The Trust for America’s Health, the Center for Biosecurity of the University of Pittsburgh Medical Center and the Robert Wood Johnson Foundation also listed 10 lessons from the H1N1 outbreak and 10 recommendations. Among them were a call for continuously updating and restocking the national vaccine stockpile, boosting the capacity for vaccine development and production, and reinforcing health care systems.

Nearly 20,000 cases of the H1N1 virus have been confirmed worldwide, with more than half of the cases from the United States, according to the World Health Organization.

The Centers for Disease Control and Prevention reported, as of Thursday, 11,468 probable and confirmed U.S. cases and 19 deaths from the H1N1 virus, also known as the swine flu. About 2.5 percent of the cases resulted in hospitalizations.

Health officials have warned that the H1N1 outbreak is not over, with more deaths being reported.

On Wednesday, Connecticut and Michigan both confirmed their first H1N1 deaths; both individuals had underlying illnesses, according to state health authorities. All 50 states have confirmed cases, but flu activity seems to be declining in the nation as a whole, according to the CDC.

During the summer, the agency will take steps to better prepare and coordinate with health systems, said Dr. Anne Schuchat, the CDC’s interim deputy director for the Science and Public Health Program. Scientists are keeping close attention to the Southern Hemisphere as the flu season begins there.

According to the Pandemic Flu Preparedness report, the H1N1 outbreak showed that the “investment the country has made in preparing for a potential pandemic flu has significantly improved U.S. capabilities for a large scale infectious disease outbreak.”

“One of the lessons in this is that everyone was concerned about the avian flu [H5N1], and biology played a trick on us,” said Jeff Levi, the executive director of Trust for America’s Health, a nonprofit organization that focuses on public health. “It was a different form of the virus that became widespread. Most of the preparation around H5N1 is totally transferable to H1N1.”

Avian flu was “a wake-up call for the world that serious influenza threats exist” and resulted in better test kits, diagnostic tests and emergency exercises, Schuchat said.

“There has been a lot of payoff from worrying about the bird flu,” she said. “A lot of lessons have been learned that put us in better shape to be prepared right now. We have a lot more work to do to make sure we’re as well-prepared for the fall.”

After the avian flu scare, county health departments started preparedness drills, said Dr. Christian Sandrock, a physician in infectious diseases at the University of California Davis Medical Center and a deputy health officer for Yolo County, California, who specializes in disaster preparedness and emerging infectious diseases.

“A lot of things we worked on then seemed far-fetched but worked really well,” Sandrock said. “They had mock pills we sent around for years, and we would practice. Then, when it was the real thing, it was just like the drills. So it married what was spent and what we trained on.”

The report also said the H1N1 outbreak “revealed how quickly the nation’s core public health capacity would be overwhelmed if the outbreak were more widespread and more severe.”

Many public health departments do not have resources to carry out pandemic flu plans or respond to a severe outbreak. Laboratory testing is days to weeks behind the on-the-ground reality. Hospitals, which are already overcrowded on a daily basis, don’t have the capacity to treat large numbers in an outbreak.

The report evaluated “what policy changes, what investments might be needed, what policies need to be adapted to better prepare us in months ahead, because it’s likely to be resurgent in the fall,” Levi said.

The report recommended that the federal government provide guidance on hospital capacities and sustain the public health work force, despite tough economic times. Read the entire report

It credited national public health officials with effective communications by having daily briefings and conveying a consistent message about good hygiene and coughing and sneezing etiquette.

“This is where planning paid off,” Levi said. “They were sending a clear message. The public was informed about what we knew. The public was warned that the recommendations may change as the situation evolved. … I think they were appropriately alerting the public. I think the response was quite balanced.”

One of the challenges was communicating the latest H1N1 information to physicians and health care providers. Although public health departments were in contact with the CDC, some medical practitioners didn’t receive guidance in timely fashion.

So those practitioners “start calling public health departments or send patients to the emergency department, or they’re getting lab tests when they don’t need to,” Sandrock said. “What happens is, there’s a surge of patients. That could’ve worked better. It wasn’t a complete catastrophe.”

Better real-time information is needed to track the outbreak, said David Fleming, director and health officer of Seattle and King County, Washington, a report co-author. National statistics were about one to two weeks behind what was happening.

“If this virus returns, it’s going to return in differential and unpredictable way,” Fleming said. “There’s going to be a jigsaw of epidemics around the country.”

WHO Director-General Margaret Chan said the flu outbreak needed to be tackled with the utmost seriousness because there were still many unknowns about which path it will take.

“We are all under pressure to make urgent and far-reaching decisions in an atmosphere of considerable scientific uncertainty,” she told her U.N. agency’s World Health Assembly.

“For the first time in humanity, we are seeing, or we may be seeing, pandemic influenza evolving in front of our eyes,” Chan said, noting this had not been the case in 1968, 1957 or 1918.

Richard Besser, head of the U.S. Centers for Disease Control and Prevention (CDC), told a high-level meeting during the week-long Assembly that the new H1N1 virus had spread to nearly all 50 U.S. states and showed no signs of abating.

“While we are not seeing the seriousness of illness that was initially reported in Mexico, the outbreak is not over,” he said, adding the new virus was likely to circulate worldwide.

Assembly delegates were to discuss how best to harness drugs and vaccines and respond to the H1N1 flu, which has caused mild symptoms in most of the 8,829 patients infected to date in 40 countries, killing 74 people.

FLEXIBILITY

Mexico’s Health Minister Jose Angel Cordoba told the high-level segment that 3,646 cases had been confirmed in Mexico where there was a slow but steady fall in the number of cases.

Officials will also seek an agreement on how samples of the virus should be handled and shared with pharmaceutical companies working to develop vaccines to fight the strain, which is a genetic mixture of swine, bird and human viruses.

Rich and poor countries remain at odds over whether the biological material can be patented. The meeting will also discuss poor countries’ needs for antiviral drugs like Roche’s Tamiflu and GlaxoSmithKline’s Relenza and any vaccines developed to confront the strain.

Egypt’s envoy said that the threat from the deadly bird flu virus should not be ignored, noting there had been three new human cases of H5N1 in his country in the last week.

Chan said the new strain might pose particular risks when it mixed with the H5N1 flu virus, which has proven deadly in birds and humans but not transmitted easily between people.

It could also cause risks for people with HIV/AIDS and tuberculosis, and in crowded shantytowns, she said.

Chan raised the WHO’s pandemic alert level to Phase 5 last month in response to the spread of H1N1 in North America, which has had 95 percent of the nearly 9,000 confirmed cases to date.

Under the U.N. agency’s rules, signs that the disease is spreading in a sustained way in a second region of the world would prompt a declaration that a full pandemic is underway.

Countries from Britain to China said the WHO should have more flexibility to interpret its pandemic alert scale and decide whether to declare a full pandemic. Declaring a top-level phase 6 alert should reflect the severity of a new virus, not just its geographical spread, they said.

WHO laboratories have confirmed 125 cases in Japan, making it the largest cluster of H1N1 outside of the Americas, followed by Spain with 103 and Britain with 101, a top WHO official said.

Most of those cases have been deemed related to travel or restricted within schools, and not examples of the new virus spreading freely in broad communities, according to the WHO.

Chan and U.N. Secretary-General Ban Ki-moon meet top pharmaceutical executives on Tuesday to discuss their ability to make vaccines to fight the H1N1 strain. Making a pandemic shot could lead to lower output of vaccines for seasonal flu, which kills up to 500,000 people a year.

In its latest tally, which tends to lag national reports but is considered more secure, the U.N. agency said 45 people in Mexico have died from the new flu strain that is a genetic mixture of swine, bird and human viruses.

Its previous toll said there were 44 Mexican deaths.

The Mexican government has said the worst is over and eased restrictions on commercial and public activity in the country that has been at the epicenter of the outbreak.

The WHO’s latest flu tally increased the number of confirmed infections in the United States to 1,639 from 896 reported on Friday, while the number of reported deaths remained at two.

It increased the number of infections in Canada to 242, from 214, and added one reported death.

European countries with cases confirmed in WHO laboratories include Spain (88), Britain (34), Germany (11), Italy (6), France (12), Portugal (1), Ireland (1), Netherlands (3), Austria (1), Denmark (1), Sweden (1), Switzerland (1) and Poland (1).

The WHO also confirmed the following infections in the rest of the world: Israel (7), Brazil (6), New Zealand (5), South Korea (3), El Salvador (2), Hong Kong, China (1), Guatemala (1), Colombia (1) and Costa Rica (1).

Countries with cases added to its list for the first time were: Argentina (1), Australia (1), Japan (3) and Panama (2).

Evidence that the disease, popularly known as swine flu, has taken hold in communities outside the Americas would prompt WHO Director-General Margaret Chan to declare a full pandemic.

Chan raised the global pandemic alert level last week to 5 out of 6 in response to the spread of H1N1 flu. Phase 5 means a pandemic is imminent.

The WHO also repeated its guidance that international travel should not be restricted as a result of the outbreak.