The plan, released Wednesday by the Department of Health and Human Services, estimates a flu pandemic could kill 1.9 million people in the United States and hospitalize another 10 million if no interventions were taken.

Disease experts are concerned a strain of avian flu called H5N1, which has been circulating for several years in Asia, could mutate to become easily transmissible from person to person and lead to a pandemic. Other strains of flu, however, also could emerge at any time and result in a global outbreak.

"If it isn't the H5N1 virus, it will be another virus, because pandemics in fact do occur," HHS Secretary Mike Leavitt said during a news briefing.

Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, a component of the National Institutes of Health, said the probability of H5N1 causing a global outbreak is unlikely, but added he would not be surprised if it happened tomorrow.

"We're assuming the worst-case scenario," Fauci said.

President George W. Bush issued a flu plan Tuesday that requested $7.1 billion in budget authorizations from Congress for improving the nation's preparedness to respond to a global flu outbreak.

The Senate recently authorized $8 billion for flu-preparedness expenditures, and Sen. Tom Harkin, D-Iowa, noted the effort addressed many of the provisions outlined by Bush's plan.

Harkin also criticized the president, however, for requiring states to pay for many of the plan's costs, while the administration's proposed fiscal year 2006 budget slashes funding for state and local public-health departments by $129 million from the previous year's funding levels.

The Association of State and Territorial Health Officials decried the lack of funding in Bush's plan for local health departments, noting only $100 million of the $7.1 billion package is earmarked for state and local preparedness efforts.

"A pandemic will affect all sectors of our society, from the operation of schools and businesses to the ability to staff hospitals and clinics to the logistics of keeping transportation routes open," said Dr. Mike Crutcher, Oklahoma's commissioner of health and chair of the ASTHO Infectious Diseases Policy Committee.

"The final responsibility for oversight of the distribution of medication and supplies will rest with state and local public health departments and many simply do not have the necessary resources."

HHS has been developing a vaccine for H5N1 in conjunction with Sanofi Pasteur and Chiron, but it is not clear when the vaccine will be ready, and the production capacity of vaccine manufacturers may be inadequate to generate enough product for nearly 300 million Americans.

The agency also has begun stockpiling anti-viral medications, including GlaxoSmithKline's Relenza and Roche's Tamiflu, that could be effective against H5N1, but infectious-disease experts have criticized the supply as inadequate to deal with a pandemic.

The HHS flu plan will go into effect as soon as sustained human-to-human transmission of a deadly flu strain is detected. If an adequate vaccine supply is not available, HHS could restrict travel and implement other strategies, such as closing schools and quarantining exposed persons, to limit the spread of the virus, according to the plan.

The H5N1 strain has killed 62 people so far, but it does not yet appear to have developed the capability to pass readily from person to person.

The federal plan calls for expanding the capacity of the existing vaccine-production technique, which involves a slow process of growing the virus in eggs.

HHS also is focused on developing new cell-based production technology that would permit faster production of vaccines, but vaccines resulting from those efforts may not be available for several years.

Promising cell-based technologies already are being developed by some companies, and "we're optimistic that we could have licensed vaccines in the next four or five years," said Dr. Bruce Gellin, director of the National Vaccine Policy Office.

Fauci said the NIH plans to begin early in 2006 studies of compounds called adjuvants to determine if these could reduce the dosage required to elicit an adequate immune response with the avian-flu vaccine. Previous studies indicated the bird-flu vaccine required two separate doses of 90 micrograms, or 12 times the amount of the regular flu vaccine.

If the adjuvants lower the required dosage, then a supply of the vaccine may be available earlier than anticipated, Fauci said.

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