WHEN an outbreak of the Spanish flu spread worldwide in 1918, a doctor in Newark advised his patients that they could cure their illness with red onions and coffee. In Atlantic City, the authorities closed amusement parks and theaters indefinitely. And in upstate New York, public health officials distributed a poster warning people against “careless spitting, coughing, sneezing.”

Today, New Jersey, Connecticut and New York are much more prepared than they were 90 years ago in the event that an influenza outbreak turns into a pandemic. But five years after an avian flu outbreak in Asia made pandemic flu planning a priority, some experts are concerned that states have not been equally vigilant about preparing, and as attention and federal financing begin to decrease, they fear that preparedness efforts will slacken.

“There is a worry that there was a lot more attention to the issue two or three years ago,” said Richard Hamburg, government relations director for Trust for America’s Health, a Washington-based nonprofit health watchdog. “The fact is that it’s still spreading. There are still cases throughout the world. Preparedness is not a one-shot deal. You don’t know if this will hit this year, next year, five years, 10 years from now.”

Federal officials are tracking the flu worldwide, but it is up to cities and states to prepare their own public health plans. So in 2002, when fears of a new pandemic began to escalate, the federal government agreed to send the states billions of dollars to prepare for a pandemic. The health and human services secretary, Michael O. Leavitt, warned states in 2005 that if they expected the federal government to bail them out when a pandemic hit, they would be “tragically wrong.”

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