ROME — From the marbled halls of Italy to the wheat fields of Kansas, health authorities are increasingly warning that the question isn't whether a second wave of coronavirus infections and deaths will hit, but when — and how badly.
As more countries and U.S. states chaotically re-open for business — including some where infection rates are still rising — managing future cases is as important as preventing them.
In India, which partly eased its virus lockdown this week, health authorities scrambled Wednesday to contain an outbreak at a massive market. Experts in hard-hit Italy, which just began easing some restrictions, warned lawmakers that a new wave of virus infections and deaths is coming. They urged intensified efforts to identify possible new victims, monitor their symptoms and trace their contacts.
Germany warned of a second and even a third wave, and threatened to re-impose virus restrictions if new cases can't be contained. German Chancellor Angela Merkel was meeting Wednesday with the country's 16 governors to discuss further loosening restrictions that have crippled Europe's largest economy.
"There will be a second wave, but the problem is to which extent. Is it a small wave or a big wave? It's too early to say," said Olivier Schwartz, head of the virus and immunity unit at France's Pasteur Institute.
Many areas are still struggling with the first wave of this pandemic. Brazil for the first time locked down a large city, the capital of Maranhão state. Across the ocean, the number of confirmed coronavirus cases in Africa has shot up 42% in the past week and infections are expected to surpass 50,000 on Wednesday.
An Associated Press analysis, meanwhile, found that U.S. infection rates outside the New York City area are in fact rising, notably in rural areas. It found New York's progress against the virus was overshadowing increasing infections elsewhere.
"Make no mistakes: This virus is still circulating in our community, perhaps even more now than in previous weeks," said Linda Ochs, director of the Health Department in Shawnee County, Kansas.
The virus is known to have infected more than 3.6 million and killed more than 251,000 people, according to a tally by Johns Hopkins that all experts agree is an undercount due to limited testing, uneven victim criteria and deliberate concealment by some governments.
The U.S. has seen over 71,000 deaths amid its 1.2 million infections, and Europe has endured over 144,000 reported coronavirus deaths. Behind each of those vast numbers is a family in pain.
"Burying both parents at the same time? It's hard," said Desmond Tolbert, who lost his mother and father in rural southwest Georgia. Because they had the virus, he couldn't be with them when they died.
U.S. President Donald Trump, with his eye on being reelected in November, is pushing hard to ease state stay-at-home orders and resuscitate the U.S. economy, which has seen over 30 million workers lose their jobs in less than two months. Trump is expected to wind down the country's coronavirus task force, possibly within weeks, despite concerns that states aren't being careful enough as they reopen.
A century ago, the Spanish flu epidemic's second wave was far deadlier than its first, in part because authorities allowed mass gatherings from Philadelphia to San Francisco.
As Italy's lockdown eased this week, Dr. Silvio Brusaferro, president of the Superior Institute of Health, urged "a huge investment" of resources to train medical personnel to monitor possible new cases. He said tracing apps — which are being built by dozens of countries and companies and touted as a possible technological solution — aren't enough to manage future waves of infection.
"We are not out of the epidemic. We are still in it. I don't want people to think there's no more risk and we go back to normal," said Dr. Giovanni Rezza, the head of the institute's infectious disease department.
In Germany, authorities may reimpose restrictions on any county that reports 50 new cases for every 100,000 inhabitants within the past week.
Lothar Wieler, head of Germany's national disease control center, said scientists "know with great certainty that there will be a second wave" of infections but said Germany is well-prepared to deal with it. The country has been hailed for testing widely and has suffered four times fewer deaths than Italy or Britain, which both have smaller populations.
Britain has begun recruiting 18,000 people to trace contacts of people infected. British officials acknowledge that they should have done more testing and tracing earlier and could learn from South Korea, which brought its outbreak under control by rigorously testing, tracing and isolating infected people.
South Africa, which has years of experience tracking HIV and other infections, is already testing and tracing widely. Turkey has an army of 5,800 teams of contact tracers who have tracked down and tested nearly half a million people linked to infected cases. Israel plans to conduct 100,000 antibody tests to determine how widespread the coronavirus outbreak has been and prevent a second wave.
India was concentrated on the immediate drama around the market in the southern city of Chennai, which is now tied to at least 1,000 virus cases. Another 7,000 people connected to the now-shuttered Koyambedu market are being traced and quarantined. Experts are worried about a health catastrophe in a country of 1.3 billion people with an already stressed medical system.
New confirmed daily infections in the U.S. exceed 20,000, and deaths per day are well over 1,000, according to the Johns Hopkins tally. And public health officials warn that the failure to lower the infection rate could lead to many more deaths — perhaps tens of thousands — as people venture out and businesses reopen.
"The faster we reopen, the lower the economic cost — but the higher the human cost, because the more lives lost," New York Gov. Andrew Cuomo sai d. "That, my friends, is the decision we are really making."
Trump acknowledged the toll but argued that keeping the U.S. economy closed carries deadly costs of its own, such as drug abuse and suicides.
"I'm not saying anything is perfect, and yes, will some people be affected? Yes. Will some people be affected badly? Yes. But we have to get our country open and we have to get it open soon," he said during a visit to Arizona in which he did not don a face mask.