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Another 1918?

Despite preparations, a flu pandemic could still kill millions of Americans.

ON MONDAY, the Department of Health and Human Services released a progress report on its preparations for a flu pandemic in the United States. Not stressed, but nevertheless clear, was how much the country would rely on antiviral drugs such as Tamiflu, a drug that can reduce the severity of flu symptoms, to treat Americans while new vaccines were developed. Public health authorities are frantically stockpiling Tamiflu, and they hope to have more than 50 million courses of antiviral medication on hand by the end of 2008 to administer in the event of an outbreak.

But a report released by the World Health Organization earlier this month said that strains of the H5N1 "bird flu" virus -- a likely candidate for mutation into a pandemic flu -- might be developing resistance to Tamiflu and other antivirals. The influenza virus is unpredictable and quick to mutate. No one knows how, or how fast, the bird flu virus will change, so no one knows if the reported cases of Tamiflu resistance will remain isolated or if the virus will become increasingly more resistant to standard antivirals -- as it has with other drugs. But the country faces the possibility that its reserve of Tamiflu might not do much to counter a pandemic flu.

The federal government is also collecting doses of vaccines that protect against existing strains of the bird flu virus, though on a much smaller scale than its purchase of Tamiflu. These shots, the HHS report said, might eliminate or ease symptoms caused by new forms of the virus. But the WHO report was pessimistic about the effectiveness of the vaccines against strains of the virus they were not designed to fight.

In other words, if a pandemic flu began spreading tomorrow, the government's most effective strategies for saving lives could be old-fashioned quarantine and public education, techniques akin to those used during the great flu pandemic of 1918. It is not surprising, then, that the federal government currently estimates that as many as 2 million people could die if a virulent and contagious strain of flu hit the United States.

Given the capriciousness of the virus, says Columbia epidemiologist Stephen S. Morse, the government has "no silver bullet" in its arsenal. But HHS should consider investing heavily in technologies such as the reverse genetic engineering of flu vaccines, a process that promises to speed up vaccine production dramatically. The federal government should also focus more on aiding the World Health Organization's efforts to monitor avian flu and to improve the health infrastructure in Southeast Asia. Added American assistance to the understaffed WHO in Indonesia, Thailand and Vietnam could save many more American lives than 50 million courses of antivirals.