the party to hold a huge meeting when all public gatherings are banned, and even worse to show thousands of cadres in masks. The party’s leaders already have faced criticism for their response to the outbreak.

The U.S. government evacuated hundreds of Americans on Sunday night from the Diamond Princess cruise liner, docked in Tokyo and quarantined since Feb. 5, and flew them out of Japan on two chartered planes bound for U.S. military bases – a carefully monitored process that will include another quarantine once they land.

Another 44 Americans aboard the Diamond Princess tested positive for coronavirus and will stay at hospitals in Japan as they recover, Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, told The Washington Post on Sunday.

At the same time, public health officials scrambled to determine whether passengers onboard a different cruise ship, the Westerdam, were exposed to the virus after an 83-year-old woman tested positive days after disembarking in Cambodia. The unexpected finding upended a basic assumption by several governments, including the United States, that the ship was virus-free, which motivated local and U.S. officials to allow passengers to disembark and depart for other cities and countries around the world.

As these cruise passengers and other travelers fan out across the globe, infectious-disease experts say the dynamic illustrates how the virus could be introduced into new communities in quiet ways. Until now, officials have been aggressively monitoring those who traveled to China and those who have had close contact with an infected person. But the Westerdam oversight demonstrates how travelers without obvious symptoms could slip through screening processes.

“This illustrates there is transmission occurring in unexpected places that we’re not aware of,” said Jeff Duchin, health officer and chief of communicable disease epidemiology section at Seattle and King County health department. “The virus is moving very quickly and silently and presents a real challenge to containment.”

Duchin noted, however, that the reported cases occurring in places outside China are not large-scale yet. Health officials still need to focus on where they can have the greatest impact on controlling the outbreak, he said, which is in China.

“But increasingly, we are seeing it pop up in other parts of the world and in other settings, and that makes it difficult for us as a country to know when someone who may have been exposed outside of China enters the United States,” Duchin said.

Health experts have warned that the coronavirus is difficult to contain precisely because symptoms are often mild and the coronavirus could replicate inside the human body and infect others for up to 14 days before showing symptoms at all.

As of Sunday, the World Health Organization has reported cases in 26 countries, the majority of which remain in mainland China. Chinese officials have tallied about 70,500 cases of the illness and 1,770 deaths. Outside of China, the WHO reports about 680 confirmed cases and three deaths.

Chinese officials said Sunday that they believed measures taken across the country to control the epidemic were paying off. Several cities in the central region have declared strict “wartime measures” that allow residents to leave their homes only several times a week and upon approval from neighborhood authorities.

Guards in Hubei are required to check identification 24 hours a day at the entrance to residential compounds, and driving is banned for all nonessential purposes under new regulations released Sunday.

The number of new cases across China, including in Hubei, has been falling, said Chinese National Health Commission spokesman Mi Feng, who noted that doctors in the hardest-hit province had broadened their diagnosis criteria for patients suspected of suffering from the disease and were able to treat them more quickly.

“The effects of our counter-coronavirus measures in every part of the country are already becoming apparent,” Mi said.

In Taiwan, authorities reported the first death Sunday, a man in his 60s with diabetes and hepatitis but no recent history of overseas travel, according to the state-run Central News Agency. Officials said they were still investigating how the man contracted the virus while living in the central part of Taiwan, which has so far recorded 20 confirmed cases across the island.

On Saturday, Cambodia’s health minister issued a statement urging the public to “not be overly afraid” but to take protective measures. That night, charter flights that were originally scheduled to take Westerdam passengers to Kuala Lumpur were canceled by Malaysian authorities.

The Westerdam was believed to have no infections onboard among the 2,200 crew and passengers who were stranded at sea for weeks as countries rejected their entry after a stop in Hong Kong, where they took on hundreds of new passengers.

The 83-year-old American woman, whose identity has not been disclosed, was among the relieved passengers who were let off the Westerdam on Friday and welcomed and embraced by Cambodian Prime Minister Hun Sen, who has downplayed the epidemic’s threat and described the decision to bring them onshore as an act of humanitarian goodwill. The ship had been stranded at sea for nearly two weeks and was running low on provisions after it was denied entry to Taiwan, Japan, the Philippines, Thailand and the U.S. territory of Guam.

U.S. Ambassador to Cambodia Patrick Murphy brought his family onto the cruise ship and posed for pictures on Saturday with American passengers. Murphy and other passengers did not appear to be wearing masks in photos shared on the embassy’s Twitter account.

Holland America, the cruise operator, said in a statement Sunday that no other passengers or crew who were on the ship have reported any symptoms of the coronavirus. About 1,000 people remain on the ship, with the rest on their way home.

Grant Tarling, Holland America’s chief medical officer, said in the statement that the company was working with health experts to contact national health authorities around the world to investigate and follow up with individuals who may have come into contact with the American woman found to carry the virus.

In Japan, U.S. passengers were faced with a difficult decision. They could stay on the Diamond Princess until Feb. 19, when the original quarantine is scheduled to lift, but risk being stuck in Cambodia and bound by commercial flight restrictions, or leave on the chartered flights to military bases in Texas and California – only to face another 14-day quarantine.

About 400 Americans were on the cruise ship when it docked in Japan, and the Japanese Defense Ministry said 300 of them disembarked Sunday night, The Associated Press reported.

The number of coronavirus diagnoses has continued to rise sharply among the 3,700 passengers and crew members originally on board. Japanese Health Minister Katsunobu Kato said early Sunday that the quarantined ship floating near Tokyo has 355 confirmed cases, or about 30% of the 1,219 people who have been tested. That represents one of the highest infection rates in the world.

“The degree of transmissibility on that cruise ship is essentially akin to being in a hot spot,” Fauci, who is also a member of the White House task force for the coronavirus, told CBS.

Canada, South Korea, Italy and Hong Kong announced Sunday that they would also arrange charter flights.

“He had not come to our house to live,” Daniel Wallace, his son-in-law, told me. “He had come to our house to die. The last thing he wanted to do was die at a hospital.”

Kellison was part of a striking trend: For the first time since the early part of the 20th century, more Americans are dying at home than in the hospital or a nursing home. This finding, included in a recent study by me and co-author Sarah Cross, is encouraging because the vast majority of Americans say they prefer to die at home. So this reflects that many more people are being able to achieve that goal.

But as more people die at home, it also means that much more responsibility falls on the shoulders of patients and their caregivers. Caregiver burden is a growing problem in America. As a doctor tending patients with heart failure, I am keenly aware of how hard managing care can be for both patients and family members.

Taking care of an ailing loved one can be exhausting physically and emotionally, and frequently caregivers lose sight of themselves. My study co-author used to work as a social worker and has seen many families struggle with managing a loved one at home. “Caregivers need to prioritize their own care,” she told me. “It isn’t selfish to take breaks, make time with friends, ask for help, look into respite options.”

After Kellison moved in with his daughter, he stayed mostly in the upstairs guest room, and for the last five months rarely, if ever, came downstairs. That physical separation was important for everyone.

“It was helpful that we delineated the house and our lives. We still went out and we still had people over,” Daniel Wallace said. “Sometimes he was part of that and sometimes he wasn’t.”

Making shared living space work is just one issue. If dying at home is important to someone, that person and their caregivers should think about – and prepare for in advance, if possible – other factors:

Perhaps most importantly, the person nearing the end needs to make clear that they want to die at home. Family, friends and medical teams need to know that. Physicians and nurses will frequently ask patients how they would like their end to be, particularly what types of intensive treatments they might or might not want. They rarely ask people where they would like to die, however.

Once at home, there are certain physical considerations worth noting: Many people have strong feelings about where in the house they would like to spend their last days – in a dark, quiet room, or looking out a window, or away from too much hubbub. Nearness to a bathroom is key. Sometimes, light remodeling, such as installing handrails in bathrooms or ramps, is helpful.

A person at the end of life will probably have feelings about who they want to spend time with – or who they don’t want – so it is important to discuss in advance who will provide caregiving, along with who might provide occasional backup for regular caregivers.

There are often community resources available as well, such as end-of-life doulas trained to care for the physical, emotional and spiritual needs of a dying person. Adaire Petrichor is one such doula. She said she “helps with rituals, ceremonies, legacy work and advice on nonmedical comfort care.”

Online resources are available through such organizations as Compassion & Choices. The Conversation Project can provide guidance for patients and their loved ones about what to expect in the final days.

Perhaps the most critical resource available for those wanting to die at home is hospice care. Hospice is covered by Medicare (and most other insurance) for patients with an expected life expectancy of less than six months. It is designed to help caregivers take care of a dying loved one at home with 24-hour call-in numbers to answer urgent questions, visits from hospice nurses, social workers and other staff. But home hospice does not provide full hands-on service, and caregivers still carry the bulk of the responsibility. While in many cases the care of the patient can be tougher than loved ones expect, most people find hospice guidance and support invaluable.

Wallace said hospice was key for taking care of his wife’s father after he moved in with them to die.

“Hospice was a way to bring a quality of life that he didn’t have before, because he couldn’t take care of himself and we couldn’t take care of him without hospice,” Wallace said. “If you need a wheelchair, they have that. If you need Haldol (an antipsychotic drug to treat end-stage delirium and agitation), morphine, they have it, and you can have it the next day.”

While the vast majority of hospice services are delivered at home, hospice care can also be provided in nursing facilities for dying patients who require more intensive medical care or don’t have other social supports.

Hospice is the primary reason more Americans are able to die at home today. Yet, only half of Americans who die receive hospice help. One reason may be that some people don’t ask for it because they think it is sending a depressing message to their ailing loved one or admitting what they may not want to acknowledge – that the person is in their last days.

“The obvious misconception is that it’s a death sentence,” Wallace said. But “it really is a quality-of-life sentence.”

Outside remote regions, most areas have multiple hospice agencies from which to choose.

Agencies can differ in how often nurses visit, what they might offer in crises and what equipment they provide, including hospital bed, oxygen tanks, wheelchairs. It is worth having a discussion about the support they’ll provide and other options before committing to a particular hospice provider.

With advances in public health, medicine and longevity, people now live longer with disabilities. Death is not just the terminal event in our mortal lives, but the final word of a story that can often take years to unfold.

Intermixed with periods of relative stability can be moments of terror as someone hits their final days. Physicians and other health-care providers need to prepare patients and families for these health shocks, such as worsening breathing for a patient with heart or lung disease or a pain crisis for someone with cancer.

Calling 911 when an end-of-life crisis hits initiates a cascade that can often lead to the hospital. This might be necessary if a patient has symptoms that caregivers at home feel unable to manage. For that reason, Cross said, “I recommend not making promises to a loved one such as ‘I promise I’ll always take care of you at home.’ When it becomes too much to manage at home, I’ve seen many caregivers racked with guilt for having ‘broken a promise.’ ”

Some endings can take a much more erratic course, common for those with heart or lung disease. This might be one reason our study showed that patients with cancer are more likely to be able to die at home than those with heart or lung disease.

One morning, a year after his father-in-law had moved in, Wallace went upstairs to check on him and unexpectedly found he had died.

“He did not present himself as dying when it happened,” he said. “We weren’t on death watch or anything like that.”

Some caregivers I have talked to feel uncomfortable with the idea of their loved one dying at home. Even though death has occurred at home for eons, the 20th century interrupted that historical legacy, and for many, it is a novel concept.

But for many, fulfilling a loved one’s wish to die at home provides a fitting and natural end to the story of that person’s life.

When I asked Wallace whether he viewed his house differently after his father-in-law died in it, he said: “It deepens my experience of being alive, to be in a house where someone has died. It’s a remarkable thing.”

– – –

Warraich is associate director of the Heart Failure Program at VA Boston Healthcare System and a cardiologist at Harvard’s Brigham and Women’s Hospital.

Malaysian Deputy Prime Minister Wan Azizah Wan Ismail told reporters Sunday that an 83-year old American passenger on the cruise liner tested positive for the coronavirus twice – once on Friday and once on Saturday – after she landed in Kuala Lumpur despite being screened earlier by Cambodian health officials.

https://www.washingtonpost.com/video/c/embed/7c89362b-5db8-400a-854e-e37aeb7dcdb0

“The results were the same. That is positive for the wife and negative for her husband,” Wan Azizah told reporters at a news conference, adding that Malaysia would now bar entry for all passengers from the cruise ship, according to Reuters.

The unexpected finding upends a basic assumption by several governments, including the United States, that the ship was virus-free and that passengers could be greeted at proximity without protective gear and allowed to travel.

The American woman, whose identity has not been disclosed, was among hundreds of relieved passengers who were let off the Westerdam on Friday and welcomed and embraced by Cambodian Prime Minister Hun Sen, who has downplayed the epidemic’s threat and described the decision to bring them onshore as an act of humanitarian goodwill.

The U.S. ambassador, W. Patrick Murphy, also brought his family onboard the cruise ship and posed for pictures on Saturday with American passengers. Murphy and other passengers did not appear to be wearing a mask in photos shared on the embassy’s Twitter account.

Disembarkation, which was set to continue over the weekend, was halted Sunday, according to Cambodian journalists at the scene.

On Saturday, Cambodia’s health minister issued a public statement urging the public to “not be overly afraid” but to take protective measures. On Saturday night, charter flights that were originally scheduled to take Westerdam passengers to Kuala Lumpur were canceled by Malaysian authorities.

As of Sunday, authorities worldwide have tallied roughly 69,000 cases of covid-19 and 1,669 deaths. The overwhelming majority of infections remain in mainland China, which reported 2,009 new cases on Saturday.

In Taiwan, authorities reported the first death on Sunday, a man in his 60s with diabetes and hepatitis but no recent history of overseas travel, according to the state-run Central News Agency. Officials said they were still investigating how the man contracted the virus while living in the central part of Taiwan, which has so far recorded 20 confirmed cases across the island.

Chinese officials said Sunday they believed that measures taken across the country to control the epidemic were paying off. Several cities in the central region have declared strict “wartime measures” that allow residents to leave their homes only several times a week and upon approval from neighborhood authorities.

Guards in Hubei are now required to check identification 24-hours a day at the entrance to residential compounds and driving is also banned for all nonessential purposes under new regulations released Sunday.

The number of new cases across China, including in Hubei, were falling, said Chinese National Health Commission spokesman Mi Feng, who noted that doctors in the worst-hit province had broadened their diagnosis criteria for patients suspected of suffering from the disease and were able to treat them more quickly.

“The effects of our counter-coronavirus measures in every part of the country are already becoming apparent,” Mi said.

The Westerdam was believed to have no infections onboard among the 2,200 crew and passengers who were stranded at sea for weeks as countries rejected their entry following a stop in Hong Kong where they took on hundreds of new passengers.

https://www.washingtonpost.com/video/c/embed/8c69ef04-cbfd-4251-9323-a12e167ad082

Health experts have warned that the coronavirus is difficult to contain precisely because symptoms are often mild and the coronavirus could replicate inside the human body and infect others for more than two weeks before showing symptoms at all.

The U.S. Embassy in Phnom Penh said Cambodian officials individually screened all disembarking passengers for fever with the help of embassy staff this week, and any passenger who reported feeling ill had received lab tests, all of which returned negative. The tests were processed by a lab trusted by the U.S. Centers for Disease Control, the U.S. Embassy said.

The Westerdam and another cruise ship, the Diamond Princess in Japan, are posing logistical and public health challenges for governments as they try to contain the spread of the disease known as covid-19 and repatriate citizens.

The United States prepared to evacuate American citizens from the Diamond Princess on Sunday as the number of coronavirus diagnoses continued to rise sharply among the 3,700 passengers and crew originally onboard.

Japanese Health Minister Katsunobu Kato said early Sunday that the quarantined ship floating near Tokyo now has 355 confirmed cases, or about 30 percent of the 1,219 people who have been tested so far. That represents one of the highest infection rates in the world.

Three Israelis on board have been found positive for the virus, according to the Israeli Health Ministry, but their condition is mild and they are now in a hospital in Japan. The ministry added that an expert physician has been sent to liaise with Japanese health officials.

The U.S. government-chartered flights comes days after public health experts warned that time spent on the Diamond Princess, which has been quarantined since Feb. 5, increases the risk of coronavirus exposure and Japanese authorities began letting some passengers disembark to complete their quarantine on land.

Two charter flights are scheduled to depart from Japan Sunday evening and bring roughly 380 evacuated Americans from the Diamond Princess to military bases in Texas and California, where they will be quarantined and monitored for an additional 14 days.

Canada, South Korea, Italy and Hong Kong announced Sunday they would also arrange charter flights.

Amid widespread shortages of protective equipment for health care workers in China’s Hubei province, Friday’s announcement highlighted the challenges Beijing faces as its overwhelmed heath care system tries to contain the epidemic.

At the same time, officials noted the infection rate among health care workers is in line with that of previous respiratory viruses, including the 2003 SARS outbreak. The total appeared to be a count of infections that have occurred over many weeks, rather than a sudden escalation of the crisis.

“This isn’t surprising, if I’m being honest,” said Saskia Popescu, senior infection prevention epidemiologist for Honor Health, a hospital system in Phoenix. “It is very, very easy to have failures in infection control.”

Michael Ryan, executive director of the World Health Organization’s Health Emergencies Program, said he believes the cases peaked in the third and fourth week of January and have declined since because of improved training and awareness.

“It’s a lower percentage than has occurred in other coronavirus outbreaks,” Ryan said. “Now that’s not a guarantee that it won’t change.”

A total of 1,716 Chinese medical providers were infected as of Feb. 11, 3.8 percent of the confirmed cases, Chinese health authorities said. Six have died. One health care worker in Singapore also was infected.

The Feb. 7 death of Li Wenliang, an ophthalmologist at Wuhan Central Hospital who had warned fellow medical school graduates in a private chat of an outbreak of the virus, prompted a national outpouring of grief and rage toward authorities. He died after being detained and released by police for speaking out.

By acknowledging the toll on health professionals, Beijing is trying to signal some transparency on a flash point issue, and letting ordinary people know officials share their sense of alarm.

“It might raise a red flag about how serious the situation is,” said Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations. “And hopefully that leads to a more effective government response.”

But Huang cautioned against seeing the figure as the final word on medical workers. “If it is coming from an official source, we have to take it always with a grain of salt,” he said.

Concerns about how medical personnel are faring in this crisis have been front and center from the start. Photos and video from Wuhan have shown exhausted doctors and nurses working in overflowing hospitals.

At Zhongnan Hospital in Wuhan, 40 health care workers were infected with the virus in January, according to a JAMA study. The majority worked in the general wards, but seven were assigned to the emergency room and two worked in the intensive care unit. In one case, a single patient infected more than 10 health care workers.

Still the toll on front line workers appears to be smaller than it was in other lethal coronavirus outbreaks. When SARS emerged in 2002, health care workers accounted for a fifth of the cases. A study of MERS infections from 2012 to 2018 found that health care workers made up a similar share – 415 of the 2,223 confirmed cases.

“Patients need to be wearing a mask. Physicians taking care of them need to be protected themselves – not only medical doctors or nurses, but people who work in the hospitals: the transporters, the person who is at the front desk. All these individuals are at risk,” said Charles Dela Cruz, a pulmonary and critical care physician at Yale University School of Medicine.

To date, covid-19, the disease caused by the new coronavirus, has caused more than 1,500 deaths, all but two in China, and 66,000 illnesses, with only 600 of those outside China. The United States has seen 15 cases and no fatalities.

Egypt’s Ministry of Health confirmed Friday that it had detected a case of coronavirus, the first known example of the outbreak in Africa. Health officials have worried about the virus reaching the continent because of its weak health care systems.

A spokesperson for the ministry, Khaled Megahed, said in a statement that a foreign national had tested positive for the coronavirus and the WHO had been notified.

Although the person had not shown symptoms, they were tested because of their travel history. The person was subsequently transported to a hospital and they are in stable condition under quarantine.

A number of people who came into contact with the patient have been tested for the virus, Megahad said. All tested negative, but they will be placed under 14-day quarantine as a precaution.

In Japan, meanwhile, the Health Ministry said Friday that 10 people evacuated from the quarantined Diamond Princess cruise ship in the port of Yokohama are in serious condition, with eight confirmed to have the new coronavirus. One of the other two is still awaiting test results.

Amid persistent criticism of its approach, the government said it would begin allowing some people who have tested negative for the virus to leave the ship and finish their quarantines on shore. Priority will be given to passengers over the age of 80 and those with existing medical problems, as well as people in windowless cabins, Health Minister Katsunobu Kato said.

So far, 218 people aboard the ship have tested positive for the virus out of 713 who were assessed. The government says it plans to step up testing in a bid to examine everyone on board before the quarantine ends Feb. 19.

A quarantine officer involved in screening passengers also fell sick. The health ministry said he did not follow proper procedures, wiping away sweat with his gloves and reusing a mask he had worn earlier, Japan’s national television network, NHK, reported.

The U. S. Centers for Disease Control and Prevention, moving forward with its plan to boost disease surveillance, named the five cities where labs will begin testing flu specimens for the coronavirus. They are Chicago, Los Angeles, New York, San Francisco and Seattle.

The public health labs are part of CDC’s existing flu surveillance network, which monitors seasonal influenza and hospitalizations. Specimens that are negative for flu will be tested for coronavirus, the CDC’s Nancy Messonnier said. Testing will be expanded to additional labs in coming weeks.

Lab tests that confirm additional coronavirus cases could allow public health authorities to take actions to forestall outbreaks, such as canceling large gatherings or calling for telemedicine and telework.

At the same time, flu illnesses have risen sharply in recent weeks, Messonnier said, complicating efforts to determine whether an illness is caused by the new coronavirus or the flu virus. So far this season, at least 26 million people in the U.S. have contracted the flu, including 14,000 who died and 250,000 who were hospitalized.