Bird flu shot to the top of a lot of people's worry lists on November 1, 2005 when President George Bush announced his request for $7.1 billion in federal funding to prepare for the possibility of a worldwide avian flu pandemic. The next day, the Department of Health and Human Services issued its massive Pandemic Influenza Plan, which explains the assumptions scientists have made to assess the threat and outlined plans for a coordinated response among all government agencies down to the local level.

How Worried Should We Be?

Certainly a worldwide flu pandemic is worth worrying about. The HHS plan outlines two potential scenarios for a major U.S. outbreak: in the worst-case scenario, 90 million people, or 30 percent of the population, would become ill, and 1.9 million would die. At the other end of the scale, assuming a less virulent form of flu, the same number would become infected, and 209,000 would die.

"People need to understand that it is a virtual certainty that there will be a flu pandemic at some point," said Dr. Henry Bernstein, a pediatrician and member of the American Academy of Pediatrics' committee on infectious diseases. "It's not a question of if but when... We need to be sure that we recognize the special needs of children in the event."

The scientists expect that school-age children would have the highest rates of infection—40 percent—but that older people would have higher mortality rates.

Epidemic, Pandemic: What's the Difference?

Seasonal influenza epidemics are an annual reality: every year about 200,000 people are hospitalized in the U.S. from complications of the flu, and about 36,000 of them die—most of them elderly or very young children.

Influenza pandemics are, thankfully, pretty rare. According to the World Health Organization, a pandemic can start "when three conditions have been met: a new influenza virus subtype emerges; it infects humans, causing serious illness; and it spreads easily and sustainably among humans." The key is that a pandemic results from the emergence of a new flu strain to which humans have no resistance.

Behind the current high level of concern over bird flu is the H5N1 virus: a strain that is firmly established in Asia and spreading widely in domestic and wild bird populations. It has infected more than 100 humans, killing more than half of those infected. (WHO keeps close track of human infections with H5N1 and updates the information every day or so.) So H5N1 has already met two of the WHO's three conditions.

What Next?

The release of the federal government's plan on November 2 offers state and local authorities a starting point for getting ready—and as the plan makes clear, the quality of the local response to a pandemic will be key.

"The public health agencies—your local public health departments—are the front line. CDC can say certain things about increasing production, making vaccines available. But when it comes to understanding community attitudes and developing distribution approaches, public health departments are critical," said Dr. Thomas Burke, a professor of international health and epidemiology at the Johns Hopkins Bloomberg School of Public Health.

"What needs to happen now is a lot of discussion at the community level, public health agencies talking broadly about what the issue is, and what are some possible action steps," said Dr. Georges Benjamin, executive director of the American Public Health Association.

For example, said Benjamin, "It could happen that we are going to have 'snow days,' days when we ask people voluntarily to stay home, to limit people's exposure to each other. In that event, how do you get to those people who can't get out, such as elderly shut-ins? And how do you deal with schools?"

Benjamin recommended that school communities start discussing now how they might handle being shut down for days or weeks—could existing emergency plans be put into play? Could they consider providing distance learning services? In the near term, they should be considering what their policies will be towards kids who come to school feeling sick.

Meanwhile, local governments are being urged to update their quarantine laws (rarely used now in the age of vaccinations), and coordinate plans with utilities to keep phones working and power flowing, etc.

A Communications Challenge

One key to a successful flu pandemic strategy will be public compliance with government directives. That is an area where public health experts see huge challenges. "It won't be like asking people to line up for their polio vaccines in the 50s," noted Burke. "There is a lot more diversity in the population, there are a lot more sources of information—our communications challenges are going to be more difficult than ever."

According to Benjamin, public health agencies in Maryland and Washington, DC publish flyers in 15 languages urging parents to vaccinate their children against various diseases. A public information campaign about avian flu will have to be carried on in many more languages and through a wide variety of outlets.

Benjamin noted that in communities that are particularly mistrustful of government, even seasonal flu shots are regarded with suspicion. "There are urban legends. I've heard 'There's something in the flu shot, you can get HIV from it,' that kind of thing," said Benjamin. The flip side of that suspicion, he said, is a fear that low-income or minority communities might not receive a bird-flu vaccine, if and when one is developed and needed, on time or in adequate amounts. "We are concerned about access," said Benjamin. "We have 46 million people without health insurance in this country, and that leads to reasonable concerns about equity."

Focusing on Kids

Bernstein noted that planners need to really pay attention to the health needs of children, both in terms of teaching them certain behaviors to reduce their risk of getting ill, and in terms of being prepared to care for them if they do become sick.

"We know that kids are particularly at risk, at certain ages, of influenza infection and its complications," says Bernstein. "And we know that they have unique needs in terms of their care... It's not enough to just open up a children's ward, you need the resources to care for children. They need more help with more things, so there are different personnel needs, for instance."

He noted that any vaccine or medication intended for use by young children needs to be in a form that they can consume—perhaps a palatable liquid or in the form of an injection or spray.

And Bernstein also pointed out that young children are likely to behave in ways that promote the spread of infection: forgetting to wash their hands, or skimping on the soap; sharing sippy cups; sneezing without putting an elbow in front of their mouths; wiping their noses on the back of their hands or their sleeves.

Neighborhood groups "should be thinking about this now," said Bernstein. "Schools and communities will need to practice what to do—like fire drills. That kind of exercise would be very helpful. This calls for the ultimate in collaboration."

What Individuals and Families Can Do

Bernstein recommends that anyone who would usually be advised to have a flu shot should certainly do that this year. The shot probably won't provide protection against a mutated form of avian flu, but it will reduce the chances of becoming sick with regular flu, which can lower resistance and leave a person weaker and more vulnerable to complications.

Hand washing "is absolutely positively the best thing we can do. You can never do it enough," said Bernstein. Parents and others who care for toddlers and preschoolers should demonstrate good hand washing techniques, and supervise kids' efforts—lots of soap, lots of rubbing, lots of rinsing, hot water—and get after kids to wash their hands throughout the day.

Bernstein was emphatic that families "absolutely should not" try to obtain Tamiflu or any other anti-viral medication such as Relenza to use in the event a flu pandemic does break out. For one thing, there is no guarantee that these medicines will be effective, said Bernstein. For another, they are strong drugs with side effects that need to be used appropriately. He warned that people could easily mistake a bad cold for a case of the flu, and take the medicines at the wrong time.

However, the most compelling argument against personal stockpiling of Tamiflu is that it risks creating a shortage of the medicine to use to control an outbreak.

This is another area where public mistrust of government can create problems, noted Burke. "I think it is hard for people right now to feel reassured that when the need arises, they will be able to obtain the necessary drugs," he said. That attitude has strengthened since Hurricane Katrina. "People think, 'The government isn't going to be able to look out for me, I have to look out for myself.'"

A Solid Beginning

Despite the challenges, the experts we spoke to said the government's plan provides a solid foundation for preparing for a pandemic.

And, said Bernstein, the attention could provide the push we've needed to improve flu vaccination rates generally. "That's one very positive thing that could come out of all this. Our rates of immunization against the flu, every year, are pretty bad—we could be doing a lot better. If this raises the awareness in families about making sure all six-to-23-month olds get their flu shot—that's great."