Hawaii, both tourist mecca and western gateway to the nation, is ahead of many states in preparing for a possible global flu epidemic.
With thousands of tourists arriving daily, many from Asia, officials here were first to start an airport flu monitoring program. Experts say the state is "in the vanguard" when it comes to preparedness.
And no wonder. Hawaii's early history is filled with the ravages of disease after Captain James Cook arrived in 1778. Cook's crew and the Europeans who followed brought smallpox, measles and syphilis — devastating to the islanders.
Today the fear is over the potential for a deadly flu epidemic if the bird flu in Asia mutates into a form that is more dangerous to people.
"We are very concerned in Hawaii about the fact we are the western doorway to the United States," said Dr. Chiyome Fukino, director of the state Department of Health. "We see a large number of visitors ... and a good proportion of them are from the Far East where we know a good number of emerging diseases are originating."
The Honolulu airport's program to examine incoming passengers on a voluntary basis was announced in November, making Hawaii the first state to monitor airports for signs of bird flu or other flu viruses.
Officials also have plans for limited quarantines and amassed a supply of protective gear for doctors and nurses. Next month, the state will hold a seminar to help employers learn how a pandemic might affect their workers and businesses.
Dr. Gregory Poland, director of the Mayo Vaccine Research Group at the Mayo Clinic in Rochester, Minn., said Hawaii authorities understand the danger posed by the disease.
"Very definitely you guys are in the vanguard, in the lead of state level and local level preparations," Poland said on the sidelines of a Waikiki conference convened to educate island nurses, doctors, police and others about pandemic flu. "I think you've crossed the biggest hurdle which I said is imaginability. People here seem to get it."
No one knows if there will be a global flu epidemic. But scientists and public health officials are worried about a deadly form of H5N1 flu that has killed millions of birds from Asia to Europe to Africa. Although it is not easily spread to people, about half of the nearly 200 who have caught it since 2003 have died.
If it mutates into a form more easily spread among people, it could unleash a deadly new type of flu.
In Hawaii, which has 1.3 million residents, there are an average of 171,000 travelers at any given time. About 20,000 people fly in each day.
Hawaii's airport plan calls for a nurse to take a swab from a potentially infected passenger on any plane, at the gate, or inside the airport. If tests show the traveler has the H5N1 variety, authorities are prepared to quarantine the entire jet. Officials are also ready to cordon off a gate or other section of the airport to isolate people exposed to the passenger.
Still, officials know they won't be able to fully block the virus even with this approach because some people won't immediately show symptoms and won't be singled out for testing.
Instead, the state expects the screening to alert officials to the presence of the illness so they can contain it as much as possible, said Dr. Sarah Park, deputy chief of the Health Department's disease outbreak and control division.
"You can't guarantee a 100 percent barrier. You need to think more in terms of how do we detect it and once it's detected, how do we control it," Park said.
During an outbreak, Hawaii expects to test 6,000 samples per day. That's enough for more than a third of Hawaii's population over eight weeks — roughly the length of time experts estimate each outbreak will last before petering out.
If the next pandemic proves to be as virulent and deadly as the 1918 Spanish flu, the federal government estimates 90 million people will contract the disease and 1.9 million people will die from it nationwide.
Even if Hawaii is not the first state to suffer heavy losses, experts say it's vital that the islands be prepared.
Robert Kim-Farley, a professor at the University of California at Los Angeles School of Public Health, said Hawaii is right to get an early start because all 50 states will be too busy dealing with their own outbreaks to help anyone else if the disease strikes.
"A pandemic is a local emergency happening worldwide. It's something that has to be handled and dealt with on a local level," Kim-Farley said. "We will never be blamed for preparing too far in advance. We will be blamed, however, if we prepare too late."