State Department recommends all Americans avoid cruise ships

WASHINGTON - Governments intensified their efforts Sunday to combat the global spread of the novel coronavirus as Saudi Arabia followed Italy in enacting new travel restrictions, Iran suspended flights to Europe, and the United States, where the number of cases topped 500, warned citizens against cruise travel.

Uncertainty continued to permeate the response effort, however, amid muddled directives from the Trump administration and reports of some patients unable to access testing. A virus-stricken cruise ship made its way to California to dock - only for Housing and Urban Development Secretary Ben Carson to decline to discuss the details of the federal response plan during a national television interview.

The Department of Health and Human Services said later Sunday that the Grand Princess cruise ship's more than 3,500 passengers, at least 21 of whom have tested positive for the coronavirus, will be quarantined in California, Texas and Georgia.

Some White House officials privately believe the number of U.S. cases will double - or more - in the next 48 hours. At least 21 people have died.

As the number of cases rises nationwide, public health officials are getting a better sense of the scale of the crisis, Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said Sunday. The outlook, he said, is worrisome.

“Unfortunately, that better sense is not encouraging, because we’re seeing community spread,” Fauci said in an interview on NBC’s “Meet the Press.”

He echoed the advice of the Centers for Disease Control and Prevention for older people and those with underlying health conditions to refrain from traveling by cruise ship or air.

"If you're a person with an underlying condition . . . particularly an elderly person with an underlying condition, you need to think twice about getting on a plane, on a long trip - and not only think twice, just don't get on a cruise ship," he said.

The State Department on Sunday afternoon went one step further than Fauci, issuing a statement recommending that all U.S. citizens avoid taking cruises. The agency noted that other countries with strict screening procedures have stopped passengers on cruise ships from disembarking or subjected them to lengthy quarantine periods.

Over the weekend, some countries took increasingly drastic measures in an effort to contain the virus.

In Iran, the epicenter of a wider outbreak of the coronavirus across the Middle East, 49 new deaths and more than 700 new cases were reported Sunday, as authorities urged citizens to stay home and avoid travel between cities.

The country’s flagship carrier IranAir suspended flights to Europe because of “restrictions” placed on the airline, state media reported, citing Iran’s Civil Aviation Organization.

Saudi Arabia suspended travel to and from a key eastern province and ordered businesses and government offices there closed after confirming four new cases on Sunday, bringing the total number of infections in the country to 11. Authorities temporarily restricted traffic in and out of Qatif province, state media reported, quoting an official at the Interior Ministry.

And in Italy, authorities have launched a plan to lock down large swaths of the country's hard-hit north, where virologists said they have traced the epidemic to an outbreak at a car parts manufacturer in Germany. Experts believe an infected employee from Shanghai visited the manufacturer and then a person infected with the virus probably traveled from Germany to the region of Italy hit hardest by the virus in late January.

Egypt, meanwhile, had its first death related to the virus on Sunday. A 60-year-old German tourist died in a Red Sea hospital after being infected, the country’s Health Ministry said in a statement.

His death came a day after Health Ministry officials announced dozens of new cases of the virus on a Nile cruise ship, though it was not immediately known whether the German tourist was a passenger on the ship.

Some reports have also emerged of Americans being unable to access coronavirus testing because of decisions made at the local level.

In a Facebook post shared widely on Saturday, Maggie McDow, 46, a District of Columbia resident, said that to her alarm, the D.C. Department of Health overruled an emergency room doctor treating her Friday at George Washington University Hospital, preventing her from being tested for the virus.

"It's really worrisome to me when a doctor feels you should have a test and someone's overruling them," McDow said in a phone interview Saturday while self-quarantined with achiness and chills. "To me that's just wrong."

McDow had traveled to Thailand and through the airport in Seoul on a recent trip. A top Health Department official said McDow did not qualify for a test because airport exposure, even in a country such as South Korea with community spread of the disease, does not warrant testing.

The response to the crisis at the federal level has also prompted criticism, with some arguing that Trump administration officials - including the president himself - have delivered mixed messages.

In an appearance Sunday on ABC News' "This Week," Carson declined to discuss the details of the federal plan for quarantining the passengers of the Grand Princess cruise ship. Carson would say only that Vice President Mike Pence and CEOs of major cruise lines met Saturday and would come up with a plan "within 72 hours of that meeting."

Later Sunday, HHS identified the four federal facilities to which the passengers will be transferred - an announcement that prompted concern from some officials in San Antonio, which has hosted more than 100 evacuees and is expected to receive more.

In his "This Week" appearance, Carson also advised Americans to "go about your normal daily activities if you are healthy," and "if you are not healthy, think very seriously about attending places where there are crowds."

Some experts have advised that limiting exposure to crowds is a smart step for all Americans, not just unhealthy ones, to take, and several organizations have reassessed their plans for conferences and large-scale events in recent weeks. The AFL-CIO, the largest group of labor unions in the country, announced Sunday that it is canceling its presidential forum, which had been scheduled for later this week in Orlando.

Josh Michaud, associate director for global health policy at the Kaiser Family Foundation, said in a phone interview Sunday that studies of previous large flu outbreaks suggest that major "social distancing" measures can limit the spread of infectious disease. These steps include closing schools for an extended period, canceling large gatherings such as conferences and having people work from home.

"Those kinds of social distancing measures, if taken early and of sufficient duration, were very effective in reducing the transmission of and mortality from influenza, and eased the burden on the health system," Michaud said.

But he added that the fact that there's been a delay in testing is "holding up the decision-making process" on whether to impose such precautions.

The campaigns of Sen. Bernie Sanders, I-Vt., former vice president Joe Biden and President Donald Trump have all said they will move ahead with plans to hold public events despite mounting concerns about the spread of the coronavirus. Sanders also plans to hold a roundtable Monday with public health experts in Detroit to discuss the virus and how the country should address it.

Michaud noted that the candidates might soon find themselves facing obstacles, however, if local officials decide to limit crowds from gathering in possible coronavirus hotspots.

"Campaigns should be considering alternatives for massive campaign rallies, because they might be a victim of these measures," he said.

The Washington Post’s Erin Cunningham in Istanbul, Loveday Morris in Berlin, Sudarsan Raghavan in Cairo, and Josh Dawsey, Jenna Portnoy and Lateshia Beachum in Washington contributed to this report.