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There is even a "worst-case scenario" highlighted by federal health officials for state and local planners to ponder and dread: the Spanish flu pandemic of 1918-19, the deadliest outbreak in the 20th century, which killed an estimated 675,000 Americans and up to 100 million people worldwide.

"It's the biological Katrina," said Steve Cline, North Carolina's deputy public health director.

A prime suspect for a pandemic: the H5N1 avian flu virus, an Asian strain that has proven ultralethal to humans, producing some of the same sudden-death symptoms as the Spanish flu virus and the same ability to kill young adults with healthy immune systems.

"It could be the closest thing to 1918 we've ever seen," said Dr. Paul Biddinger, an associate director at the Harvard School of Public Health.

Although a different avian flu strain could mutate into a pandemic killer, scientists focus on the H5N1 strain because it already has proved it can jump from birds to humans and has shown a limited ability to pass between people in close contact, killing 50 percent or more of those it infects.

"Once we get human-to-human transmission, a pandemic will happen like that," said Mary Lou Dobbs, manager of the emergency response team at Rex Hospital, with a snap of her fingers.

How N.C. is preparing

North Carolina public health officials have a renewed sense of urgency about preparing for this potential disaster. The state is on pace to spend more than $12 million in state and federal money to calculate the ability of hospitals to handle a pandemic and to start stockpiling crucial medicine and medical equipment. That includes more than $4 million spent on a 400-bed tent hospital that will be divided into eight 50-bed units stationed across the state.

Health officials have conducted pandemic flu conferences, set up a task force on the ethical questions raised by a global outbreak and run tabletop training exercises with emergency managers to sharpen their planned response.

But they also have reached a grim conclusion: No amount of money, preparation and stockpiling will provide airtight protection against a severe flu pandemic.

"You can't spend that much -- it's not realistic," said U.S. Sen. Richard Burr, the North Carolina Republican who has a leading role in federal planning for pandemic flu, bioterrorism and public health preparedness. "That's why at the end of a tabletop drill, at the end of an exercise, everybody says when you ask 'What do we do?' they say 'We better get a vaccine.' "

That won't happen, though, for four to six months after the pandemic strikes. It takes time for researchers to isolate the virulent strain and concoct a vaccine serum to protect people from it. The massive quantity needed will also be delayed because flu vaccine production relies on an egg-based system developed in the 1950s.

This will force public health officials to rely on measures developed at the turn of the last century to dampen the spread of the disease -- shut down public events, isolate the sick and quarantine people suspected of infection. Expect travel restrictions, particularly on airline flights to Asia, home of the virulent avian flu.

Until there is a vaccine, doctors and nurses will be powerless to prevent infection by a flu virus from which no one is safe.

A pandemic's spread

Pandemics are caused by a virus that the immune system doesn't recognize, a new mutation far different from the strains now in circulation. Although seasonal flu symptoms are unpleasant -- fever, cough, runny nose and muscle pain -- the bug is rarely fatal. Those who die are usually victims of a secondary infection, such as bacterial pneumonia.

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