Protecting Poultry Workers from Avian Influenza (Bird Flu) - DEPARTMENT OF HEALTH AND HUMAN SERVICES
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Protecting Poultry Workers
from Avian Influenza (Bird Flu)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
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DHHS (NIOSH) Publication Number 2008–113
February 2008
Safer • Healthier • People™Protecting Poultry Workers from Avian
Influenza (Bird Flu)
WARNING!
During an outbreak of avian influenza (bird flu), poultry workers* may become
seriously ill or die after contact with infected poultry or contaminated materials.
All poultry workers and all owners and opera- Keep your poultry flock isolated from out-
tors of poultry operations should take the fol- side environments.
lowing steps to protect themselves from avian
influenza: Prevent flocks from contacting wild birds
and water sources that might be contami-
nated by wild birds.
Take the following steps BEFORE an
outbreak of avian influenza: Allow only essential workers and vehicles to
enter the farm and poultry houses.
1. Make sure that an avian influenza response
plan has been developed to complement re- Provide clean protective clothing, equip-
gional, State, and industry plans. ment, and disinfection facilities for workers.
Use the CDC guidance presented in the full Thoroughly clean and disinfect equipment
Alert to develop a response plan. and vehicles entering and leaving the farm.
Select a response plan manager. Include tires and undercarriage.
Coordinate your avian influenza response Do not borrow equipment or vehicles from
plan with appropriate State animal and other farms and do not lend yours.
public health agencies.
Avoid visiting other poultry farms.
Make sure that workers are aware of the
avian influenza response plan and their re- If you do visit another farm or a live-bird
sponsibilities. market, change footwear and clothing be-
fore contacting your own flock again.
2. Follow biosecurity practices to keep avian in-
fluenza and other diseases out of your poultry *Poultryworkers include all workers who may contact poultry
flock: or materials or environments contaminated by poultry. Do not bring birds from slaughter channels Don’t wait to report sick birds! Early detec-
(especially live-bird markets) back to the tion of avian influenza is essential to pre-
farm. vent its spread.
3. Know the signs of avian influenza in poultry. 5. Know the possible signs and symptoms of
avian influenza in humans infected with the
Be aware of the signs of avian influenza highly pathogenic H5N1 virus:
infection with the highly pathogenic H5N1
Fever
virus in poultry:
Cough
— Sudden death without clinical signs or
symptoms Shortness of breath
— Lack of coordination Sore throat
— Lack of energy and appetite Muscle aches
Conjunctivitis (redness, swelling, and pain
— Soft-shelled or misshapen eggs
in the eyes and eyelids)
— Decreased egg production
Diarrhea
— Purple discoloration of the wattles,
combs, and legs 6. Consider getting the current season’s flu
shot.
— Swelling of the head, eyelids, combs,
7. Train workers in all guidance and recommen-
wattles, and hocks
dations presented in this Alert.
— Diarrhea
— Nasal discharge
Take the following steps DURING an
outbreak of avian influenza:
— Coughing and sneezing
1. Follow the avian influenza response plan.
4. Report sick or dying birds immediately! 2. Ask your doctor about taking antiviral medica-
tion.
Immediately report any sick or dying birds
in your poultry flock to the proper authori- 3. Wear personal protective clothing.
ties: Wear the following personal protective
— Call the U.S. Department of Agriculture clothing if you may be exposed to an avian
(USDA) toll free at 1–866–536–7593. influenza virus:
— Or contact your State veterinarian or lo- — Outer garments (aprons or coveralls)
cal extension agent. — Gloves
(Continued)— Foot protection (boots or boot covers) workers adequately from avian influenza, do
the following:
— Head protection (head cover or hair
cover) Designate a qualified person to oversee the
Choose disposable, impermeable, light- program and answer workers’ questions.
weight protective clothing. Provide workers with respirator training and
Wear disposable, lightweight, waterproof fit-testing to assure a safe and comfortable
gloves (8- to 12-mil nitrile or vinyl, for ex- seal for the respirator facepiece.
ample) or heavy-duty, 18-mil rubber gloves Include all workers who may be at risk of
that are reusable after disinfection. exposure to avian influenza virus.
Use disposable boot covers or boots that
can be reused after disinfection. 7. Protect yourself when removing personal pro-
tective clothing or equipment.
Use disposable head covers or hair cov-
ers. With your respirator, goggles, and gloves on,
remove all personal protective clothing.
4. Wear eye protection. — Place disposable clothing in approved,
When working with poultry, wear unvented secure containers† for disposal.
or indirectly vented safety goggles, a res- — Place reusable clothing in approved, se-
pirator with a full facepiece, or a powered,
cure containers for cleaning and disin-
air-purifying respirator (PAPR) with a loose-
fection.
fitting hood or helmet and face shield.
Remove gloves and discard them in an ap-
Remove eye protection carefully to prevent
proved, secure container for biohazardous
contaminated equipment from contacting
wastes.
eyes, nose, or mouth.
— Thoroughly wash hands with soap and
5. Wear respirators. water.
Wear a NIOSH-approved, air-purifying res- — If no hand-washing facilities are avail-
pirator with a particulate filter whenever able, use waterless soaps or alcohol-
you are working in poultry barns or may be based sanitizers provided by your em-
exposed to infected poultry or virus-con- ployer.
taminated materials or environments.
†
Use a particulate filter that is rated N–95 Approved, secure containers should be (1) closable, (2) con-
or better. structed to contain all contents and prevent leakage of fluids
during handling, storage, transport, or shipping, (3) labeled
or color-coded, and (4) closed before removal, in accordance
6. Follow a written respiratory protection pro- with the OSHA standard in the Code of Federal Regulations
gram. To make sure that respirators protect [29 CFR 1910.1030(d)(4)(iii)(B)].— Be careful about using waterless soaps exposed birds or to virus-contaminated
or alcohol-based sanitizers too often, materials or environments:
as they can be very harsh to the skin.
— Fever
Next, carefully remove your goggles and — Cough
then your respirator.
— Shortness of breath
— Thoroughly wash hands again with soap
and water. — Sore throat
— If no hand-washing facilities are avail- — Muscle aches
able, use waterless soaps or alcohol- — Conjunctivitis (eye infections)
based sanitizers provided by your em-
ployer. — Diarrhea
8. Use good hand hygiene (proper use of gloves, Tell the health care provider about the pos-
hand-washing, and waterless hand sanitizers) sible avian influenza exposure before the ill
and the decontamination procedures outlined person arrives.
here to prevent infection, avoid taking viruses Promptly report suspected human cases to
home, and keep them from spreading to other supervisors and to local health authorities.
farms.
9. Shower at the end of the work shift and leave all For additional information, see NIOSH Alert: Protect-
contaminated clothing and equipment at work. ing Poultry Workers from Avian Influenza (Bird
Flu) [DHHS (NIOSH) Publication No. 2008–113]. To
Shower at the worksite or at a nearby de- request single copies of the Alert, contact NIOSH at
contamination station.
1–800–CDC–INFO (1–800–232–4636)
Never wear contaminated clothing or equip- TTY: 1–888–232–6348
E-mail: cdcinfo@cdc.gov
ment outside the work area.
or visit the NIOSH Web site at
10. Participate in health surveillance and monitor- www.cdc.gov/niosh
ing programs. For a monthly update on news at
Make sure a surveillance program has been NIOSH, subscribe to NIOSH eNews by
visiting www.cdc.gov/niosh/eNews
established to identify symptomatic work-
ers for 10 days after exposure to infected DEPARTMENT OF HEALTH AND HUMAN SERVICES
birds or virus-contaminated materials or Centers for Disease Control and Prevention
environments. National Institute for Occupational Safety and Health
Seek immediate medical care for workers
who develop any of the following symptoms
within 10 days of exposure to infected orProtecting Poultry Workers from
Avian Influenza (Bird Flu)
WARNING!
During an outbreak of avian influenza (bird flu), poultry workers* may become
seriously ill or die after contact with infected poultry or contaminated materials.
The National Institute for Occupational Workers at egg production facilities
Safety and Health (NIOSH) requests (caretakers, layer barn workers, and
help in protecting poultry workers from chick movers)
infection with viruses that cause avian Veterinarians and their staff who work
influenza (also known as bird flu). Al- with poultry
though human infection with avian in-
Disease control and eradication work-
fluenza viruses is rare, workers infected
ers on poultry farms (State, Federal,
with certain types of these viruses may
contract, and poultry farm workers)
become ill or die.
This Alert describes the following:
Some types of avian influenza viruses
can cause serious illness or death in 1. Avian influenza in humans
poultry and other birds. These viruses
2. Avian influenza outbreaks in chickens
are referred to as highly pathogenic
viruses. Rarely, these viruses may be 3. Recommendations for protecting poul-
passed to humans who contact infected try workers from avian influenza
poultry or virus-contaminated materials
or environments. Remember these facts:
No avian influenza epidemic now ex-
The following workers are at risk of in-
ists in humans.
fection with highly pathogenic avian in-
fluenza viruses: Scientists are currently most con-
cerned about the highly pathogenic
Poultry growers and their workers
*Poultryworkers include all workers who may contact
Service technicians of poultry grow- poultry or materials or environments contaminated
ers by poultry.
1avian influenza A virus known as Influenza A viruses are divided into two
H5N1. As of February 2008, all hu- groups based on their pathogenicity (capac-
man cases of influenza caused by ity to cause disease) to poultry:
this virus have occurred outside the
United States.† Low-pathogenic avian influenza vi-
ruses, which cause a mild disease or no
The avian influenza virus rarely in-
noticeable signs of disease, and
fects humans.
Highly pathogenic avian influenza vi-
The avian influenza virus does not
ruses, which cause serious disease and
pass easily from person to person.
high rates of death.
NIOSH requests that owners and opera-
Scientists are currently most concerned
tors of poultry operations follow the rec-
about the highly pathogenic avian influenza
ommendations in this Alert and use the
A virus known as H5N1.‡ Although the H5N1
controls presented here.
virus causes serious illness in birds, it has
rarely infected humans.
NIOSH also requests that safety and
health officials, editors of trade jour-
The first known cases of human infec-
nals, labor unions, and employers bring
tion with H5N1 avian influenza occurred in
the recommendations in this Alert to
1997 in Hong Kong. Outbreaks of H5N1
the attention of all poultry workers and
avian influenza in poultry and some cases
poultry farm operators.
in humans began again in Asia in late 2003
and continue to be reported there. In addi-
tion, outbreaks in birds and humans have
BACKGROUND been reported in Africa, and outbreaks in
birds have occurred in Europe. As of Febru-
ary 2008, no outbreaks in birds or humans
What is avian influenza? have been reported in North, Central, or
Avian influenza is caused by influenza A vi- South America.
ruses and occurs worldwide in many species
of birds. For this reason, avian influenza is Avian influenza outbreaks from the H5N1
often referred to as “bird flu.” virus have occurred in birds in more than
50 countries and in humans in 12 coun-
Avian influenza viruses normally reside in the tries (see WHO [2008] at www.who.int/csr/
intestinal tracts (guts) of water and shore disease/avian_influenza/en/).
birds, and they usually cause little if any dis-
ease. Only a few of these viruses can cause
Important avian influenza facts
disease in other animals and in humans—
for example, the highly pathogenic H5N1 Remember the following facts about the
and H7N7 viruses. highly pathogenic H5N1 virus:
†
For current information about outbreaks of avian
influenza around the world, see www.cdc.gov/flu/ ‡
In this document, H5N1 always refers to the highly
avian/outbreaks/current.htm. pathogenic form of avian influenza virus.
2 Avian Influenza Most human infections with this virus mild symptoms (such as ruffled feath-
have resulted from contact with infected ers or a drop in egg production).
poultry or virus-contaminated materials
or environments. 2. What is the risk of infection to
H5N1 virus rarely infects humans. humans?
When this virus does infect humans, it Avian influenza viruses do not usually
does not pass easily from person to per- infect humans. However, 353 human
son—that is, transmission between hu- cases of avian influenza A (H5N1) were
mans has not been efficient or sustained reported to the World Health Organization
[DHHS 2006]. (WHO) between late 2003 and January
As of February 2008, the H5N1 virus has 24, 2008 [WHO 2008]. About 63% of
not been detected in the United States. these cases (221) were fatal. No human
cases have been reported within North,
H5N1 virus can be spread from one lo- Central, or South America.
cation to another through
—— migrating birds (which may not show H5N1 virus can be transmitted to people
symptoms of disease) and who contact infected poultry or virus-
contaminated materials or environments.
—— legal and illegal trade in poultry and This type of transmission has not been
other birds as well as their products. frequent or sustained from one human to
If the virus changes so that it can be eas- another.
ily passed from one person to another,
it could cause a pandemic (worldwide) Health risks related to human exposure
influenza outbreak in humans. to the low-pathogenic avian influenza vi-
ruses are poorly understood, but they are
thought to be minimal. Only rare cases of
human infection with low-pathogenic vi-
FREQUENTLY ASKED QUESTIONS ruses have been reported. Nonetheless,
anyone likely to have prolonged exposure
to any avian influenza virus should take
1. How are poultry affected by
protective measures.
avian influenza?
Domestic poultry may be infected with ei-
ther low-pathogenic or highly pathogenic
viruses through contact with infected
poultry, wild birds, or virus-contaminated
materials or environments:
Highly pathogenic avian influenza vi-
ruses spread quickly and may kill an
entire poultry flock in 48 hours.
Low-pathogenic avian influenza virus-
es may go unnoticed or cause only Photograph courtesy of USDA.
Avian Influenza 3Examples of workers at risk include the Litter
following:
Egg flats
Poultry growers and their workers Cages
Service technicians of poultry growers For more information about human in-
fection with avian influenza viruses, see
Caretakers, layer barn workers, and chick
www.cdc.gov/flu/avian/gen-info/avian-flu-
workers at egg production facilities
humans.htm.
Veterinarians and their staff who work
with poultry
4. Why are scientists concerned
Workers involved in disease control about the H5N1 virus?
and eradication on poultry farms
(Federal, State, contract, and poultry Scientists are concerned about the
farm workers) H5N1 virus for the following reasons:
H5N1 virus causes serious illness and
death in poultry and therefore threatens
domestic poultry throughout the world.
This virus can cause serious illness
and death in humans.
If a strain of H5N1 changes so that
it is highly infectious to humans and
spreads easily from person to person,
it could cause an influenza p andemic.
Public health authorities are monitoring
outbreaks of human illness linked with
avian influenza. To date, human infec-
3. How is the virus passed to tions with highly pathogenic avian influ-
humans? enza viruses identified since 1997 have
not resulted in continued transmission
Avian influenza virus is excreted in the
from one person to another.
droppings, saliva, and nasal secretions
of infected birds. The virus is believed to
enter humans through the mouth, nose,
or eyes. Scientists believe that the virus REPORTED OUTBREAKS
is most often passed to humans from
contact with infected poultry that was Current news about avian influenza deals
sick or dead. Contact with the following mostly with human illness caused by the
materials or equipment may also be a H5N1 virus. However, human infections
source of infection: have also been caused by other subtypes
of avian influenza virus such as H7N7 and
Droppings
H7N3. The following reports describe out-
Feathers breaks involving several subtypes of highly
4 Avian Influenzapathogenic avian influenza virus. One report infected flocks (about 30 million chickens).
describes an outbreak in poultry alone, with The virus may have been introduced to the
no reported human cases. commercial flocks by infected wild ducks.
At the time of the outbreak, local authorities
Report 1—Eighteen H5N1 human believed the risk to humans was low. How-
cases in Hong Kong, 1997 ever, 89 human infections were identified,
with health complaints primarily consisting
An outbreak of H5N1 avian influenza oc-
of conjunctivitis. Mild, influenza-like illness
curred in humans and poultry in Hong Kong
was associated with the conjunctivitis in a
during 1997. This outbreak involved 18 con-
few cases.
firmed human cases, including six deaths
[Chan 2002].
However, one human fatality occurred in a
veterinarian who had not received antivi-
The first human case occurred in May, soon
ral medication but had spent a few hours
after outbreaks in poultry were reported at
screening flocks that were later confirmed to
three farms. Seventeen more human cases
be infected with the H7N7 virus. The high-
occurred in November and December after
est risk of infection was in veterinarians and
infected poultry were found in wholesale
workers who culled infected poultry.
and retail markets. Many of the infected hu-
mans had visited either a retail poultry stall
The outbreak was brought under control in
or a live poultry market before becoming ill about 2 months by culling infected flocks.
[Mounts et al. 1999]. All chickens and other An outbreak-management response team
poultry in Hong Kong were culled (destroyed) advised all workers who screened and
to stop the outbreak. No additional human culled poultry to wear goggles and respira-
cases were detected during this outbreak tors to reduce their exposures to the avian
after the culling operation was complete. influenza virus. The team recommended
that vaccination with the current flu vaccine
Commercial poultry cullers and workers were be made mandatory for all poultry farmers
not included among the 18 cases described and their families within a 3-kilometer ra-
here. However, laboratory tests showed that dius of infected farms. They stressed the
about 3% of poultry cullers and 10% of importance of hand washing and personal
poultry workers showed evidence of earlier hygiene at home. Immediate treatment with
infection with H5N1 virus [Bridges 2002]. oseltamivir (Tamiflu®) was recommended for
all new conjunctivitis cases and a preventive
dose (75 mg daily) was started for all per-
Report 2—Eighty-nine H7N7
sons handling potentially infected poultry.
human cases in the Netherlands, This dose was continued for 2 days after the
2003 last exposure.
In February 2003, a large outbreak of avian
influenza was caused by the highly patho-
Report 3—Two H7N3 human cases
genic H7N7 virus in commercial poultry
farms in the Netherlands [Koopmans et al.
in Canada, 2004
2004]. The infection spread to approximate- On February 19, 2004, the Canadian Food
ly 255 farms and resulted in the culling of all Inspection Agency announced an outbreak
Avian Influenza 5of avian influenza in poultry from highly the flock. The flock was culled on February
pathogenic H7N3 virus in the Fraser Val- 21, 2004. No human infections were re-
ley region of British Columbia [Tweed et ported.
al. 2004; CDC 2006a]. Health Canada re-
ported two cases of laboratory-confirmed
H7N3 infections in humans. Both patients Report 5—Eight H5N1 human
were poultry workers; one was involved in cases in Indonesia, 2006
culling operations on March 13−14, 2004,
and the other had close contact with poul- Poultry in Indonesia and other nearby coun-
try on March 22−23, 2004. Both patients tries have suffered continuing outbreaks of
developed conjunctivitis and other flu-like illness from the H5N1 virus in 2006 and
symptoms. Their illnesses resolved after 2007. This virus is considered to be en-
treatment with antiviral medication (oselta- trenched in poultry throughout much of In-
mivir). Ten other poultry workers developed donesia. This widespread presence of the
conjunctivitis symptoms and/or upper respi- virus and local conditions have resulted in
ratory symptoms after contacting poultry. a substantial number of human cases (102
However, these infections were not labora-
cases since 2005).
tory-confirmed as H7N3 infections.
In June 2006, Indonesia became the focus
Culling operations by Federal workers and of media attention when H5N1 was identi-
other measures were undertaken to control fied in an outbreak involving eight members
the spread of the virus. Authorities required of an extended family in northern Sumatra
personal protective equipment for all persons
[Butler 2006]. No samples were taken from
involved in culling activities. This equipment
the first patient, a 37-year-old woman who
included N–95 respirators, gloves, goggles,
became ill on April 24 and died on May 4.
biosafety suits, and footwear. Authorities
also monitored compliance with prescribed However, samples from seven other family
safety measures. Epidemiologic, laboratory, members confirmed the presence of H5N1
and clinical surveillance was done for signs virus. Investigators assumed that the first
of avian influenza in exposed persons. How- patient was also infected with H5N1 virus
ever, no person-to-person transmission was (which she is thought to have contract-
detected during this outbreak. ed from infected poultry). In all, seven of
the eight infected family members died. A
25-year-old brother of the first patient sur-
Report 4—H5N2 in poultry, Texas, vived.
2004: no human cases
The outbreak was considered to be con-
In February 2004, an outbreak of avian in-
trolled on June 12, 2006—3 weeks after
fluenza from highly pathogenic H5N2 virus
was detected in a flock of 7,000 chickens the death of the last victim—with no new
in south-central Texas [Lee et al. 2005]. cases reported. This cluster of H5N1 cases
The chickens at the affected farm were be- is the first instance in which WHO reported
ing sold to live-bird markets in Houston. Ap- that human-to-human transmission may
proximately 1,700 chickens had been sold have occurred. Concerns over the cluster of
to the live-bird markets about a week before cases have eased since no other large clus-
the laboratory confirmed avian influenza in ters of human cases have been identified.
6 Avian InfluenzaPreventive steps
CONCLUSIONS
Additional efforts are needed to prevent new
cases of avian influenza in humans. In Thai-
Outbreaks in Birds land, public health education campaigns and
media reports about avian influenza have
In birds, outbreaks of the H5N1 virus continue
reached rural people at greatest risk [Olsen
to spread in Europe, Asia, and Africa. These
et al. 2005]. However, this information has
outbreaks are on a scale that has not been
not resulted in changed behavior to control
seen before. Continued worldwide spread of
risks for many Thai people. Culling flocks of
this virus will place poultry and poultry work-
ill birds has been highly effective in controlling
ers at increased risk of infection.
some avian influenza outbreaks. But this pre-
ventive measure may not be effective in areas
Human cases of Southeast Asia, where backyard flocks are
common and poultry movement is difficult to
Since January 2003, WHO has published control [CDC 2004a,b; Olsen et al. 2005].
the numbers of confirmed human illnesses
and deaths from the H5N1 virus. Between Poultry producers in the United States and
January 2003 and January 24, 2008, WHO around the world should take preventive steps
reported 353 confirmed human cases of in- to protect their workers and poultry flocks.
fection with H5N1 virus in 14 countries— Poultry producers can substantially reduce the
Azerbaijan, Cambodia, China, Djibouti, risk to workers if they follow the recommenda-
Egypt, Indonesia, Iraq, Laos, Myanmar, Ni- tions listed in the following section.
geria, Pakistan, Thailand, Turkey, and Viet-
nam [WHO 2008]. Of these cases, 221
(63%) were fatal.
RECOMMENDATIONS FOR PRO-
In 2007, Indonesia reported 42 new hu- TECTING POULTRY WORKERS
man cases of avian influenza, followed by
Egypt (25), Vietnam (8), China (5), Laos NIOSH recommends the following preventive
(2), Cambodia (1), Myanmar (1), Nigeria steps for protecting poultry workers who are
(1), and Pakistan (1) [WHO 2008]. at risk of exposure to avian influenza virus-
es. These recommendations are discussed
Human cases of avian influenza have most in more detail in the following subsections.
often been linked to close human contact Recommendations are intended for both
with sick or dying poultry from backyard op- poultry producers (owners and operators of
erations. Such contact is common in coun- poultry farms) and poultry workers.
tries where poultry are numerous and birds
are not generally confined by enclosures.
Summary of recommendations
Continued sporadic infections of humans Take the following steps BEFORE an
with H5N1 could increase the chances that outbreak of avian influenza:
the virus will change so that it can pass more
easily from human to human. This change 1. Make sure that an avian influenza re-
could result in an influenza pandemic. sponse plan has been developed.
Avian Influenza 72. Follow the biosecurity practices pre- 9. Shower at the end of the work shift and
sented in this Alert. leave all contaminated equipment and
3. Know the signs of avian influenza in clothing at work.
poultry. 10. Participate in health surveillance and
4. Report sick or dying birds immediately. monitoring programs.
5. Know the possible signs and symptoms
of avian influenza in humans. Detailed recommendations
6. Consider getting the current season’s Take the following steps BEFORE an
flu shot. outbreak of avian influenza:
7. Train workers in all guidance and rec-
ommendations presented in this Alert. 1. Make sure that an avian influenza
response plan has been developed
Take the following steps DURING an to complement regional, State, and
outbreak of avian influenza: industry plans.
1. Follow the avian influenza response plan. Use the following guidance to develop
an avian influenza response plan:
2. Ask your doctor about taking antiviral
medication. —— CDC guidance in this Alert and at
the following Web site: www.cdc.
3. Wear personal protective clothing:
gov/flu/avian
—— Outer garments (impermeable aprons
—— The USDA national plan for re-
or coveralls)
sponding to an outbreak of highly
—— Gloves pathogenic avian influenza in the
—— Footwear (boots or boot covers)
—— Disposable head cover or hair cover
4. Wear eye protection (goggles or a full-
facepiece respirator).
5. Wear a NIOSH-certified, air-purifying res-
pirator with a particulate filter (N–95 or
better).
6. Follow a written respiratory protection
program.
7. Protect yourself when removing person-
al protective equipment and clothing.
8. Use good hand hygiene (proper use of
gloves, hand-washing, and waterless
hand sanitizers) and decontamination
procedures.
8 Avian InfluenzaUnited States [APHIS 2007b]: —— Use EPA-registered disinfectants
www.aphis.usda.gov/newsroom/ that are labeled as effective
hot_issues/avian_influenza/avi- against influenza viruses.
an_influenza_summary.shtml. This —— Use heating and drying (which in-
plan is intended to complement re- activate the viruses).
gional, State, and industry plans.
Do not borrow equipment or vehicles
Select a response plan manager. from other farms and do not lend
Coordinate your avian influenza re- yours.
sponse plan with appropriate State Avoid visiting other poultry farms.
animal and public health agencies.
If you do visit another farm or a live-
Make sure that workers are aware bird market, change footwear and
of the avian influenza response plan clothing before contacting your own
and their responsibilities. flock again.
Do not bring birds from slaughter
2. Follow biosecurity practices to keep channels (especially live-bird mar-
avian influenza and other diseas- kets) back to the farm.
es out of your poultry flock [APHIS
2007a]: 3. Know the signs of avian influenza in
poultry.
Keep your poultry flock isolated from
outside environments. Be aware of the signs of avian influenza
infection in poultry so that you can do
Prevent flocks from contacting wild
the following:
birds and keep them away from wa-
ter sources that might be contami- Recognize sick birds
nated by wild birds.
Quarantine the farm to prevent the
Allow only essential workers and ve- spread of disease
hicles to enter the farm and poultry
Protect workers from infection
houses.
In domestic poultry, signs of infection
Provide clean protective clothing,
with the highly pathogenic H5N1 virus
equipment, and disinfection facilities
may vary depending on the viral strain,
for workers.
age and species of bird, other existing
Thoroughly clean and disinfect equip- diseases in the poultry, and environment.
ment and vehicles entering and The signs may include the following:
leaving the farm. Include tires and
undercarriage. Sudden death without clinical signs
or symptoms
—— Use detergents and disinfectants
Lack of coordination
(avian influenza viruses are sen-
sitive to most). Lack of energy and appetite
Avian Influenza 9 Soft-shelled or misshapen eggs Shortness of breath
Decreased egg production Sore throat
Purple discoloration of the wattles, Muscle aches
combs, and legs
Conjunctivitis (redness, swelling, and
Swelling of the head, eyelids, combs, pain in the eyes and eyelids)
wattles, and hocks
Diarrhea
Diarrhea
Watch for these signs and symptoms of
Nasal discharge avian influenza for up to 10 days after
exposure to infected or exposed birds
Coughing and sneezing
or to virus-contaminated materials or
Some birds may be infected with avian environments.
influenza but appear to be healthy.
So far, conjunctivitis has been extremely
4. Report sick or dying birds immedi- rare in humans infected with the high-
ately. ly pathogenic H5N1 virus—but it is a
common symptom in humans infected
Immediately report any sick or dy- with the highly pathogenic H7N7 virus.
ing birds in your poultry flock to the Avian influenza can also lead to pneu-
proper authorities: monia, acute respiratory distress, and
—— Call the U.S. Department of Ag- other life-threatening complications.
riculture (USDA) Veterinary Ser-
vices toll free at 6. Consider getting the current sea-
son’s flu shot.
1–866–536–7593
CDC recommends the current season’s
—— Or contact your State veterinar- flu shot for workers involved in avian in-
ian or local extension agent. fluenza control activities. Other poultry
Don’t wait to report sick birds. workers should also consider getting the
Early detection of avian influenza is current flu shot. Although a flu shot will
essential to prevent its spread. not prevent infection with avian influen-
za, it could prevent dual infection—that
is, infection with both an avian influ-
5. Know the possible signs and symp-
enza virus and a human influenza virus
toms of avian influenza in humans.
at the same time. Such dual infection
might result in the formation of new vi-
Know the signs and symptoms of avian
ral strains. If one of these new strains
influenza in humans infected with the
passes easily from person to person, an
highly pathogenic H5N1 virus so that ill
influenza pandemic could result.
persons can be treated immediately:
For information about dual infection, use
Fever
of antiviral medications, and vaccination
Cough of poultry workers, see the CDC Web site
10 Avian Influenzaon avian influenza at www.cdc.gov/flu/ garments, or coveralls), hands (gloves),
avian/index.htm. feet (boots or boot covers), and head
(head covers or hair covers) from expo-
7. Train workers in all guidance and sure to harmful agents. Many poultry
recommendations presented in this workers routinely wear personal protec-
Alert. tive clothing.
Take the following steps DURING an Poultry workers should be required to
outbreak of avian influenza: wear personal protective clothing when-
ever they may be exposed to avian influ-
1. Follow the avian influenza response enza viruses. Such clothing will prevent
plan.
skin contact with virus-contaminated
2. Ask your doctor about taking antivi- materials or environments. It will also
ral medication. reduce the chances of carrying contam-
inated material outside the poultry barn
Before you begin disease control activi- or worksite.
ties during an outbreak of avian influen-
za, ask your doctor about taking antivi- Outer garments. When selecting pro-
ral medication. The Centers for Disease tective outer garments such as aprons
Control and Prevention (CDC) recom- or coveralls, take the following steps:
mends that workers receive an influenza
antiviral drug daily for the entire time they Select impermeable, disposable pro-
are in direct contact with infected poultry tective clothing when possible.
or with virus-contaminated materials or
environments [CDC 2006b]. In addition, Select lightweight clothing when ap-
the Occupational Safety and Health Ad- propriate to protect workers from
ministration (OSHA) recommends that heat stress. For example, choose a
workers take the antiviral drug for 1 week lightweight impermeable coverall in-
following exposure [OSHA 2006]. stead of a chemical-resistant suit if
possible.
Oseltamivir is currently the antiviral drug
most often used for influenza. This drug Gloves. Gloves may be lightweight and
is preferred because the avian influenza disposable (8- to 12-mil nitrile or vinyl,
virus is less likely to be resistant to it for example), or they may be heavy duty
than to amantadine or rimantadine (two rubber (18 mils thick or greater) and re-
other drugs used to prevent or treat usable after disinfection. Gloves should
influenza A). A fourth drug, zanamivir, be waterproof. When selecting gloves,
may be considered as an alternative to consider the following:
oseltamivir for prophylaxis when avail-
able [Hayden and Pavia 2006]. Activities performed by the w
orker
3. Wear personal protective clothing. Dexterity requirements
Personal protective clothing is clothing Need for glove durability and resis-
that protects the torso (aprons, outer tance to tearing and abrasion
Avian Influenza 11Regardless of the type of gloves select- —— indirectly vented.
ed, make sure they do not make exist-
If indirectly vented goggles are prop-
ing dermatitis worse or damage healthy
erly fitted and have a good antifog
skin from prolonged exposure to water
coating, they may be used by poultry
or sweat. Wearing a thin cotton glove
workers with a low risk of exposure to
under a protective outer glove may pre-
avian influenza. However, such gog-
vent dermatitis.
gles are not airtight and will not pre-
vent exposures to airborne material.
Foot protection. Select disposable
boot covers or boots that can be disin- Do not use directly vented goggles
fected. These will protect workers from or safety glasses for working with
contact with harmful agents and will infected birds. They do not protect
prevent them from being carried from workers from fine particles, splash-
one location to another. es, or aerosols.
Head protection. Select disposable, If you need prescription lenses,
lightweight head covers or hair covers. use
—— protective eyewear with built-in
Sources of personal protective prescription lenses,
clothing and equipment. For sources
and manufacturers of personal protec- —— lens inserts,
tive clothing or other personal protec- —— protective eyewear that fits
tive equipment, see the Buyer’s Guide snugly over prescription glasses
of the International Safety Equipment without changing their position
Association [www.safetyequipment.org]. or obstructing vision (such as
full-facepiece respirators, PAPRs
4. Wear eye protection. with hoods or helmets, and some
Eye protection is important to prevent styles of goggles), or
eye contact with virus-contaminated —— contact lenses with goggles, a
dusts, droplets, and aerosols and to respirator with a full facepiece, or
keep workers from touching their eyes a PAPR with a loose-fitting hood
with contaminated fingers or gloves. or helmet and face shield.
When working with poultry, wear un- Fit eye protection and respirators at
vented or indirectly vented safety the same time:
goggles, a respirator with a full face- —— Some goggles can change the fit
piece, or a powered, air-purifying of a full-facepiece respirator.
respirator (PAPR) with a loose-fitting
—— Eye protection may interfere with
hood or helmet and face shield.
the seal of a half-facepiece res-
If you wear safety goggles, make pirator.
sure they are either
Wear your eye protection or prescrip-
—— unvented (eyecup goggles, for tion glasses when you check the
example) or seal of a respirator before each use.
12 Avian InfluenzaGlasses should not protrude into the Designate a person trained in the se-
seal area of a full-facepiece respira- lection, use, and fitting of respirators
tor. to oversee the program and answer
workers’ questions.
Remove eye protection carefully to
prevent contaminated equipment from Provide workers with respirator train-
contacting eyes, nose, or mouth. ing and fit testing to assure a safe
and comfortable seal for the respira-
For more information about eye safety, tor facepiece.
see www.cdc.gov/niosh/topics/eye. Include all workers who may be at risk
of exposure to avian influenza virus.
5. Wear a NIOSH-certified, air-purifying
See Safety and Health Topics: Respira-
respirator with a particulate filter
tory Protection [OSHA 2005] at www.
(N–95 or better).
osha.gov/SLTC/respiratoryprotection/
In agricultural environments, respirators index.html for more information about
are important to prevent exposures to respiratory protection programs and
viruses as well as to other agents such respirators.
as bacteria, fungi, and endotoxins.
7. Protect yourself when removing per-
Wear a NIOSH-certified, air-purifying sonal protective clothing and equip-
respirator with a particulate filter (N–95 ment.
or better) whenever you are working in
Protect yourself and prevent the avian
poultry barns or may be exposed to
influenza virus from spreading to other
infected poultry or virus-contaminated
areas by taking these steps when remov-
materials or environments. These are
ing protective clothing and equipment:
the most practical and appropriate
respirators for such use. With your respirator, goggles, and
See Table 1 to compare the costs gloves on, remove all personal pro-
and advantages of the five types of tective clothing.
air-purifying respirators.
—— Place disposable clothing in ap-
See NIOSH Respirator Selection proved, secure containers§ for bio-
Logic [NIOSH 2005] and Histoplas- hazardous wastes (see the OSHA
mosis—Protecting Workers at Risk standard [ 29 CFR** 1910.1030(d)
[NIOSH 2004] for more information (4)(iii)(B)]).
about selecting and using respira-
tors for infectious agents.
Approved, secure containers should be (1) closable,
§
(2) constructed to contain all contents and prevent
6. Follow a written respiratory protec- leakage of fluids during handling, storage, transport,
tion program. or shipping, (3) labeled or color-coded, and (4) closed
before removal, in accordance with the OSHA blood-
To make sure that respirators protect borne pathogens standard in the Code of Federal Reg-
ulations [29 CFR 1910.1030(d)(4)(iii)(B)].
workers from avian influenza, do the
following: **Code of Federal Regulations. See CFR in references.
Avian Influenza 13—— Place reusable clothing in ap- alcohol-based sanitizers provided by
proved, secure containers for your employer.
cleaning and disinfection.
Be careful about using waterless
Remove gloves and discard them in soaps or alcohol-based sanitizers
an appropriate, secure container for too often. They can be very harsh to
biohazardous wastes. the skin.
9. Shower at the end of the work shift
—— Thoroughly wash your hands with
soap and water. and leave all contaminated clothing
and equipment at work.
—— If no hand-washing facilities are
available, use waterless soaps or Shower at the worksite or at a nearby
alcohol-based sanitizers provided decontamination station.
by your employer. Never wear contaminated clothing or
Next, carefully remove your goggles equipment outside the work area.
and then your respirator.
10. Participate in health surveillance
and monitoring programs.
Thoroughly wash your hands again
with soap and water. If no hand- Make sure a surveillance program
washing facilities are available, use has been established to identify
waterless soaps or alcohol-based workers who develop symptoms of
sanitizers provided by your employer. avian influenza.
Seek immediate medical care for
8. Use the good hand hygiene and de- workers who develop any of the fol-
contamination procedures outlined lowing symptoms within 10 days of
here to prevent infection, avoid tak-
exposure to infected or exposed birds
ing viruses home, and keep them
or to virus-contaminated materials or
from spreading to other farms:
environments:
Wear gloves whenever you may be
—— Fever
exposed to infected poultry.
Remove your gloves immediately af- —— Cough
ter work and after removing protec- —— Shortness of breath
tive clothing. Dispose of gloves in
containers approved for biohazard- —— Sore throat
ous wastes to prevent the spread of —— Muscle aches
disease (see the OSHA standard [29
CFR 1910.1030(d)(4)(iii)(B)]). —— Conjunctivitis (eye infections)
Wash your hands thoroughly with —— Diarrhea
soap and water. Tell the health care provider about
If no hand-washing facilities are the possible avian influenza expo-
available, use waterless soaps or sure before the ill person arrives.
14 Avian Influenza Promptly report suspected human
cases to supervisors and to local REFERENCES CITED
health authorities.
APHIS [2007a]. Biosecurity for the birds.
Washington, DC: Animal and Plant Health
ACKNOWLEDGMENTS Inspection Service, United States Depart-
ment of Agriculture [www.aphis.usda.gov/
The principle contributors to this Alert were vs/birdbiosecurity/hpai.html].
Greg Kullman, Ph.D., C.I.H.; Lisa J. Delaney, APHIS [2007b]. Draft summary of the na-
M.S., C.I.H.; John Decker, M.S., C.I.H.; Kath- tional avian influenza (AI) response plan,
leen MacMahon, M.S., D.V.M.; and Anne August 2007. Washington, DC: Animal and
Hamilton. Gino Fazio and Vanessa Becks Plant Health Inspection Service, U.S. De-
provided desktop design and production. partment of Agriculture [www.aphis.usda.
gov/newsroom/hot_issues/avian_influenza/
Please direct comments, questions, or re- avian_influenza_summary.shtml].
quests for additional information to the fol-
lowing: Bridges CB, Lim W, Hu-Primmer J, Sims L,
Fukuda K, Mak KH, Rowe T, Thompson WW,
Conn L, Lu X, Cox NJ, Katz JM [2002]. Risk
David Weissman, M.D.
of influenza A (H5N1) infection among poul-
Director, Division of Respiratory Disease
try workers, Hong Kong, 1997–1998. J In-
Studies
fect Dis 185:1005–1010.
National Institute for Occupational Safety
and Health Butler D [2006]. Family tragedy spotlights
1095 Willowdale Road flu mutations. Nature 44(13): 114–115.
Morgantown, WV 26505–2888
CDC (Centers for Disease Control and
Telephone: 304–285–5749
Prevention) [2004]. Cases of influenza A
Or call 1–800–CDC–INFO (1–800–232– (H5N1)—Thailand, 2004. MMWR 53:100–
4636) (TTY: 1–888–232–6348) 103.
We greatly appreciate your assistance in CDC (Centers for Disease Control and Pre-
protecting the health of U.S. workers. vention) [2006a]. Past avian influenza out-
breaks [www.cdc.gov/flu/avian/outbreaks/
past.htm#h7n3canada].
CDC (Centers for Disease Control and Pre-
vention) [2006b]. Interim guidance for
protection of persons involved in U.S. avi-
an influenza outbreak disease control and
eradication activities [www.cdc.gov/flu/avi-
an/professional/protect-guid.htm].
John Howard, M.D.
Director, National Institute for DHHS (U.S. Department of Health and Hu-
Occupational Safety and Health man Services) [2006]. Indonesia situation
Centers for Disease Control and update—May 31 [www.pandemicflu.gov/
Prevention news/indonesiaupdate.html].
Avian Influenza 15Hayden F, Pavia A [2006]. Antiviral manage- 2005–100 [www.cdc.gov/niosh/docs/2005-
ment of seasonal and pandemic influenza. J 100/default.html].
Infect Dis 194 (Suppl 2): S119–S126.
Olsen SJ, Laosiritaworn Y, Pattanasin S, Pra-
Koopmans M, Wilbrink B, Conyn M, Natrop pasiri P, Dowell SF [2005]. Poultry-handling
G, van der Nat H, Vennema H, Meijer A, van practices during avian influenza outbreak,
Steenbergen J, Fouchier R, Osterhaus A, Thailand. Emerg Infect Dis 11:1601–1603.
Bosman A [2004]. Transmission of H7N7
avian influenza A virus to human beings dur- OSHA [2006]. Protecting employees from
ing a large outbreak in commercial poultry avian flu (avian influenza) viruses. Wash-
farms in the Netherlands. Lancet 363:587– ington, DC: U.S. Department of Labor, Oc-
593. cupational Safety and Health Administra-
Lee CW, Swayne DE, Linares JA, Senne DA, tion [www.osha.gov/OshDoc/data_AvianFlu/
Suarez DL [2005]. H5N2 avian influenza avian_flu_guidance_english.pdf].
outbreak in Texas in 2004: the first highly
OSHA [2007]. Safety and health topics: re-
pathogenic strain in the United States in 20
spiratory protection. Washington, DC: U.S.
years? J Virol 79:11412–11421.
Department of Labor, Occupational Safety
Mounts AW, Kwong H, Izurieta HS, Ho Y, Au and Health Administration [www.osha.gov/
T, Lee M, Buxton Bridges C, Williams SW, SLTC/respiratoryprotection/index.html].
Mak KH, Katz JM, Thompson WW, Cox NJ,
Fukuda K [1999]. Case-control study of risk Stegeman A, Bouma A, Elbers ARW, Mart C,
factors for avian influenza A (H5N1) disease, de Jong MCM, Nodelijk G, de Klerk F, Koch
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508. virus (H7N7) epidemic in the Netherlands
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from avian influenza H7N3, British Colum-
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16 Avian InfluenzaAppendix A
Advantages, Disadvantages, and Costs of Air-purifying Respirators
for Protecting Poultry Workers*
Cost
Respirator type† and APF‡ Advantages Disadvantages (2004 dollars)
Avian Influenza
Filtering-facepiece respirator Is lightweight. Provides no eye protection. $0.70 to $10
(disposable; dust mask); APF Needs no maintenance or Provides no protection against irritant gases such
= 10 cleaning. as ammonia.
Has no effect on mobility. Can add to heat burden.
Permits inward leakage at gaps in face seal.
Does not have adjustable head straps on many
models.
Is difficult for a user to do a seal check.
Varies greatly in level of protection provided by dif-
ferent models.
May make communication difficult.
Requires fit testing to select proper facepiece size.
May not fit properly when used with some eye-
wear.
Elastomeric half-facepiece Requires low maintenance. Provides no eye protection. Facepiece: $12 to $35
respirator; APF = 10 Has reusable facepieces and Can add to heat burden. Filters: $4 to $8 each
replaceable filters and car- Permits inward leakage at gaps in face seal.
tridges.
Requires cleaning and disinfection of facepiece
Permits use of dual cartridges before reuse and thus poses a contact exposure
to protect workers from expo- risk.
sures to particles, gases, and
vapors. May make communication difficult.
Has no effect on mobility. Requires fit testing to select proper facepiece size.
May not fit properly when used with some eye-
17
wear. (Continued)
See footnotes at end of table.(Continued). Advantages, Disadvantages, and Costs of Air-purifying
18
Respiratorsfor Protecting Poultry Workers*
Cost
† ‡
Respirator type and APF Advantages Disadvantages (2004 dollars)
Powered, air-purifying respira- Provides eye protection. Has added weight from battery and blower. Unit: $400 to $1,000
tor (PAPR) with hood, helmet, Provides protection for people Is awkward to wear for some tasks. Filters: $10 to $30
or loose-fitting facepiece; with beards, missing dentures,
APF = 25 Requires cleaning and disinfection of components
or facial scars. before reuse and thus poses a contact exposure
Has low breathing resistance. risk.
Has combination cartridges Requires battery charging.
that can be used for expo- Requires air-flow testing with flow device before
sures to particles, gases, and use.
vapors.
Creates a cooling effect with
flowing air.
Has face seal leakage that is
generally outward.
Requires no fit testing.
Permits wearing of prescription
glasses.
Permits better communication
than rubber half-facepiece or
full-facepiece respirators.
Has reusable components and
replaceable filters.
Elastomeric, Provides eye protection. Can add to heat burden. Facepiece: $90 to
full-facepiece respirator with Requires low maintenance. Has reduced field of vision compared with a half- $240
N–100, facepiece respirator.
Has reusable facepieces and re- Filters: $4 to $8
R–100, or P–100
filters; APF = 50 placeable filters and cartridges. Permits inward leakage at gaps in face seal. Each nose cup: $30
Avian Influenza
(Continued)
See footnotes at end of table.(Continued). Advantages, Disadvantages, and Costs of Air-purifying
Respiratorsfor Protecting Poultry Workers*
Cost
† ‡
Respirator type and APF Advantages Disadvantages (2004 dollars)
Avian Influenza
Has combination cartridges Requires cleaning and disinfection of facepiece
that can be used for expo- before reuse and thus poses a contact exposure
sures to particles, gases, and risk.
vapors. Requires fit testing to select proper facepiece size.
Has no effect on mobility. May require nose cup or lens treatment to prevent
Has a more effective face seal fogging of facepiece lens.
than a filtering-facepiece or Requires spectacle kit for users who wear pre-
rubber half-facepiece respira- scription glasses.
tor.
Powered, air-purifying respira- Provides eye protection with Has added weight from battery and blower. Unit: $500 to $1,000
tor (PAPR) with tight-fitting full facepiece. Is awkward to wear for some tasks. Filters: $10 to $30
half facepiece or Has low breathing resistance.
full facepiece; APF = 50 Provides no eye protection with a half facepiece.
Has face seal leakage that is Requires cleaning and disinfection of components
generally outward. before reuse and thus poses a contact exposure
Creates a cooling effect with risk.
flowing air. Requires fit testing to select proper facepiece size.
Has reusable components and Requires charging of battery.
replaceable filters.
May make communication difficult.
Has combination cartridges
that can be used for expo- Requires spectacle kit for people who wear
sures to particles, gases, and prescription glasses with full-facepiece respirators.
vapors. Requires air-flow testing with flow device before
use.
*
All respirator types mentioned here meet the minimum requirements for N–95 respirators.
†
Alternative filter types may be obtained for each type of respirator described here.
‡
19
APF = assigned protection factor.NOTES 20 Avian Influenza
NOTES Avian Influenza 21
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Institute for Occupational Safety and Health 4676 Columbia Parkway Cincinnati, Ohio 45225–1998 Delivering on the Nation’s promise: Safety and health at work for all people through research and prevention. To receive NIOSH documents or for more information about occupational safety and health topics, contact NIOSH at 1–800–CDC–INFO (1–800–232–4636) TTY: 1–888–232–6348 E-mail: cdcinfo@cdc.gov or visit the NIOSH Web site at www.cdc.gov/niosh For a monthly update on news at NIOSH, subscribe to NIOSH eNews by visiting www.cdc.gov/niosh/eNews DHHS (NIOSH) Publication No. 2008–113 3!&%2 s (%!,4()%2 s 0%/0,%©
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