The World Health Organization confirmed on Thursday that two teenagers in Turkey have died from bird flu -- the first human cases outside of eastern Asia. At the same time, the Bush administration is pressing cities and states to prepare for a flu pandemic.

There's been no sustained human-to-human transmission of the H5N1 flu strain yet. But Congress recently authorized nearly $4 billion to begin preparing for potentially devastating pandemic.

Many local authorities in the United States are just getting started. Few have any plans in place to deal with the massive number of people who could need hospital care. Fewer still have concrete plans to cope with extended periods of cancelled school sessions, business shutdowns and disruptions of commerce.

There's at least one exception: Seattle and surrounding King County, Washington.

For some time now officials there have been making the rounds of health care facilities, businesses and schools, warning about the scope of a potential flu pandemic. They've also been talking about and what might be done to minimize illness, death and social disruption. Their master plan, just released, is based roughly on the deadly flu pandemic of 1918.

But NPR has new estimates showing more precisely how a severe pandemic could unfold in Seattle and shared those numbers with city and county planners there as they detailed their evolving plans to deal with a pandemic.

The scenario for a pandemic starts at SeaTac International Airport. At just past noon on a recent Monday, a special observer waited as a jumbo jet from Taipei pulled into the gate. Passengers from the 14-hour flight filed past a checkpoint under the gaze of Dr. Peter Houck of the U.S. Centers for Disease Control and Prevention.

"On this flight I've kept track for awhile -- just very randomly," Houck explained. "And six or 10 people have cleared their throat or coughed between that doorway and the escalator over there. But if somebody's really having more of an influenza cough, that's going to stand out."

That person would be pulled aside and isolated while a flu test was done. The rest of the passengers could be quarantined for several days.

Thousands of people fly into Seattle from abroad every day.

If a flu pandemic were starting anywhere in the world, Peter Houck would be meeting every international flight, trying to identify infected passengers.

But Houck said that it's ultimately an impossible job.

"We can only find people who have symptoms," Houck said. "There's no way for us to say that the asymptomatic person in seat 22A is either infected or not infected. They look normal. We can't pick up on that."

So if a pandemic virus is circulating anywhere, it will get into the United States. There's just no stopping it. That's why health officials like Dr. Jeff Duchin are spending a lot of time these days planning for the inevitable.

Duchin is lanky and low-key. He's chief of infection control for the Seattle-King County Public Health Department. That makes him the messenger for the warning that the flu is coming to the Seattle area. He delivers that warning to just about any hospital, public agency or business that will listen to him.

Duchin tells them the number of people who could get sick and die is like nothing in living memory.

"The bad pandemic scenario is absolutely the worst thing you can imagine," Duchin said during a recent hospital planning session. "It stresses the system in a way that no other disaster does."

Nationally the federal government is estimating that 90 million Americans would get sick in a flu pandemic. That number is based in part on recent research from Emory University and the Los Alamos National Laboratory.

The researchers provided NPR with numbers showing how the pandemic would unfold in the Seattle area. Eighty thousand people would be sick in the Seattle area within two months of an outbreak, according to the projections. And 1-in-10 of them might need to be hospitalized.

"No health care system is built to manage these large numbers," Duchin said. "Currently the health care system is designed to be efficient -- lean and mean. And unless we start investing in changing that to prepare for public health emergencies, it's just going to be plain mean."

Chris Martin is worried about that. She's director of emergency services at Harborview, King County's public hospital. She's thought a lot about what could happen during a worst-case pandemic.

"It's very frightening, I think, for all of us to think about running out of supplies," Martin said.

The new analysis obtained by NPR shows how overwhelming it could be. On day 68 of a pandemic, Seattle-area hospitals might have to take care of 1,900 flu patients.

Martin's pretty confident the area's hospitals could handle that number of patients. But on Day 78, there might be 6,300 people needing hospital care. And on Day 86 -- the peak -- it could be 9,000, just on that one day alone.

"Clearly, we could not take care of 9,000 patients and support them from a ventilatory standpoint," Martin said of those peak numbers.

Martin said there'd be a dire shortage of ventilators, or breathing machines.

Jeff Duchin says health-care officials might even have to train volunteers to support critically ill patients with manual, hand-held respirators -- literally by standing by the bedside and squeezing a rubber bag to help patients breathe.

"If you don't have any choice, and that's the way you can keep somebody alive, we'll find people to squeeze the bags," Duchin said.

Chris Martin says doctors and nurses would have to make hard choices during the worst weeks of a pandemic. Planners openly acknowledge they wouldn't make heroic efforts to save people past a certain age or those who have conditions such as emphysema or heart disease.

Many older patients would probably be allowed to die during a severe pandemic.

Dr. Peter McGough, a primary care doctor in Seattle, says the clamor for drugs, hospital beds and respirators could result in chaos. He says that decisions must be made now about who will live and who will die.

"We need to have someone to say these are the health care criteria that we're establishing for how these limited resources are being disbursed," McGough explained. "In this case, since it would literally be life and death, I totally understand there would be people that would be just frantic trying to access some of this stuff."

The medical examiner's office is planning for as many as a 1,000 deaths a day -- more than 10 times the usual rate.

Crematoriums and embalmers couldn't handle that load. The county's even planning a Web site to advise families on how to ice down a corpse until mortuary workers could collect it.

But public health officials acknowledge they have few tools to minimize the impact of a pandemic. Duchin says the best strategy would probably be to close down places where people gather, like Seattle's Pike Place Market. It's a popular gathering spot on the weekends.

Duchin observed that people at the market are "literally in one another's faces." That's an ideal way to spread flu viruses, which pass easily by face-to-face contact through respiratory droplets. It's one of the most contagious germs around.

To slow the spread, Seattle officials say they'd be urging people to stay home from work and avoid going out in public whenever they can. They'll do that early -- when only a few dozen people are sick in the entire county.

Schools are expected to be a main vehicle for expanding a pandemic. Schoolchildren spread flu viruses around the community better than any other group. Duchin says officials would probably close schools early on in an outbreak.

"When I mentioned this to my own wife, I said, 'We have to be prepared to home-school our kids for six to 12 weeks,'" Duchin said. "She looked at me like I had two heads -- both of them bald."

Closing schools, shutting down movie theaters, canceling Seattle Sonics basketball games -- these are almost impossible political decisions.

Seattle Mayor Ole Hanson was vilified when he imposed these classic public health measures during the 1918 pandemic. Hanson resigned and left town within a year.

But Ron Sims, the current chief executive of King County, says he wouldn't hesitate.

"I have no problem pulling the trigger on this; I really don't," Sims said. "Our sole goal is to reduce the prospect of loss of life."

Sims assumes the region will be on its own, partly because every city and town in America would be dealing with its own flu problems.

"We're not waiting for the federal government to come and tell us what to do next," Sims said.

Sims doubts King County can ever be really prepared for a pandemic that would drag on for months.

"We have maximized our effort for King County. We are prepared to move heaven and earth," Sims said. "But we are not prepared to handle 9,000 sick people who need acute care. We're not prepared for that."

Jane Greenhalgh and Anna Vigran produced this report.

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