ST PAUL -- Health officials are preparing for a pandemic flu that kills many Minnesotans.
Or a flu almost no one notices.
Or something in between.
"Anything could happen," said John Stine, assistant Minnesota Health Department commissioner. "There is no way of giving you a forecast."
The current pandemic flu strain has made 94,000 people sick worldwide and 34,000 in the United States. But Stine and other Minnesota health leaders fear it could get far worse if the current flu virus mutates as has happened in the past.
"It's now everywhere," Stine said. "It moves easily from person to person, but it is not as severe as the 1918 virus."
Health officials worldwide think about 1918's pandemic that killed up to 50 million people worldwide when they prepare for what could be a rough fall and winter.
"You prepare for it like you do for a hurricane," said nationally known epidemiologist Michael Osterholm of the University of Minnesota. "At this point, we are preparing for this being a very serious situation come fall."
The biggest fear is the deadly bird flu that Osterholm and others discussed so much in 2005 combines with the rapidly spreading strain now circling the globe. That could form a new, deadly virus that would leave humans nearly defenseless. Such a transformation could happen in weeks.
While the bird flu now cannot be transmitted from human to human, 60 percent of people who get it from animals die, Osterholm said. If that high death rate were to combine with the current pandemic flu's easy transmission from person to person, health officials fear they could be looking at a situation like in 1918, when a flu strain made a similar transformation.
Flu talk has subsided since the spring, when what then was called swine flu jumped from Mexico to other countries. The United States has been especially hard hit, although the current flu strain produces relatively mild symptoms in many of its victims.
In Minnesota, other than the reporting of a recent death -- one of three in the state -- the public has heard little about the flu in the past few weeks. But health officials remain on high alert.
Up to 100 of the Minnesota Health Department's 1,300 workers are focused on the flu, getting ready for an expected new wave in the fall and winter.
Even before that next wave hits, however, the flu still is spreading.
In the first few days of the outbreak, Minnesota and other states released information whenever a case was found. Now, only people hospitalized are being tested, so no one knows how many people have the pandemic flu.
The World Health Organization earlier this year declared the H1N1 flu a pandemic, meaning it was widespread around the world, a step beyond an epidemic.
The pandemic flu, as it is now, presents similar symptoms to the seasonal flu that spreads in winter months.
At about the same time the seasonal flu makes its annual visit beginning in the fall, the pandemic flu could begin its second wave. That dual flu outbreak will produce confusion among Minnesotans, state health officials say.
For instance, Kristen Ehresmann of the Minnesota Health Department said, people will need vaccinations both for seasonal and pandemic flu.
"The goal is all Minnesotans who want to be vaccinated will be vaccinated," said Ehresmann, the Health Department's infectious disease, epidemiology, prevention and control division director.
It could end up being three shots, one for seasonal and two for pandemic flu. However, Ehresmann said, those making the vaccine hope to put an additive in the pandemic flu vaccine that eliminates the need for a second shot.
If the flu strain mutates, the vaccine would have to be changed to provide adequate protection.
"That is not an instant process," said Aggie Leitheiser, the Health Department's emergency preparedness director. "They are developing the vaccine the way it (the flu) looks today."
Stine said that before the 1918 pandemic, the flu strain mutated in six to 12 weeks, that in a time when people were much less mobile.
"We assume it can move more readily now," Stine said.
That easy movement around the world could help bird flu, known as H5N1, combine with the current pandemic flu, H1N1.
"There is an assumption there will be some cross mixing," Leitheiser said. "That's our worst nightmare."
At this point, the pandemic flu is hitting younger people harder than their elders, just the opposite of how seasonal flu works.
In Minnesota, 39 percent of those hospitalized with the new flu are 5 to 24 years old.
Ehresmann said that people born before 1957 may have been exposed to a flu similar to H1N1 "to provide some level of protection."
However, health experts say, anyone of any age with health problems is at risk.
"Very few people over 65 are getting this, but if they do get this, their chance of dying is a bit greater," said Anne Schuchat of the Centers for Disease Control and Prevention.
Health officials recommend Minnesotans keep a supply of medicine and food on hand in case they catch the flu. Since doctors recommend that people with flu symptoms stay home seven days, and some schools and businesses could close, it may be difficult to pick up needed supplies.
"One key thing is if you are sick don't go to work," Osterholm said. "Stay home."
Don Davis works for Forum Communications Co., which owns the Bemidji Pioneer.