ISSUE REPORT FACING THE FLU: From the Bird Flu to a Possible Pandemic, Why Isn’t America Ready? TRUST FOR AMERICA’S HEALTH IS A NON-PROFIT, NON-PARTISAN “WHETHER NATURALLY OCCURRING OR INTENTIONALLY INFLICTED, MICROBIAL AGENTS [INFECTIOUS DISEASES] CAN CAUSE ILLNESS, DISABILITY, AND DEATH IN INDIVIDUALS WHILE DISRUPTING ENTIRE POPULATIONS, ORGANIZATION DEDICATED TO ECONOMIES, AND GOVERNMENTS. IN THE HIGHLY INTERCONNECTED AND READILY TRAVERSED ‘GLOBAL SAVING LIVES BY PROTECTING VILLAGE’ OF OUR TIME, ONE NATION’S PROBLEM SOON BECOMES EVERY NATION’S PROBLEM AS GEOGRAPHICAL T H E H E A LT H O F E V E RY AND POLITICAL BOUNDARIES OFFER TRIVIAL IMPEDIMENTS TO SUCH THREATS.”1 COMMUNITY AND WORKING TO – 2003 Institute of Medicine report: Microbial Threats to Health: Emergence, Detection, Response MAKE DISEASE PREVENTION A NATIONAL PRIORITY. INTRODUCTION B etween 10 and 20 percent of the U.S. population is estimated to contract influenza annually. Each year, it is responsible for approximately 36,000 deaths in this country.2 However, the nation lacks a unified and effective flu management strategy. The recent emergence of avian influenza, A second strain of bird flu, discovered in two commonly referred to as “bird flu,” in at least flocks of Delaware poultry and four New 10 Asian nations, has further complicated the Jersey live chicken markets in February ACKNOWLEDGEMENTS: national and international flu response activ- 2004, has not spread to humans.4 However, This report is supported by a ities this season. It has killed 20 individuals as its emergence demonstrates that the impact grant from The Robert of February 16, 2004 and disrupted of avian influenza is not limited to Asia. In Wood Johnson Foundation economies worldwide. The genetic makeup addition to flu’s potential as a looming (RWJF). The opinions of this strain of influenza, specifically its health crisis, the recent ban on U.S. poultry expressed in this report are potential to exchange genes with a human imports enacted by numerous nations illus- those of the authors and do flu virus, has public health officials particu- trates the outbreak’s impending toll on the not necessarily reflect the larly worried about the emergence of a dev- nation’s economy. As a result, containment views of RWJF. astating influenza pandemic, a worldwide dis- efforts and preparedness planning must be ease outbreak, capable of causing chaos and afforded the highest national priority. FEBRUARY 2004 casualties in the hundreds of thousands.3 While the U.S. public health community has by-disease brand of thinking that has charac- reacted quickly by destroying infected flocks terized the American public health system in Delaware, quarantining surrounding over recent decades would put the nation’s farms, enacting Asian bird importation bans, health and safety in a tenuous position. dispatching teams of expert epidemiologists In the midst of the current flu outbreak and to Southeast Asia, and harnessing interna- the emergence of avian influenza in Asia, Trust tional media attention to benefit public for America’s Health (TFAH) examines signif- awareness,5 the unsettling fact remains: the icant flu-related questions in this issue paper stateside emergence of a pandemic flu would and recommends actions that public health cripple the resources of a U.S. public health officials should take to better prepare for the system already stretched too thin. The sys- threat flu poses to the country every year. tematic under-funding and narrow, disease- I. While this season's flu outbreak seemed to receive more attention than in previous years, why can't health officials determine if more Americans actually contracted the flu than usual? It was difficult to say if this Currently, there is no system in place to and we’ve asked them to consider official- year’s childhood death toll track and count the number of flu cases in ly making influenza deaths among chil- from the flu was higher than the country, which makes determining its dren a reportable condition in the long levels of severity a serious challenge. The run...In general, we have a very collabo- average, because they “don’t Centers for Disease Control and rative agreement with these experts, and have detailed, accurate Prevention (CDC) does not require states we often come to close agreement in a information on the number to report influenza cases or even influenza rapid timeframe when something is as of children who die every deaths. CDC requests that states and important as this.”7 year from influenza specifi- health workers voluntarily report flu cases A strong public health defense begins with cally because it hasn’t been and particularly deaths. effective disease surveillance capabilities. A a reportable illness.”6 Without tracking, it is difficult to develop comprehensive disease tracking system and evaluate containment and prevention monitors the occurrence of disease and can – Dr. Julie Gerberding strategies because there is no reliable or help inform the rapid identification of out- Director of the CDC consistent information available. breaks, corresponding response protocols, amounts and types of vaccines needed, and On December 19, 2003, during a telebrief- ongoing prevention strategies. ing, Dr. Julie Gerberding, Director of the CDC, referred to the nation’s flu manage- The emergence of the strain of bird flu ment as a “complex, multijurisdictional demonstrates the heightened need for problem.” tracking information to help prepare and contain flu management efforts. Due to the During a January 8, 2004 telebriefing with interconnectivity of the contemporary reporters, Dr. Gerberding stated: world, it is imperative that nations rapidly I “One of the things that we do routinely is disclose any information related to suspect- work with our partners in states to help ed cases of avian influenza and that nation- get consistency about reportable condi- al boundaries do not trump global con- tions. So we already have engaged the cerns. Chinese officials were slow to individuals in the Council of State and acknowledge and inform the world of the Territorial Epidemiologists -- or CSTE -- SARS emergence in the Guangdong who are generally the people in states province in 2003, needlessly delaying the who are the experts in disease reporting, arrival of expert epidemiologists who even- 2 tually helped control the virus. Similarly, In order for critical surveillance systems to Thai health officials were slow to disclose live up to the national standard all the illness and eventual death of several Americans deserve, CDC needs to be pro- patients due to the avian flu in January vided the resources to effectively administer 2004. Chinese officials have promised and oversee such a network; the current openness in the nation’s battle against bird strategy of relying on “surveillance by con- flu, but say “parts of its animal disease pre- sensus” of outside committees does not vention system are weak and vulnerable.”8 afford sufficient jurisdictional authority. II. How is the severity of a flu outbreak determined? There are a number of variables that deter- the Spanish flu, killed 550,000 Americans in mine the severity of an influenza outbreak, ten months and 30 million people world- most notably, the specific genetic makeup of wide. A similar outbreak today could inflict the influenza strain. Typically, the “flu sea- equal damage -- a toll that even a severe son” coincides with the winter months in bioterrorism attack is unlikely to reach. the United States and afflicts 10-20 percent Recent findings have discovered that the of Americans each year.9 The current “bird strain of flu behind the 1918 pandemic was flu” in Asia is particularly pathogenic, as evi- more avian than originally believed; a fur- denced by the mortality rate within birds ther indication of the importance of dealing and humans.10 decisively with the present bird flu out- breaks in Asia and the United States.13 The ultimate severity of any flu outbreak depends on the genetic form of the predom- In the 20th century, two other notable flu inant virus. True pandemics emerge when pandemics illustrated the devastating poten- different strains of influenza trade genes tial of influenza in the United States. In within a “vessel” organism carrying multiple 1957 and 1958, an outbreak of influenza strains. If the current avian influenza mixed spread from China across the globe, killing with an existing human influenza strain, the approximately 70,000 in the U.S. A decade resultant blend would prove a potent virus later, 34,000 were killed in the U.S. as a wave that humans have no natural immunity of “Hong Kong” flu circulated in 1968 and against.11 As a result, the world public health 1969.14 Based on historical trends and pro- community is treating the avian influenza jections, virologists and epidemiologists outbreak with extreme trepidation. speculate a new flu pandemic will emerge three or four times each century.15 The disclosure that the virus has possibly been discovered in pigs is a dangerous While medical care is significantly advanced development -- the pig’s immune system is from generations ago, today’s high volume of similar to humans, making them an “ideal international travel, increased elderly popu- vessel for mixing genes from the bird flu lation, and the bird flu’s demonstrated capac- pathogen and the human influenza virus.”12 ity to affect children and the infirmed would make the arrival of a pandemic flu a severe The outbreak of pandemic flu that hit the test for the nation’s public health system. United States in 1918, often referred to as 3 III. Why did the vaccines run out and prove ineffective this flu season? The creation of a vaccine to combat flu sea- 2003-2004, the strains predicted vary slightly son is an annual “best guess” by virologists. from the real-world strains that emerge. The influenza vaccine available each year is The vaccine’s demand has been higher than carefully engineered to respond to the par- expected this flu season, due to factors rang- ticular strains of flu most likely to emerge ing from the season’s demonstrated viru- based on projections and prior outbreaks’ lence to increased media attention on genetic makeup. Some years, including emerging epidemics. “PRODUCTION OF INFLUENZA VACCINES IS A COMPLEX PROCESS THAT REQUIRES MANY STEPS, INCLUDING SELECTION OF SUITABLE VACCINE VIRUSES, GROWTH OF THESE VIRUSES IN EGGS, AND TESTING TO ENSURE SAFETY AND PURITY OF THE VACCINE. RECOMMENDATIONS ABOUT WHICH STRAINS SHOULD GO INTO THE VACCINES FOR THE UNITED STATES ARE BASED ON YEAR-ROUND SURVEILLANCE AND ARE TYPICALLY MADE IN FEBRUARY FOR VACCINE THAT WILL BE USED IN THE FOLLOWING SEASON.”16 – CDC, Questions & Answers: The 2003-2004 Flu Season Over the course of the twentieth century tries. Public health organizations must also and into the twenty-first, vaccines have been concentrate upon continuing education developed and systematically administered about the value of immunization and the to eliminate many devastating infectious dis- horrible impact of the diseases they prevent, eases and drastically reduce the impact of particularly where segments of the public others. Moreover, immunization programs are either complacent or ill-educated con- are incredibly cost-effective; every public cerning risks and benefits. and private dollar spent on immunization Controlling and treating avian influenza generates exponential return on investment poses a challenge for the public health in the form of savings on otherwise neces- community more complex than the usual sary direct medical expense, and even flu season’s impact. Due to the destructive greater return when indirect savings are cal- potential of a new pandemic emerging from culated. For example, according to CDC, a cross-strain of avian and human influenza, for every $1 spent to control diphtheria, the control strategy centers on destroying tetanus and pertussis, $27 are saved; for the vector population before it can mix with every $1 spent on measles, mumps and humans. Additionally, experts are working rubella, $23 are saved.17 to develop a human bird flu vaccine to New technologies have been developed that address the current strains of bird flu and would allow for much more rapid response, prepare for the arrival of a pandemic but breakthroughs have not been a public strain.18 In testimony before the U.S. House policy priority nor have sufficient incentives of Representatives, Committee on to relevant manufacturers been offered for Government Reform in February 2004, Dr. further development and dissemination. Gerberding described an effort to “move toward the development of a modern, cell For the long term, the public health system culture influenza vaccine, for which produc- must cope with challenges posed by project- tion can be scaled up more rapidly than the ed substantial increases in the cost of stan- traditional egg-based vaccine.”19 dardized vaccines, and structural changes in the public and private immunization indus- 4 IV. What is the bird flu? There are two known varieties of the The current bird flu spreading through Asia influenza virus, Influenza A and Influenza is of the Influenza A (H5N1) virus. Wild B.20 All known Type A influenza viruses are birds are the natural hosts of this subtype, further divided into subtype strains based which circulates among birds throughout on their surface’s composition (categorized the world.22 Traditionally, flu seasons fea- by the antigens hemagglutinin (H) and turing type A viruses are more severe to neuraminidase (N)).21 humans, resulting in increased hospitaliza- tions and fatalities.23 “WHEN CASES OF AVIAN INFLUENZA IN HUMANS OCCUR, INFORMATION ON THE EXTENT OF INFLUENZA INFECTION IN ANIMALS AS WELL AS HUMANS AND ON CIRCULATING INFLUENZA VIRUSES IS URGENTLY NEED- ED TO AID THE ASSESSMENT OF RISKS TO PUBLIC HEALTH AND TO GUIDE THE BEST PROTECTIVE MEASURES. THOROUGH INVESTIGATION OF EACH CASE IS ALSO ESSENTIAL. WHILE WHO AND THE MEMBERS OF ITS GLOBAL INFLUENZA NETWORK, TOGETHER WITH OTHER INTERNATIONAL AGENCIES, CAN ASSIST WITH MANY OF THESE ACTIVITIES, THE SUCCESSFUL CONTAINMENT OF PUBLIC HEALTH RISKS ALSO DEPENDS ON THE EPIDEMIOLOGICAL AND LABORATORY CAPACITY OF AFFECTED COUNTRIES AND THE ADEQUACY OF SURVEILLANCE SYSTEMS ALREADY IN PLACE.”24 –”Avian Influenza Frequently Asked Questions,” World Health Organization. This particular bird flu subtype has generat- infect humans. While infected bird carcass- ed international attention and began in mid- es endanger handlers, the most dangerous December 2003 in Korea. Since 1997, H5N1 vector is surviving birds, which spread the strains have showed an ability to directly virus via excretions for at least 10 days.25 V. Why are public health experts particularly concerned about this strain of the bird flu? The current avian influenza outbreak has land where poultry are kept, which are then demonstrated itself to be highly pathogenic widely distributed to food markets. and a significant public health danger. International travelers, poultry exporters, Within a nation, the disease spreads easily and migrating birds and fowl then spread between such places as farms and food mar- the virus from region to region and nation kets. Infected wild birds contaminate farm- to nation.26 “THE REAL DANGER IS MORE DISTANT: THE POSSIBILITY THAT SOONER OR LATER SOMEONE WILL BE SIMUL- TANEOUSLY INFECTED WITH AN AVIAN FLU VIRUS AND A HUMAN FLU VIRUS, ALLOWING THE VIRUSES TO SWAP GENES IN A WAY THAT MAKES THE BIRD VIRUS HIGHLY TRANSMISSIBLE AMONG HUMANS, WHO WOULD HAVE NO NATURAL IMMUNITY.”27 – New York Times editorial, January 30, 2004 5 The current destruction of poultry popula- poultry helped avert a larger-scale public tions throughout many Asian nations and health disaster.29 This decisive action was in widespread importation bans illustrate the part influenced by the lessons learned five severity with which officials are regarding this years earlier in Mexico, where a strain of low flu strain. Lessons learned from past bird flu pathogenic avian influenza was not controlled outbreaks demonstrate that the most impor- and evolved into a more virulent and fatal tant control measures are rapid destruction form.30 While such measures are appropriate of infected or potentially exposed birds, and due to the virulence of the current health the quarantining of related farms.28 threat, they would become an absolute neces- sity if a new virus emerged, blending the exist- When the first human case of avian influenza ing bird flu with a human flu gene partner. virus was diagnosed in Hong Kong in 1997, the rapid destruction of the area’s 1.5 million “SINCE MID-DECEMBER 2003, A GROWING NUMBER OF ASIAN COUNTRIES HAVE REPORTED OUTBREAKS OF HIGHLY PATHOGENIC AVIAN INFLUENZA IN CHICKENS AND DUCKS. INFECTIONS IN SEVERAL SPECIES OF WILD BIRDS AND IN PIGS HAVE ALSO BEEN REPORTED. THE RAPID SPREAD OF HIGHLY PATHOGENIC AVIAN INFLUENZA, WITH OUTBREAKS OCCURRING AT THE SAME TIME IN SEVERAL COUNTRIES, IS HISTORICALLY UNPRECEDENTED AND OF GREAT CONCERN FOR HUMAN HEALTH AS WELL AS FOR AGRICULTURE. PARTICULARLY ALARMING, IN TERMS OF RISKS FOR HUMAN HEALTH, IS THE DETECTION OF A HIGHLY PATH- OGENIC STRAIN, KNOWN AS “H5N1”, AS THE CAUSE OF MOST OF THESE OUTBREAKS. H5N1 HAS JUMPED THE SPECIES BARRIER, CAUSING SEVERE DISEASE IN HUMANS, ON TWO OCCASIONS IN THE RECENT PAST AND IS NOW DOING SO AGAIN.”31 – ”Avian Influenza Frequently Asked Questions,” World Health Organization. If a pandemic flu were to emerge, the U.S. needed to address a bioterrorism event” and public health system would be stretched well that needed to deal with pandemic flu by com- beyond its capacity. Decades of underinvest- pleting state-specific pandemic plans. ASTHO ment and a narrow disease-by-disease refers to the communications, laboratory, response has weakened the entire public disease surveillance, and emergency response health infrastructure. Recent investments in capabilities being developed for a possible bioterrorism preparedness have improved bioterrorism attack as the “scaffolding” upon elements of our overall public health defens- which the unique capabilities required to deal es, but recent reports, including a December with pandemic flu can be built. 2003 state-by-state examination of public In many ways, pandemic flu could be much health preparedness by TFAH, have illustrat- more demanding on state and local health ed that significant gaps remain, most notably resources and much more damaging to the at the state and local level. The U.S. General general population than a bioterrorism attack. Accounting Office (GAO) studied local and Most experts believe a bioterrorism attack is state bioterrorism preparedness in 2003 and most likely to involve isolated locations ini- found deficiencies in capacity, communica- tially. In the event of an attack, aid can be tion, and coordination elements essential to swiftly dispatched both from the federal gov- preparedness and response.32 ernment and from unaffected states. But The Association of State and Territorial pandemic flu would affect most every state Health Officials (ASTHO) has been urging its simultaneously. People would be forced to members to take advantage of “the substantial rely almost exclusively on their local and overlap between public health infrastructure state health infrastructure for assistance. 6 Conclusions and Recommendations for Better U.S. Flu Preparedness T he initial response to the recent emergence of avian flu underscores the importance of strong public health systems, from the global to the local, as well as integrated and well-functioning systems for health care delivery. Future preparedness also will depend on a well-educated and trained clinical and public health workforce. In addition, the nation needs a sound research agenda addressing near and long-term requirements for new insights into the nature of infectious disease threats, human host responses, and the opportu- nities to develop new diagnostics, drugs, and vaccines. The diversity and sheer number of chal- the traditionally separate jurisdictions of lenges confronting our public health system animal and public health. in recent months, from ricin attacks to Throughout the United States, animal and emerging epidemics, has demonstrated the public health departments exist as wholly sep- necessity for a revitalized a 21st century pub- arate entities with different jurisdictions and lic health defense system. The current “dis- purviews, separated in both organization and ease du jour” approach to funding and con- culture. Without better integration and coor- tainment is simply not able to deal with the dination between these two fields, the respons- range and volume of health threats we face. es to diseases originating in animals will be at The emergence of the potential flu pandemic a piecemeal and emergency basis and coincides with renewed attention being paid response and coordination efforts will remain to public health. With today’s news stories on below optimal. The domestic spread of West emerging epidemics and bioterrorism pre- Nile virus, which was first evident in birds paredness activities, most Americans have a beginning in 1999, illustrates the dangers of better understanding of areas of vulnerability. poor coordination and cooperation between animal and public health entities. (For addi- Recent outbreaks of animal-borne diseases tional information on animal-borne diseases, in the United States, while frightening and see TFAH’s “Animal-Borne Epidemics Out of attention-getting, resulted in relatively few Control: Threatening Our Nation’s Health,” casualties. However, their emergence pro- which is available at healthyamericans.org) vided real-time “trial runs” of our national response and diagnostic capabilities. U.S. The threat from biological and chemical ter- efforts in combating SARS, monkeypox, rorism also has provided a much-needed West Nile virus, and Mad Cow disease will impetus for policymakers and the public to prove invaluable in the continuing efforts to recognize the importance of a strong and well- prepare against the flu pandemic and have funded public health system. While federal helped illustrate the dangers caused by poor bioterrorism preparedness funding has communication and cooperation between exceeded $2 billion since 9/11, gaps persist, 7 especially at the state and local level. TFAH should initiate a process that leads to con- recommends shifting focus and funding sensus toward common goals and the role of towards an “all hazards” approach to public each entity in reaching them. health, rather than a siloed approach to The President, in consultation with bioterrorism readiness. An integrated, “all Congress, should convene a White House hazards” protocol would strengthen the fun- summit that will develop a concrete vision damentals of our entire system, especially pub- for the future of the American public health lic health workforce recruitment, retention system and the resources needed to make it and training, laboratory capacity at the state a reality. The summit would consider how and local level, and communications and the country can best build a robust, inte- rapid response networks capable of meeting grated public health infrastructure. TFAH the demands of 21st century health threats. believes that such a summit could craft a The current effort to improve the nation’s blueprint for a public health system that is ability to respond to a public health emer- designed to meet both America’s current gency faces a significant organizational chal- and emerging health threats. lenge. Whatever the threat, the response is The discussion must include how to develop largely dependent on the functioning of a a public health system for the 21st century -- patchwork of state and local public health the summit should address all aspects essen- agencies, whose funding sources, bureau- tial to public health, such as biological, cratic structure, and responsibilities can chemical and radiological terrorism pre- vary significantly from state to state and paredness, known and emerging infectious even county to county. diseases, and chronic disease prevention and It is clear that the U.S. needs a more cohe- control. At the same time, it could foster a sive, national public health system, though long-overdue dialogue about the resources no one is suggesting that state and local required to implement needed changes and agencies be subsumed by a new national guarantee accountability at every level of the body. However, public health officials public health system. REPORT AUTHORS Michael J. Earls Shelley A. Hearne, Dr.PH Communications Specialist Executive Director Trust for America’s Health Trust for America’s Health 8 Endnotes 14 “Basic Information about Avian Influenza (Bird Flu),” Centers for Disease Control and 1 Smolinski, Mark S., Hamburg, Margaret A., Prevention. <http://www.cdc.gov/flu/ avian/facts.htm.> 6 February 2004. and Lederberg, Joshua, Microbial Threats to Health: Emergence, Detection, and Response. 15 “Avian Influenza Fact Sheet,” World Health Committee on Emerging Microbial Threats to Organization. <http://www.who.int/csr/don/ Health in the 21st Century, Board on Global 2004_01_15/en/.> 6 February 2004. Health, Institute of Medicine, National 16 “Questions and Answers: The 2003-2004 Flu Academies of Science, 2003: xvii. Season,” Centers for Disease Control and 2 “Questions and Answers: The Disease,” Centers Prevention. <http://www.cdc.gov/flu/about/ for Disease Control and Prevention. qa/fluseason.htm.> 6 February 2004. <http://www.cdc.gov/flu/about/qa/disease.htm 17 “Immunization Grant Program (Section 317),” .> 5 February 2004. Centers for Disease Control and Prevention. 3 “Avian Influenza Frequently Asked Questions,” <http://www.cdc.gov/programs/immun4.htm. World Health Organization. > 11 February 2004. <http://www.who.int/csr/disease/avian_influen- 18 ”Human Bird Flu Vaccine Closer,” The Atlanta za/avian_faqs/en/.> 5 February 2004. Journal-Constitution. 7 February 2004. 4 ”Bird Flu Found in N. Jersey Live Poultry 19 Gerberding, Julie, M.D., M.P.H., “Protecting the Market,” Reuters. <http://www.reuters.com/ Public’s Health: CDC Influenza Preparedness newsArticle.jhtml?type=scienceNews&storyID=43 Efforts,” Statement before Committee on 47948.> 12 February 2004. Government Reform, U.S. House of 5 “HHS, USDA Ban Importation of Birds from Representatives. 12 February 2004. Southeast Asia,” United States Department of 20 “Background on Influenza,” Centers for Health and Human Services. Disease Control and Prevention. <http://www.hhs.gov/news/press/2004pres/200 <http://www.cdc.gov/flu/professionals/back- 40204.html.> 4 February 2004. ground.htm.> 4 February 2004. 6 “CDC News Conference Transcript: Influenza 21 “Basic Information about Avian Influenza (Bird Update.” Centers for Disease Control and Flu),” Centers for Disease Control and Prevention. http://www.cdc.gov/od/oc/media/ Prevention. <http://www.cdc.gov/flu/avian/ transcripts/t031219.htm> 19 December 2003. facts.htm.> 6 February 2004. 7 “CDC News Conference Transcript: Influenza 22 “Avian Influenza (Bird Flu) Outbreak”, Centers Update.” Centers for Disease Control and for Disease Control and Prevention. Prevention. <http://www.cdc.gov/od/oc/ <http://www.cdc.gov/flu/avian/index.htm.> 5 media/transcripts/t040108.htm> 8 January 2004. February 2004. 8 “Pig Fears as Bird Flu Death Toll Hits 18,” 23 “Questions and Answers: The 2003-2004 Flu Reuters. <http://www.reuters.co.uk/ Season,” Centers for Disease Control and newsPackageArticle.jhtml?type=worldNews&stor Prevention. <http://www.cdc.gov/flu/about/ yID=453507&section=news.> 6 February 2004. qa/fluseason.htm.> 6 February 2004. 9 “Questions and Answers: The Disease,” Centers 24 Ibid for Disease Control and Prevention. 25 Ibid <http://www.cdc.gov/flu/about/qa/disease.htm. > 5 February 2004. 26 “Avian Influenza Frequently Asked Questions,” 10 “Avian Influenza (Bird Flu) Outbreak”, Centers World Health Organization. for Disease Control and Prevention. <http://www.who.int/csr/disease/avian_influen- <http://www.cdc.gov/flu/avian/index.htm.> 5 za/avian_faqs/en/.> 5 February 2004. February 2004. 27 “The Spread of Avian Influenza,” The New 11 “Avian Influenza Frequently Asked Questions,” York Times. 30 January 2004. World Health Organization. 28 “Avian Influenza Frequently Asked <http://www.who.int/csr/disease/avian_influe Questions,” World Health Organization. nza/avian_faqs/en/.> 5 February 2004. <http://www.who.int/csr/disease/avian_infl 12 “Pig Fears as Bird Flu Death Toll Hits 18,” uenza/avian_faqs/en/.> 5 February 2004. Reuters. <http://www.reuters.co.uk/news 29 “Avian Influenza Fact Sheet,” World Health PackageArticle.jhtml?type=worldNews&storyID Organization. <http://www.who.int/csr/don/ =453507&section=news.> 6 February 2004. 2004_01_15/en/.> 6 February 2004. 13 “New Clue About Why 1918 Flu Epidemic Was 30 Ibid Deadliest,” CNN.com. <http://www.cnn.com/ 31 Ibid 2004/HEALTH/02/05/historic.flu.ap/.> 5 32 State and Local Bioterrorism Preparedness. February 2004. GAO-03-373. Washington, DC: U.S. General Accounting Office. 2003. 9