The US health system is struggling to come to grips with COVID-19. Now, it’s reporting the highest fatality rate in the world.

A rebel doctor defied Donald Trump by warning the public about the coronavirus before the US President had a chance to play it down.

Mr Trump’s own health officials decided late last month that when the President returned from a trip to India they would tell him he had to be more blunt about the dangers of the outbreak.

However, Dr Nancy Messonnier, the director of the National Centre for Immunisation and Respiratory Diseases at the Centres for Disease Control and Prevention, couldn’t wait that long.

So at midday on February 25, as Mr Trump was boarding Air Force One in New Delhi for his flight home, she held a conference call with reporters across the US with a worrying message.

She warned that life was about to change in the US. Schools might have to close, conferences could be cancelled, businesses might make employees work from home.

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“We expect we will see community spread in this country,” she said. “It’s not so much a question of if this will happen anymore, but rather more a question of exactly when this will happen and how many people in this country will have severe illness.”

By the time Mr Trump landed in the US, it was too late for him to play down the outbreak. It was all over the news and the stock markets had begun to tumble.

Now, the US death toll from the virus has climbed to at least 21, with all but three victims in Washington state. The number of infections swelled to more than 500, scattered across the US.

Dr Anthony Fauci, the National Institutes of Health’s allergy and infectious diseases chief, said on Sunday that widespread closure of a city or region, as Italy had done, was “possible”.

“You don’t want to alarm people, but given the spread we see, you know anything is possible, and that’s the reason why we’ve got to be prepared to take whatever action is appropriate to contain and mitigate the outbreak,” Dr Fauci told Fox News.

US Surgeon General Jerome Adams said communities would need to start thinking about cancelling large gatherings, closing schools and letting more employees work from home as many companies have done in the Seattle, Washington area amid an outbreak at a care home that has killed 17.

Oregon Governor Kate Brown declared a state of emergency on Sunday after the number of confirmed cases there doubled from the previous day to 14.

Overnight, politicians in California tried to reassure the public that none of the passengers from a ship carrying people with the virus would be released before undergoing a 14-day quarantine.

Federal, state & local govts w/ public health partners & local communities continue to work together responding to #COVID19. All of us have a role to play in keeping ourselves, families & communities safe. See Preventing COVID-19 Spread in Communities: https://t.co/2w7kyMo89k pic.twitter.com/jDW8KYoXMD — Dr. Nancy Messonnier (@DrNancyM_CDC) March 5, 2020

The Grand Princess, carrying more than 3500 people from 54 countries, is expected to dock on Monday in Oakland, in the east San Francisco Bay, and was idling off the coast on Sunday as officials prepared a port site.

Those needing acute medical care will come off first.

“This is a time that we must be guided by facts and not fears, and our public deserves to know what’s going on,” Mayor Libby Schaaf said.

Mr Trump on Saturday said he wasn’t worried about the coronavirus getting closer to the White House after the first case in the nation’s capital was confirmed over the weekend. Officials also said an attendee of a recent political conference where Mr Trump had spoken also tested positive for the virus.

“No, I’m not concerned at all. No, I’m not. We’ve done a great job,” Mr Trump said.

– With wires