Forty-nine states have Internet websites that include statewide pandemic influenza procedures and plans or, in a few instances, have simply addressed broad questions about state-based responses to pandemic influenza (Table A1). Often these plans, which are funded by a Centers for Disease Control and Prevention (CDC) preparedness cooperative agreement, were posted in the last half of 2005 or early 2006, and these documents are still largely in transition. US HHS has recently issued guidelines (1); however, specific planning, problem solving, and funding are still left to the individual states.

Almost all of the states' plans address a wide range of issues regarding command and control, surveillance, vaccination, antiviral drugs, communication, and emergency management and containment measures. The purpose of this review was to focus on community public health strategies, especially vaccination, surveillance and detection, and containment, which the various states develop as they refine their plans.

The control of future pandemic or interpandemic influenza will necessarily rely on each individual state's plan to vaccinate persons and detect and contain this disease. Still, the current national (HHS) pandemic influenza plan presents only a categorization and listing of steps, rather than explicit direction for the states. This lack of central coordination can result in a patchwork of plans that will not adequately detect and control this or other respiratory disease pandemics.

Given the lack of clear guidance, coupled with the fact that no one knows when an influenza pandemic may strike, what its characteristics will be, and the effectiveness and quantity of strain-specific vaccine, the evolving state plans are nonetheless in agreement in adhering generally to ACIP and HHS guidelines for prioritizing vaccination (1,2). In general, the elderly, those with chronic diseases, and healthcare and infrastructure personnel will be prioritized to receive vaccination, and in approximately one third of states, young children will be prioritized to be vaccinated (6). We believe the estimate that such persons make up ≈15%–20% of the population in any state is reasonable (1). However, this vaccination strategy is predicated on preventing deaths from influenza, not stopping or retarding an epidemic or pandemic (7). Given that vaccine adequate to cover the entire US population will not be available for several more years, the goal of reducing transmission would require much more vaccination than is available.

Regarding surveillance and detection, state plans are even more variable than they are about strategizing vaccinations. All states indicate that they plan to use the NSPS network and the nationwide 122 Cities Mortality Reporting System (3,4). In NSPS, each year ≈1,100 (55%) of ≈2,000 healthcare providers nationwide voluntarily report the number of weekly outpatient visits for ILI and submit specimens from a subset of patients to state public health laboratories for influenza virus testing. The 122 city-specific mortality reporting is unavoidably even more delayed. Neither system would likely detect a local outbreak of influenza <2 weeks into its establishment. Thus, some state and federal authorities are assessing the utility of syndromic surveillance of ILI (e.g., cough, headache, and fever) in emergency departments and clinics in test cities. Several such programs exist, and CDC's BioSense (5) includes plans to expand such early surveillance to 300 clinical sites. However, to our knowledge, no health authority feels confident that earlier detection of influenza by 1 to 3 weeks would necessarily lead to better control or substantial retardation of an outbreak.

Finally, confusion and lack of specificity exist in these posted state plans in proposing practical containment measures in the community. The national HHS Pandemic Influenza Plan (1) has several recommendations for infection control in the hospital setting but is weaker and nonspecific in other areas such as control of influenza in the community. For example, there is no agreed-upon definition of geographic clustering of cases or number of persons infected that will trigger the declaration of a pandemic. Much of this national plan suggests social distancing and respiratory (cough) etiquette and devotes much of its discussion to mask use. Accordingly, states are comparably nonspecific about community control plans. Vaccination or chemoprophylaxis of contacts is infrequently addressed, mainly because the vaccine supply is limited, as are the most effective antiviral drugs, the neuraminidase inhibitors oseltamivir and zanamivir, for the next several years. Even when these vaccines and drugs become available, considerable obstacles remain to detecting influenza promptly and getting vaccination or drug therapy to the contacts of influenza patients.

Several practical nonpharmaceutical containment steps need to be considered. For example, only approximately one third of the state plans are explicitly considering recommending self-isolation of adults with influenzalike symptoms and keeping children with such symptoms home from school and daycare. Even in this increasingly computer-based economy, in which a considerable percentage of persons can work from home most of the time, this simple stratagem is not addressed in most state plans. Other simple recommendations for use in the community, such as avoiding mass gatherings; shopping on off hours; and household and workplace strategies such as frequent hand washing, avoiding handshaking, and keeping towels separate, are often neglected in state plans.

Why are there these state plans so disparate? We believe some of the problem results from weak central (federal) direction, as has been a criticism of national bioterrorism preparedness (8). Fortunately, state and federal plans are still in flux, many are still in draft form (Table A1), and getting a clearer delineation of a basic plan that all states can follow is still possible. The US Secretary of HHS has been meeting with states (http://www.pandemicflu.gov/plan/convening.html) to review pandemic preparedness issues.

However, we also believe that answers are lacking to several key epidemiologic questions necessary for rational planning. What is the typical intrahousehold or institutional attack rate, and would vaccination or chemoprophylaxis of contacts retard or stem outbreaks? How well do masks work for pandemic influenza in the community, and when and for how long should they be used? Does closing a school or other institution actually reduce community-level illness and death? Does earlier detection of influenza in a community lead to behavior changes that could stem an outbreak? We know of no studies designed to address these and several other issues; e.g., the Models of Infectious Disease Agents Study (MIDAS) (9) has been forced to rely on estimates of household attack rates estimated >30 years ago (10,11) for a nonpandemic (H3N2) strain of influenza virus. Several state plans, such as California's, expressed frustration about this lack of information.

Thus, we believe that a revision of the national pandemic influenza plan, which despite unavoidable gaps in our knowledge, relies on professional and public health opinion to provide more uniform, specific, and practical influenza protection, avoidance and containment practices for pandemic and interpandemic influenza in the community would be helpful. We also believe it would be prudent to begin studies and, in the interim, create expert panels to determine if masks, school closings, social isolation, and several other nonpharmaceutical strategies would be useful in reducing the illness and death caused by pandemic influenza and its spread in the community.