Amid all the attention given to the gripping developments coming out of the Boston area during the last week and a half, you may have missed the fact that China is battling the spread of a deadly bird flu.

The threat of a bird flu pandemic in China invites the question of whether the health care system is as ready to respond to a flu pandemic as it should be, and there are signs that it isn't. Having killed 22 people and infected 108 as of yesterday, the strength of the strain spreading through China — called H7N9 — is triggering some alarm bells here in the United States. Federal agencies like the Centers for Disease Control and Prevention, the U.S. Geological Survey and the Fish and Wildlife Service have taken preliminary steps to prepare for H7N9.

While the United States has made strides in flu readiness since the H1N1 swine flu spread widely in 2009–2010 — and is poised to make even more progress — some experts say the country is not ready for a flu pandemic.

"If one started tomorrow, I think we'd be in pretty bad trouble," says Darrick Carter, vice president of adjuvant technology for the Infectious Disease Research Institute. The H1N1 pandemic was fairly mild, yet "the system was on the verge of being overloaded," Carter says.

As demonstrated during this winter's strong yet not atypical seasonal flu, hospitals and clinics can't always handle a jump in capacity. Some were overtaxed by extra patients suffering from the seasonal flu and other flu-like illnesses, with at least one hospital taking the step of erecting a tent to deal with the backlog of patients.

The supply chain is one of the major vulnerabilities during a pandemic, with hospitals not always having access to the emergency supplies they need. "It's easy to get it wrong," given the varied and complicated needs of a hospital during times of disaster and emergency, says Nathaniel Hupert, M.D., associate professor of public health and medicine at Weill Cornell Medical College, New York City.

In the 2009–2010 pandemic, the release of supplies from the strategic national stockpile saw some hospitals get equipment that wasn't requested and others that needed certain supplies not getting them.

Problems related to vaccination also exist. Low vaccination rates contribute to the country's lack of readiness, says Terri Rebman, R.N., an associate professor at the Institute for Biosecurity, Saint Louis University College for Public Health and Social Justice.

Health care worker vaccination is a basic tactic for combating a pandemic flu, says Rebman, who also has taken on leadership roles with the Association for  Professionals in Infection Control and Epidemiology. The seasonal vaccine may provide some protection against a pandemic strain, and a worker who gets the seasonal vaccine is more likely to receive a pandemic vaccine, she says.

The decision by some people — in and out of health care — to rely on myth and conjecture as reasons for not getting vaccinated has annoyed me for a while, and particularly since I started covering public health a couple of years ago. The most popular reason in my non scientific experience is that they don't want to get the flu from the vaccine, because "that happened once," they say. That's not true.

It is true that the vaccine is disappointingly less than 100 percent effective, so people can still get the flu after having gotten the vaccine. It's also true that some people with specific health issues shouldn't be vaccinated.

Regardless, more health care workers need to get the vaccine. As of last November, the vaccination rate was 62.9 percent among health care workers, down from 63.4 percent the previous year. Compounding that problem is the fact that the government is not in a position to produce enough of a non seasonal flu vaccine in time to do a lot of good.

That could change soon, if novel approaches to producing vaccines bear fruit. In January, the Food and Drug Administration approved a new, quicker vaccine manufacturing approach relying on recombinant DNA and a modified baculovirus, which is a virus that infects insects. In November, the FDA had approved the first cell-based vaccine for seasonal flu, a method that Health & Human Services stated is more flexible and reliable than traditional egg-based vaccines.

Carter also points to work being done with IDRI's participation to speed vaccine creation using a tobacco-related plant as the vehicle. "They genetically engineer the tobacco leaves to produce flu vaccine," he says.

Personally, I'm not sure that recombining insect viruses and genetically engineering tobacco leaves are going to help much in the effort to get more people to want to get vaccinated. They both sound as though they could play a role in the beginning of a movie starring Bruce Willis or Arthur Hill. But during a serious pandemic, concerns about vaccines may be swept away as the instinct for self-preservation kicks in. I know the H1N1 scare converted at least one former colleague of mine who was a vaccine non believer into getting the shot. One of my grown daughters, though, refuses every year despite a strategic amount of nagging.

And Weill Cornell's Hupert says H1N1 did lead to general improvement in readiness. "The nation as a whole in the health care system is probably better positioned now based on the experiences of H1N1," Hupert says. "I think there's been a tremendous amount of learning that we as a health care system … have accomplished."