OSHA Guidance Update on Protecting Employees from Avian Flu (Avian Influenza) VirusesU.S. Department of Labor Occupational Safety and Health Administration OSHA 3323-10N 2006
Employers are responsible for providing a safe and healthful workplace
for their employees. OSHA's role is to assure the safety
and health of America's employees by setting and enforcing
standards; providing training, outreach and education; establishing
partnerships; and encouraging continual improvement in workplace
safety and health.
This handbook provides a general overview of a particular
topic related to OSHA standards. It does not alter or determine
compliance responsibilities in OSHA standards or the Occupational
Safety and Health Act of 1970. Because interpretations
and enforcement policy may change over time, you should consult
current OSHA administrative interpretations and decisions by
the Occupational Safety and Health Review Commission and the
Courts for additional guidance on OSHA compliance requirements.
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This document is designed to serve two purposes:
(1) to provide guidance on health protection to employers
whose employees may be exposed to avian influenza (AI) viruses;
and (2) to provide technical information (in appendices) about
AI viruses and, in particular, about H5N1, an AI virus currently
circulating in Asia, Europe and Africa that rarely causes disease
in humans but when it does the case fatality rate is high.
This document updates guidance on avian flu issued by OSHA
in March 2004.
Numerous stories have aired on radio and television or been
published in various news media concerning avian influenza
and in particular the H5N1 subtype. Unfortunately there is
now much confusion about the different human diseases caused
by influenza viruses.
Influenza A viruses can cause three distinct diseases in
humans: avian, pandemic and seasonal
influenza. Avian influenza in
humans is rare and the most common route of infection is via
direct or indirect contact with secretions (nasal, oral or
fecal) from infected poultry. Transmission from human-to-human,
if it exists, is extremely rare. However, avian influenza viruses
have the potential to mutate or reassort and become pandemic
viruses; those that can be readily transmitted between humans
and those for which the population has little immunity. If
these viruses spread throughout the world, the disease caused
by them would be called pandemic influenza and
the new viruses would be called pandemic influenza viruses.
Previous pandemic influenza episodes have occurred in two or
three waves of 6-8 week duration and spanned a 12-18 month
period. After this period, the population will have built up
immunity to the virus, either naturally or through vaccination.
If the virus continues to circulate in the population and causes
disease, it would become an influenza virus that causes seasonal
influenza (more popularly called human influenza or
the flu).
Influenza A viruses are subdivided into numerous subtypes.
The subtypes are differentiated by variations in two viral
surface proteins, hemagglutinin (H) and neuraminidase (N).
Sixteen different H proteins and nine N proteins have been
identified. Subtypes are designated by numbering particular
combinations of these proteins (e.g., H5N1). Therefore, there
are a total of 144 possible subtypes (16H x 9N) of influenza
A viruses and all or most of these have been found in wild
waterfowl. Interestingly only three of the 144 subtypes, H1N1,
H2N2 and H3N2, have caused pandemic influenza in
the 20th century. Only strains of H1N1 and H3N2 are currently
circulating and causing seasonal influenza.
Recently a number of different subtypes of influenza A viruses
have emerged as agents of avian influenza in
humans and these include H5N1, H7N2, H7N3, H7N7 and H9N2.
As of October 2006, H5N1 viruses have killed more than 150
people in ten different countries since the beginning of 2003.
On the other hand, the H7N7 virus has been associated with
a single human death but numerous cases of conjunctivitis (eye
infection) in the Netherlands. The H7N2, H7N3 and H9N2 viruses
have caused only mild disease in humans. While the number of
human deaths caused by the H5N1 virus is small in comparison
to the annual deaths attributed to human seasonal influenza
viruses (~36,000/ year in the U.S.), it is of particular concern
to the public health community because many scientists believe
that this virus may continue to mutate or reassort and a strain
may ultimately develop the ability to pass readily between
humans. If this happens, the virus that emerges may cause the
next major influenza pandemic. As of October 2006,
the highly pathogenic avian influenza (HPAI) H5N1 virus has
not been detected in North or South America and it is important
to understand that a pandemic influenza virus has not yet emerged
and when, and if, it will emerge is impossible to predict.
This document is for current implementation and provides
guidance to employees that are likely to become exposed to
avian influenza if it reaches the U.S. or if they travel or
work abroad. It focuses on the following groups of employees
that are at risk of being exposed to avian influenza infections, but the list is not intended to be all-inclusive.
Poultry employees
Animal handlers other than poultry employees
Laboratory employees
Healthcare workers who treat patients with known or suspected AI viruses
Food handlers
Airport personnel exposed to passengers suspected of being AI-infected
Travelers on temporary work assignment abroad
U.S. employees stationed abroad
Other employee groups that may be at risk
There are many other employees that may become at risk if
there is a serious avian flu outbreak.
At the end of 2004, OSHA worked with NIOSH through a joint
agency Issues Exchange Group and developed a Safety and Health
Information Bulletin (SHIB 12-13-2004) titled, Avian Influenza,
Protecting Poultry Workers at Risk. The document details
safety measures that should be adopted by poultry employees.
(See www.osha.gov/dts/shib/shib121304.html).
In addition, the Centers for Disease Control and Prevention
(CDC) has issued interim recommendations in a web document
titled Interim Guidance for Protection of Persons Involved
in U.S. Avian Influenza Outbreak Disease Control and Eradication
Activities. 1 The CDC recommendations are based on precautions
that are considered best practices for protecting individuals
involved in the response to an AI outbreak.
The following guidance information synthesizes the recommendations
from both the CDC web document and the OSHA SHIB. The
guidance provided should be implemented in the event of a suspected
or confirmed avian flu outbreak at a poultry facility. Recommendations
include the following procedures: basic infection control,
personal protective equipment (PPE), antiviral drug use and
seasonal flu vaccination, medical monitoring of employees and
disinfection of contaminated areas. A safety and medical officer
should be identified to ensure compliance with procedures.
In addition, the United States Department of Agriculture (USDA)
(see: www.aphis.usda.gov/vs/birdbiosecurity/hpai.html) and
State biosecurity web sites should be consulted for additional
procedures for disease control and eradication.
Employees Potentially at Risk
Poultry farmers and their employees
Service technicians of poultry processing facilities
Caretakers at poultry facilities
Layer barn employees
Chick movers at egg production facilities
Employees involved in disease control and eradication activities including:
State;
Federal;
Contract; and
Company Employees.
Live Bird Market Employees
Bird Fighting Industry Employees
Signs that Poultry May Be Infected with AI
Employers should train employees to be alert to poultry that
develop one or more of the following signs.
Sudden death (no apparent symptoms)
Lack of energy and appetite
Lack of coordination
Purple discoloration of the wattles, combs, and legs
Soft-shelled or misshapen eggs
Diarrhea
Swelling of the head, eyelids, comb, wattles, and hocks
Nasal discharge
Decreased egg production
Coughing, sneezing.
Transmission to Humans
Exposure of the conjunctival membranes of the eyes and/or
the oral or nasal mucosa to secretions (oral, nasal or fecal)
from AI-infected birds is the predominant route of transmission
of these viruses to humans.
In contrast, seasonal human influenza viruses are primarily
transmitted from person-to-person via nasal or oral secretions
only.
Avoid direct contact with bird secretions and inhalation
of dust contaminated with these secretions.
Basic Infection Control Measures
Educate employees about the importance of strict adherence to hand hygiene, especially after any of the following activities:
contact with infected or exposed poultry;
contact with surfaces contaminated with bird feces or respiratory secretions; or
removing personal protective equipment of any kind (e.g., gloves, goggles, respirator, etc.).
Good hand hygiene should consist of the following:
washing the hands thoroughly with soap and water for 15-20 seconds; or
if hand-washing facilities are not readily available, use other standard hand-disinfection procedures as specified by state government, industry, or USDA outbreak-response guidelines.
Ensure that personnel have access to appropriate personal protective equipment (PPE) and instructions and training in PPE use.
Personnel should not eat, drink, or smoke or use bathroom facilities while engaged in activities where contact with contaminated animals or surfaces are possible. PPE should be properly removed and discarded or disinfected. Hands should then be washed thoroughly before eating, drinking, smoking or bathroom use.
Important considerations:
According to a CDC document, human influenza viruses can survive for 2 to 8 hours on surfaces. This statement is based upon a single study conducted in 1982 (Bean et al. 1982. Survival of influenza viruses on environmental surfaces. J. Infect. Dis. 146:47-51) and therefore is referring specifically to survival of influenza viruses on stainless steel surfaces.
The length of time that avian influenza viruses survive after deposit on surfaces varies with a number of environmental variables. There is even evidence that different strains of H5N1 vary in their ability to survive when exposed to similar environmental conditions (see Appendix D). There have been no published studies to determine how long the virus may survive on surfaces when expelled from a hospitalized AI-infected person.
Personal Protective Equipment (PPE)
Do not eat, drink, smoke, or use bathroom facilities while
engaged in activities where contact with contaminated animals
or surfaces are possible. PPE should be properly removed and
discarded [see section below titled, “Removal of Personal
Protective Equipment (PPE)”] or disinfected. Hands should
then be washed thoroughly before eating, drinking, smoking
or bathroom use.
Hand Protection
Wear lightweight nitrile or vinyl disposable gloves, or
Wear heavy-duty rubber work gloves that can be disinfected.
Important considerations:
Avoid touching the face and mucous membranes, including the eyes, with gloved hands that have been contaminated.
Gloves should be changed if torn, punctured, or otherwise damaged.
Remove gloves promptly after use.
Gloves used should be appropriate for the activities, e.g., for some activities it may be more appropriate to use thick rather than lightweight gloves.
Long-term use of gloves can result in dermatitis caused by prolonged exposure to perspiration. This can be alleviated by the use of a thin cotton glove worn inside the external glove.
Body Protection
Wear disposable outer garments or coveralls with an impermeable apron over them, or
Wear surgical gowns with long, cuffed sleeves, plus an impermeable apron.
Wear disposable head or hair cover to keep hair clean.
Important considerations:
Because protective clothing can be more insulating than regular work clothing, precautions should be taken to protect employees from the effects of heat stress.
Foot Protection
Wear disposable protective shoe covers, or
Wear rubber or polyurethane boots that can be cleaned and disinfected.
Eye Protection
Wear safety goggles to protect the mucous membranes of the eyes.
Important considerations:
Properly fitted, indirectly vented safety goggles with a good anti-fog coating may be a good choice for poultry employees who have lower risks of exposure (e.g., those employees not directly involved in culling of poultry). However, such goggles are not airtight, and consequently, they will not prevent exposures to airborne material.
Employees who wear prescription lenses should wear eye protection that has the correction built into the safety lenses of the protective eyewear, has lens inserts, or can be fitted over regular street-wear prescription glasses without compromising eye or respiratory protection.
Eye protection should be fitted together with a respirator because some goggles can alter the fit of a half-facepiece respirator. To ensure that the eye protection does not interfere with a facepiece seal, it should be worn when half-facepiece respirators are fit tested and when employees conduct seal checks each time they put on the respirator.
Respiratory Protection
NIOSH-approved disposable particulate respirators (e.g., N95, N99, or N100) are the minimum level of respiratory protection that should be worn.
Important considerations:
This level of respiratory protection or higher may already be in use in poultry operations due to other hazards that exist in the environment (e.g., vapors, dusts, etc.).
For farms using oils as dust suppressants, use R or P series respirators.
Employees who are unable to wear a disposable particulate respirator because of facial hair or other fit limitations should wear a loose-fitting helmeted or hooded powered air purifying respirator (PAPR) equipped with high-efficiency particulate air [HEPA] filters. A PAPR also provides needed eye and mucous membrane protection.
For employees with substantial exposure to contaminated materials (e.g., those employees directly involved in mass culling of birds), a PAPR may be a practical alternative in a hot, dirty, and wet environment compared to a disposable particulate respirator.
Note that the particulate respirators recommended above are not appropriate for protection against decontamination or sanitizing chemicals that may be used in disinfection activities (see below under the section titled: Disinfection of Areas Contaminated by AI-Infected Birds).
Children should not do any work that requires wearing a respirator.
OSHA requires that respirators must be used in the context of a complete respiratory protection program (RPP). This includes training, fit testing, and user seal checks to ensure appropriate respirator selection and use. To be effective, tight-fitting respirators must have a proper sealing surface on the wearer's face. The elements of a complete RPP are described in detail in 29 CFR 1910.134 (www.osha.gov/SLTC/etools/respiratory/oshafiles/otherdocs.html).
Employees should always remove protective clothing (except for gloves) first and discard or secure the clothing for disinfection before removing their respirators and goggles.
Remove and discard disposable gloves.
Wash hands thoroughly with soap and water.
Keep hands away from mouth and face until hands are washed thoroughly.
Remove eye protection and place in a designated receptacle for subsequent cleaning and disinfection.
Remove particulate disposable respirator and discard.
Wash hands thoroughly with soap and water a second time immediately after all PPE has been removed.
Disposable PPE should be treated as contaminated material and properly discarded.
Non-disposable PPE should be cleaned and disinfected as specified in state government, industry, or USDA outbreak-response guidelines.
Important considerations:
All PPE should be removed carefully to avoid dispersal of contaminated material.
Hand hygiene measures should be promptly performed after removal of PPE.
If soap and water are not available, use an alcohol-based hand gel.
Vaccination with Seasonal Influenza Vaccine
CDC recommends that unvaccinated employees should receive the current season's influenza vaccine.
Important considerations:
The current season's vaccine will reduce the possibility of coinfection with both an AI virus and a human influenza virus. Although there is only a small possibility that co-infection would occur, if it were to happen, there is the potential for the reassortment of the genetic material from the two viruses with the consequent development of a new human flu virus (i.e., one that is transmissible between people). This novel virus would have the potential to cause an influenza pandemic.
Administration of Antiviral Drugs
CDC recommends that employees having direct contact with infected poultry or surfaces contaminated with respiratory secretions or feces from infected birds should receive a prophylactic dose of an influenza antiviral drug daily for the entire time they are in direct contact with infected poultry or contaminated surfaces, as well as for one week following their last exposure. Antiviral medications are an important adjunct to vaccination; they are not a substitute for vaccination.
For further information about the use of antiviral drugs for influenza, see the CDC web page titled Prevention and Control of Influenza - Recommendations of the Advisory Committee on Immunization Practices (ACIP) (MMWR July 29, 2005, Vol. 54:No. RR-8:1-40) at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5408a1.htm.
Medical Monitoring of Employees
Employers should instruct employees to be vigilant for the development of AI symptoms. These symptoms have ranged from typical human influenza-like symptoms (fever, cough, sore throat, and muscle aches) to eye infections (conjunctivitis), pneumonia, severe respiratory diseases (such as acute respiratory distress syndrome), and other severe and life-threatening complications.
Important considerations:
Human AI infections are manifested in different ways dependent on the health status of the individual before infection and pathogenicity of the AI strain. Although the symptoms are, in general, flu-like, they may vary.
Individuals infected with the H7N7 virus that caused the outbreak in the Netherlands in 2003 most frequently had conjunctivitis only (see Appendix B for more specific information).
Hospitalized individuals infected with strains of the H5N1 subtype most frequently had fever combined with a cough and also had difficulty breathing and/or diarrhea. Conjunctivitis was rare. See Appendix F for specific details on some of the common symptoms of patients infected with different strains of H5N1.
Employees who become ill after possible exposure to the AI virus should do the following:
Seek medical care but prior to arrival notify their healthcare provider that they may have been exposed to AI.
Notify the occupational health and infection control personnel at their facility.
With the exception of visiting a healthcare provider, stay home until 24 hours after resolution of fever, unless:
an alternative diagnosis is established that explains the patient's illness; or
diagnostic tests are negative for influenza A virus.
While at home, ill persons should practice good respiratory and hand hygiene to lower the risk of transmission of the virus to others. For more information, visit the following CDC websites:
Disinfection of Areas Contaminated by AI-infected Birds
After an AI outbreak, it is important that the contaminated
areas be disinfected. Depending on temperature and moisture
conditions (see Appendix D for more specific details and survival
and inactivation of influenza viruses), AI viruses can survive
in the environment for long periods, even weeks. However, AI
viruses are generally susceptible to the following chemical
and physical methods of inactivation:
Chemical methods
Most detergents
Specific disinfectants
Physical methods
Heating (the higher the temperature, the more rapid the inactivation)
Complete drying.
Disinfection in the field is normally
done using a chemical method. Viruses associated with
organic material such as dust, dirt, litter, and manure
may be less susceptible to disinfection because they
may be protected from direct contact with the disinfectant.
Certain EPA-registered disinfectants labeled for use
against avian influenza viruses are effective for use
on hard, non-porous surfaces listed on the label (see:
www.epa.gov/pesticides/factsheets/avian_flu_products.htm
for product listings). The label of an EPA-registered
disinfectant describes how to use the product safely
and effectively and includes measures that persons applying
the products should take to protect themselves. The personal
protective equipment (PPE) listed on a disinfectant product
label is based on the product's toxicity and potential
risks associated with use of the product according to
the product label. Wearing less protective PPE than specified
on the label is considered misuse of the product and a Federal violation. However, employees may wear more protective PPE than required on the label.
This guidance is for situations in which highly pathogenic
avian influenza (HPAI) H5N1 has been diagnosed or is suspected
in poultry or wild birds in your area.
While AI is mostly a concern in domestic poultry stocks,
other farmworkers, pet shop owners and their employees, veterinarians
and their employees, and zookeepers should be alert to any
sick birds that show any of the AI-associated symptoms (see:
www.aphis.usda.gov/vs/birdbiosecurity/hpai.html). If such
birds are observed, immediately notify Federal or state animal
health officials or call 1-866-536-7593 (toll-free) or
your local agricultural control agent. Also note that other
animals can be infected with certain AI viruses. In particular,
H5N1 has been shown to infect cats, pigs and ferrets. These
animals should also be monitored for any unusual flu-like symptoms.
If possible, avoid handling potentially infected animals.
Allow the Federal or state officials to handle these animals.
However, if you must handle the animals to isolate them from
others or to remove dead animals, use appropriate personal
protective equipment (PPE). Refer to Guidance for Poultry
Employees (pages 7-16) for the appropriate types of
PPE to wear and also for good personal hygiene practices. A
risk assessment by Federal or state officials should assist
an employer in deciding the level of PPE that would be most
appropriate in a particular situation.
The Department of Health and Human Services (HHS) website
at www.pandemicflu.gov provides a web document titled, Contact
Information for State Departments of Agriculture, Wildlife,
and Public Health, which lists contact information for
agriculture, wildlife and public health departments for all
U.S. states and territories and can be directly accessed at:
www.pandemicflu.gov/state/statecontacts.html.
CDC has made the following recommendations for laboratory
testing for H5N1 in a website document titled, Updated
Interim Guidance for Laboratory Testing of Persons with Suspected
Infection with Avian Influenza A (H5N1) Virus in the United
States. 2 Manipulating highly pathogenic avian influenza (HPAI) viruses
in biomedical research laboratories requires caution because
some strains may pose increased risk to laboratory employees
and have significant agricultural and economic implications.
Biosafety Level 3 (BSL 3) and Animal Biosafety Level 3 (ABSL
3) practices, procedures and facilities are recommended along
with clothing change and personal showering protocols (referred
to as enhanced BSL 3 practices). Loose-housed animals infected
with HPAI strains must be contained within BSL 3 (Ag) facilities.
Negative pressure, HEPA-filtered respirators or positive air-purifying
respirators are recommended for highly pathogenic avian influenza
(HPAI) viruses with potential to infect humans. The HPAI viruses
are agricultural Select Agents requiring registration of personnel
and facilities with the lead agency for the institution (CDC
or USDA-APHIS). An APHIS permit is also required. Additional
containment requirements and personnel practices and/or restrictions
may be added as conditions of the permit.
Important considerations:
For more information about BSL levels, consult the CDC publication titled Biosafety in Microbiological and Biomedical Laboratories (BMBL 4th edition) available at: www.cdc.gov/od/ohs/biosfty/bmbl4/bmbl4toc.htm. A fifth edition is scheduled for release in late 2006.
If human specimens being examined for the presence of the AI-virus contain blood or body fluids that contain blood, they must be handled following the Bloodborne Pathogens standard (29 CFR 1910.1030). Complete details of the standard are available at: www.osha.gov/pls/oshaweb/owadisp.show_ document?p_table=STANDARDS&p_id=10051
Polymerase chain reaction (PCR) assays or commercial antigen detection testing can be conducted on clinical specimens from suspect H5N1 cases using standard BSL 2 work practices in a Class II biological safety cabinet. BSL 2 laboratory conditions include BSL 1 procedures plus:
Biohazard warning signs;
Use of leakproof transport containers; and
Use of biosafety cabinets (Class II).
Note: Commercial antigen testing and RT-PCR are not appropriate substitutes for respiratory specimen virus isolation.
CDC recommends that virus isolation studies on respiratory specimens from patients suspected of having H5N1 infections should only be conducted under enhanced BSL 3 conditions.
If a clinical laboratory does not have enhanced BSL 3 facilities, virus isolations should not be ordered for patients suspected of having H5N1 infection.
FDA regulations apply to devices used to test human specimens for avian influenza. Instructions for use may address other precautions, and use of some avian influenza tests may be subject to additional regulatory requirements. For more information contact the Office of In Vitro Diagnostic Evaluation and Safety at: 240-276-0484.
Use respiratory protection as determined by risk assessment.
OSHA requires that respirators must be used in the context of a complete respiratory protection program (RPP). This includes training, fit testing, and user seal checks to ensure appropriate respirator selection and use. To be effective, tight-fitting respirators must have a proper sealing surface on the wearer's face. The elements of a complete RPP are described in detail in 29 CFR 1910.134 (www.osha.gov/SLTC/etools/respiratory/oshafiles/otherdocs.html).
For information on respirators, see the following:
Laboratory employees should be instructed to be vigilant for symptoms of AI infection for at least one week after their last exposure to AI-infected materials. Symptoms have ranged from typical human influenza-like symptoms (fever, cough, sore throat, and muscle aches) to eye infections (conjunctivitis), pneumonia, severe respiratory diseases (such as acute respiratory distress syndrome), and other severe and life-threatening complications.
Important considerations:
Human AI infections are manifested in different ways dependent on the health status of the individual before infection and pathogenicity of the AI strain. Although the symptoms are, in general, flu-like, they may vary.
Individuals infected with the H7N7 virus that caused the outbreak in the Netherlands in 2003 most frequently had conjunctivitis only (See Appendix B for more specific information).
Hospitalized individuals infected with strains of the H5N1 subtype most frequently had fever combined with a cough and also had difficulty breathing and/or diarrhea. Conjunctivitis was rare. See Appendix F for specific details on some of the common symptoms of patients infected with different strainsf H5N1.
Laboratory employees who become ill should do the following:
Seek medical care but prior to arrival notify their healthcare provider that they may have been exposed to AI.
Notify the occupational health and infection control personnel at their facility.
With the exception of visiting a healthcare provider, stay home until 24 hours after resolution of fever, unless:
an alternative diagnosis is established that explains the patient's illness; or
diagnostic tests are negative for influenza A virus.
While at home, ill persons should practice good respiratory and hand hygiene to lower the risk of transmitting virus to others. For more information, visit the following CDC websites:
The CDC has issued Interim Recommendations for Infection Control in Healthcare Facilities Caring for Patients with Known or Suspected Avian Influenza.3 This document contains the following recommendations:
All patients who present to a healthcare setting with fever and respiratory symptoms should be managed according to recommendations for:
Patients with a history of travel within 10 days to a country with AI activity and who are hospitalized with a severe febrile respiratory illness, or are otherwise under evaluation for AI, should be managed using isolation precautions identical to those recommended for patients with known Severe Acute Respiratory Syndrome (SARS). These include:
Standard Precautions
Hand hygiene is absolutely essential
Before and after all patient contact.
As soon as possible after contact with items contaminated or potentially contaminated with respiratory secretions.
Contact Precautions
Use gloves and gown for all patient contact.
Use disposable equipment (blood pressure cuffs, thermometers) or equipment that can be disinfected before use with another patient (stethoscopes, etc.).
Droplet Precautions
Wear goggles or face shields when within 3 feet of the patient.
Important considerations:
Face shields are insufficient protection for airborne hazards or for facial splashes.
Airborne Precautions
Place the patient in an airborne infection isolation room.
Airborne infection isolation rooms should have monitored negative air pressure in relation to the corridor, with 6 to 12 air changes per hour, and
should exhaust air directly to the outside or have recirculated air filtered by a high efficiency particulate air (HEPA) filter.
Keep the doors to the patient room closed; this protects other employees who are nearby.
If an airborne infection isolation room is unavailable, contact the healthcare facility engineer to assist or use portable HEPA filters (see Environmental Infection Control Guidelines at www.cdc.gov/ncidod/hip/enviro/guide.htm) to augment the number of air changes per hour.
Use a fit tested respirator, at least as protective as a National Institute for Occupational Safety and Health (NIOSH)-approved N-95 filtering facepiece (i.e., disposable) respirator, when entering the room.
Important considerations:
OSHA requires that respirators must be used in the context of a complete respiratory protection program (RPP). This includes training, fit testing, and user seal checks to ensure appropriate respirator selection and use. To be effective, tight-fitting respirators must have a proper sealing surface on the wearer's face. The elements of a complete RPP are described in detail in 29 CFR 1910.134 (www.osha.gov/SLTC/etools/respiratory/oshafiles/otherdocs.html).
For information on respirators, see the following:
Transmission Prevention Strategies in Healthcare
Settings
Place patients that are AI-infected and those that are
suspected of being AI-infected together in the same room
if private rooms are not available. This would only be a
likely scenario if there were a major avian influenza outbreak
in your area.
If possible, try not to place patients with seasonal influenza
and those with AI in the same room. Although the risk is
relatively small, the sharing of the same room by such patients
would increase the chances of co-infection of patients with
the two viruses and this could lead to viral reassortment
of genes and the possible emergence of a pandemic virus.
Minimize transportation of influenza patients outside
of room.
Limit the number of healthcare workers caring for influenza
patients.
Limit the number of visitors to influenza patients.
For additional information regarding these and other healthcare
isolation precautions, see the Guidelines for Isolation
Precautions in Hospitals (www.cdc.gov/ncidod/hip/isolat/isolat.htm).
The precautions for healthcare employees listed above should
be continued for 14 days after onset of symptoms or until:
an alternative diagnosis is established that explains
the patient's illness or
diagnostic test results are negative for influenza
A virus.
Patients managed as outpatients or hospitalized patients
discharged before 14 days with suspected AI should be isolated
in the home setting on the basis of principles outlined for
the home isolation of SARS patients (see www.cdc.gov/ncidod/sars/guidance/i/pdf/i.pdf).
Vaccination of Healthcare Workers against Human Influenza
Healthcare workers involved in the care of patients with
documented or suspected AI should be vaccinated with the most
recent seasonal human influenza vaccine. In addition to providing
protection against the predominant circulating influenza strains,
this measure is intended to reduce the likelihood of a healthcare
worker being co-infected with both human and AI viruses, where
genetic reassortment could take place, leading to the emergence
of potential pandemic strains. Important considerations:
Influenza vaccination of U.S. healthcare workers remains
below 40% despite the vaccine's safety and effectiveness.
A recent publication clearly describes the benefits of yearly
influenza vaccination of healthcare workers. Yearly influenza
vaccination of healthcare workers has been demonstrated to
reduce absenteeism, nosocomial influenza transmission, and
the associated economic losses and disruption of routine operations.4
Surveillance and Monitoring of Healthcare Workers
Healthcare workers should be instructed to be vigilant for symptoms of AI infection for at least one week after their last exposure to AI-infected patients. Symptoms have ranged from typical human influenza-like symptoms (fever, cough, sore throat, and muscle aches) to eye infections (conjunctivitis), pneumonia, severe respiratory diseases (such as acute respiratory distress syndrome), and other severe and life-threatening complications. Important considerations: Human AI infections are manifested in different ways dependent on the health status of the individual before infection and pathogenicity of the AI strain. Although the symptoms are, in general, flu-like, they may vary.
Individuals infected with the H7N7 virus that caused the outbreak in the Netherlands in 2003 most frequently had conjunctivitis only. (See Appendix B for more specific information).
Hospitalized individuals infected with strains of the H5N1 subtype most frequently had fever combined with a cough and also had difficulty breathing and/or diarrhea. Conjunctivitis was rare. See Appendix F for specific details on some of the common symptoms of patients infected with different strains of H5N1.
Healthcare workers who become ill should do the following:
Seek medical care but prior to arrival notify their healthcare provider that they may have been exposed to AI.
Notify the occupational health and infection control personnel at their facility.
With the exception of visiting a healthcare provider, stay home until 24 hours after resolution of fever, unless:
an alternative diagnosis is established that explains the patient's illness; or
diagnostic tests are negative for influenza A virus.
While at home, ill persons should practice good respiratory and hand hygiene to lower the risk of transmitting the virus to others. For more information, visit the following CDC websites:
This guidance is for situations in which highly pathogenic
avian influenza (HPAI) H5N1 has been diagnosed or is suspected
in poultry or wild birds in your area.
Although there is no direct evidence that any human cases
of AI have been acquired by eating poultry products, raw poultry
should always be handled hygienically because it can be associated
with many infections, including salmonella. Therefore, all
utensils and surfaces (including hands) that come in contact
with raw poultry should be cleaned carefully with water and
soap immediately afterwards.
Infected poultry stocks should be destroyed before having
any possibility of entering the food chain. Ducks can be asymptomatic
(with no symptoms) H5N1 carriers and duck products could be
unknowingly contaminated with the virus. In 2001, frozen duck
meat imported to South Korea from China was contaminated with
HPAI H5N1. Once isolated from the meat, the virus was still
infective to mice (mice are used as an animal model for testing
pathogenicity of avian influenza viruses). 5 In a more recent
study, an HPAI H5N1 strain was also found in duck meat imported
into Japan from China. 6 Eggs from infected poultry could also
be contaminated with the virus and, therefore, care should
be taken in handling shell eggs or raw egg products. Fortunately,
influenza viruses are destroyed by adequate heat.
Two groups of employees most at risk in poultry food handling
are grocery store employees that process raw chicken (butcher
it into parts, package parts, etc.) and cooks at restaurants.
Grocery store employees should routinely use good hand hygiene
when handling raw poultry or poultry products and observe the
additional precautions listed below as important considerations
after guidance for cooks.
During preparation of poultry, cooks are reminded to follow
proper food preparation and handling practices, including the
following: 7
Separate raw meat from cooked or ready-to-eat foods. Do not use the same chopping board or the same knife for preparing raw meat and cooked or ready-to-eat foods.
Do not handle either raw or cooked foods without washing your hands and equipment in between.
Do not return cooked meat to the same plate or surface that it was on before it was cooked or to any surface contaminated with raw poultry.
Thoroughly cook all poultry products, including eggs and poultry blood. Egg yolks should not be runny or liquid. Poultry meat and eggs should reach a temperature of 165°F (~74 °C) throughout to ensure the destruction of the virus.
Do not use raw or soft-boiled eggs in foods that will not be cooked.
After handling raw poultry or eggs, wash your hands and all surfaces and utensils thoroughly with soap and water or an alcohol-based hand gel (if hands are not visibly soiled).
Important considerations:
Avoid touching your mouth, nose or eyes while handling raw poultry products; the virus could be transmitted in this manner.
Avoid generating aerosols when cutting up poultry; the virus could be transmitted in this manner. For more information on good hand hygiene, consult CDC's website:
This guidance applies to airport personnel potentially exposed
to passengers infected with avian influenza (AI). It is not
intended for crewmembers on aircraft in operation. The safety
and health of crewmembers on aircraft in operation are the
exclusive responsibility of the Federal Aviation Administration
(see www.faa.gov).
Unless otherwise stated, the recommendations in this guidance
section are based on standard infection control practices,
available information about avian influenza, and those portions
of the CDC guidance titled, Interim Guidance for Airline
Flight Crews and Persons Meeting Passengers Arriving from Areas
with Avian Influenza 8 that apply to airport personnel.
General Infection Control Precautions
All employees should always follow basic hygiene practices
to prevent becoming ill. Many infectious diseases can be spread
by human hands. Soiled hands are an effective means of delivering
infectious material (e.g., saliva or other body fluids that
may contain viruses) to the nose or eyes, where they can enter
the body. Hand washing is an important way to reduce exposure
to common infectious diseases. Cleaning one's hands with
soap and water removes potentially infectious material from
one's skin. Hands should be cleaned before preparing
food, eating, or touching one's face, and after handling
soiled material (e.g., used tissues, lavatory surfaces), coughing
or sneezing, and using the toilet. Waterless alcohol-based
hand gels may be used when soap is not available and hands
are not visibly soiled.
If employees are ill, the following steps should be taken:
If they are ill, they should not go to work, or, if they arrive ill, they should be sent home.
If they become ill on the job, they should do the following:
Cover mouths and noses with a tissue or hands when coughing or sneezing.
Put used tissue in a wastebasket.
Clean hands with soap and water or an alcohol-based hand gel immediately after coughing or sneezing.
Avoid close contact with coworkers.
Go home as soon as is practicable.
For more information about these issues, visit the following CDC websites:
Procedures for Protecting Airport Personnel in Close
Proximity to Passengers Suspected of Having an AI-infection
In some circumstances, employers may need to provide their airport personnel with respirators (at least a NIOSH-approved N95 or more protective) when it is necessary to protect their health (see OSHA's Respiratory Protection standard at 29 CFR 1910.134).
OSHA's Respiratory Protection standard requires that respirators be used in the context of a complete respiratory protection program (RPP). This includes initial and annual training, fit testing, and user seal checks to ensure appropriate respirator selection and use. To be effective, tight-fitting respirators must have a proper sealing surface on the wearer's face. The elements of a complete RPP are described in detail in 29 CFR 1910.134. (www.osha.gov/SLTC/etools/respiratory/ oshafiles/otherdocs.html).
Airport personnel should wear disposable gloves if touching blood or body fluids. However, gloves are not intended to replace proper hand hygiene. Immediately after activities involving contact with body fluids, gloves should be carefully removed and discarded and hands should be cleaned with soap and water or an alcohol-based hand gel (if hands are not visibly soiled). Gloves should not be washed or reused.
Management of Possibly Infected Airport Personnel
Employers should train airport personnel to be vigilant for AI symptoms. These symptoms have ranged from typical human influenza-like symptoms (fever, cough, sore throat, and muscle aches) to eye infections (conjunctivitis), pneumonia, severe respiratory diseases (such as acute respiratory distress syndrome), and other severe and life-threatening complications.
Employers should instruct their airport personnel who become ill with AI-like symptoms after possible exposure to an AI-infected person to immediately seek medical care but, prior to arrival, notify their healthcare provider that they may have been exposed to AI.
CDC has issued the following notice concerning travel to
areas known to have current or past H5N1 outbreaks: Outbreak
Notice Update: Human Infection with Avian Influenza A
(H5N1) Virus in Asia. 9
From January 2005 through October 2006, the number of countries
with outbreaks of H5N1 infection among poultry or wild birds
increased more than 3-fold from 15 to the following 54 countries:
10
East Asia
Europe, Siberia, Central Asia
Africa
Cambodia
Afghanistan
Burkina Faso
China
Albania
Cameroon
India
Austria
Djibouti
Indonesia
Azerbaijan
Egypt
Japan
Bosnia-Herzegovina
Ivory Coast
Lao PDR (Laos)
Bulgaria
Niger
Malaysia
Croatia
Nigeria
Mongolia
Cyprus
Sudan
South Korea (Republic of Korea)
Czech Republic
Thailand
Denmark
Vietnam
France
Georgia
Germany
Greece
Hungary
India
Iran
Iraq
Israel
Italy
Jordan
Kazakhstan
Pakistan
Poland
Romania
Russia (Siberia & European Russia)
Saudi Arabia
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Turkey
Ukraine
In November of 2005, human cases had been reported from only
5 countries. As of October 12, 2006, the number of countries
with human cases had doubled to the following 10 countries:
Azerbaijan, Cambodia, China, Djibouti, Egypt, Indonesia, Iraq,
Thailand, Turkey and Vietnam. Since this information is constantly
changing, consult the U.S. Government pandemic influenza website
at: www.pandemicflu.gov/, where regularly updated information
on cases in both birds and humans worldwide can be accessed.
Appendix I contains websites that provide additional information.
To reduce the risk of infection, CDC recommends that Americans
visiting areas where outbreaks of H5N1 infection among poultry
or human cases of H5N1 infection have been reported should
observe the following measures to help avoid illness.
Before Any International Travel
Always educate yourself and others who may be traveling with you about any disease risks and other travel conditions in areas you plan to visit (for information about H5N1, see the following CDC web page at: www.cdc.gov/flu/avian/index.htm and State Department Travel Warnings and Consular Information sheets at: www.travel.state.gov/travel/travel_1744.html).
Be sure that your vaccinations are up-to-date and see your doctor or healthcare provider, ideally 4–6 weeks before travel, to get any additional vaccinations, medications, or information you may need. CDC's health recommendations for international travel to Southeast Asia are provided on CDC's Travelers' Health website: www.cdc.gov/travel/seasia.htm.
Assemble a travel health kit containing basic first aid and medical supplies. Be sure to include a thermometer and alcohol-based hand rub for hand hygiene. See the following web page for other suggested items: www.cdc.gov/travel/illness_injury_abroad.htm.
Before you leave, find out how and where to get medical care in the country where you are traveling.
Check your health insurance plan or get additional insurance that covers medical evacuation in case you become ill. Information about medical evacuation services is provided on the U.S. Department of State web page titled, Medical Information for Americans Traveling Abroad (travel.state.gov/travel/tips/health/health_1185.html).
During Travel
Avoid all direct contact with poultry, even if they appear healthy and especially if they appear sick or are dead.
Avoid places where live poultry are raised or kept (e.g., poultry farms and bird markets).
Avoid handling surfaces contaminated with poultry feces or respiratory secretions. The major source of human infections is associated with contact with these substances.
As with other infectious illnesses, one of the most important preventive practices is careful and frequent handwashing. Cleaning your hands often, using soap and water (or waterless alcohol-based hand rubs when soap is not available and hands are not visibly soiled), removes potentially infectious material from your skin and helps prevent disease transmission.
Handwashing is especially important when preparing raw poultry for cooking.
Influenza viruses are destroyed by heat; therefore, as a precaution, all foods from poultry, including eggs and poultry blood, should be thoroughly cooked. See International Food Safety Authorities Network (INFOSAN) for guidelines about food safety and H5N1 at: www.who.int/foodsafety/micro/avian/en/. Also consult the USDA website on safe food handling at: www.fsis.usda.gov/Fact_Sheets/Safe_Food_Handling_Fact_Sheets/.
If you have a fever and respiratory symptoms (cough or shortness of breath) or if you have any illness that requires prompt medical attention, a U.S. consular officercan assist you in locating medical services and informing your family or friends. See the following web page for more information about what to do if you become ill while abroad: www.cdc.gov/travel/illness_injury_abroad.htm. It is advisable that you defer travel until you are free of symptoms unless your travel is health-related. Important considerations:
It is possible that you might become infected in a country
where the healthcare systems may be inadequate to cope with human avian influenza.
If an avian influenza virus develops the ability to pass freely from human to human while you are in an affected country, it is possible that either U.S. or foreign country borders will be closed and return travel to the U.S. may be impossible or delayed.
After Your Return
Monitor your health for 10 days.
If you become ill with fever and develop a cough or difficulty breathing, or if you develop any illness during this 10-day period, consult a healthcare provider. Before you visit a healthcare setting, tell the provider the following:
your symptoms;
where you traveled; and
if you have had direct poultry contact or contact with a known or suspected human case of influenza A (H5N1) in an H5N1-affected country.
More information about the following subjects can be obtained
by visiting the websites listed below:
CDC has issued recommendations for expatriates and U.S. Embassy
officials living in areas with past or present H5N1 outbreaks
titled, Update: Guidelines and Recommendations, Interim
Guidance about Avian Influenza A(H5N1) for U.S. Citizens Living
Abroad. 7
CDC continues to recommend surveillance, diagnostic evaluation,
and infection control for suspected H5N1 cases in travelers
to the U.S. These recommendations are contained in a health
update on February 4, 2005 (www.cdc.gov/flu/avian/professional/han020405.htm).
CDC remains in communication with WHO and continues to closely
monitor the H5N1 situation in Asia. Updated information can
be found at the following websites:
Avoid all contact with poultry (e.g., chickens, ducks, geese, pigeons, quail) or any wild birds, and avoid areas where H5N1-infected poultry may be present, such as commercial or backyard poultry farms and live poultry markets.
Do not eat uncooked or undercooked poultry or poultry products, including dishes made with uncooked poultry blood.
As with other infectious illnesses, one of the most important preventive practices is careful and frequent handwashing. Cleaning your hands often, using soap and water (or waterless, alcohol-based hand rubs when soap is not available and hands are not visibly soiled) removes potentially infectious materials from your skin and helps prevent disease transmission.
CDC does not recommend the routine use of masks or other personal protective equipment while in public areas.
When Preparing Food
During preparation of poultry, cooks are reminded to follow
proper food preparation and handling practices, including:
7
Separate raw meat from cooked or ready-to-eat foods. Do not use the same chopping board or the same knife for preparing raw meat and cooked or ready-to-eat foods.
Do not handle either raw or cooked foods without washing your hands in between.
Do not return cooked meat to the same plate or surface that it was on before it was cooked or to any surface contaminated with raw poultry.
Thoroughly cook all poultry products, including eggs and poultry blood. Egg yolks should not be runny or liquid. Poultry meat and eggs should reach a temperature of 165°F (~74°C) throughout to ensure the destruction of the virus.
Do not use raw or soft-boiled eggs in foods that will not be cooked.
After handling raw poultry or eggs, wash your hands and all surfaces and utensils thoroughly with soap and water.
Important considerations:
Avoid touching your mouth, nose or eyes while handling raw poultry products; the virus could be transmitted in this manner.
Avoid generating aerosols when cutting up poultry; the virus could be transmitted in this manner.
It is possible that you might become infected in a country where the health care system may be inadequate to cope with human avian influenza.
If an avian influenza virus develops the ability to pass freely from human to human while you are stationed in an affected country, it is possible that either U.S. or foreign country borders will be closed and return travel to the U.S. may be impossible or delayed.
If you believe that you might have been exposed to AI, take
the following precautions:
Monitor your health for 10 days.
If you become ill with fever and develop a cough or difficulty breathing, or if you develop any illness during this 10-day period, consult a healthcare provider but be sure to inform the provider of the following before you visit a healthcare facility:
your symptoms;
where you traveled; and
if you have had direct poultry contact or contact with a known or suspected human case of influenza A (H5N1) in an H5N1-affected country.
The U.S. Embassy or Consulate can provide names and addresses of local physicians.
Do not travel while sick, and limit contact with others as much as possible to help prevent the spread of any infectious illness.
For information about safety and security for Americans living abroad, see www.travel.state.gov.
The following employee groups may be at risk under certain
circumstances, especially if there is a massive outbreak at
a specific area of the U.S. or if there are numerous outbreaks
throughout the country:
Employers should
train employees to use good hand hygiene and to be aware
of the symptoms of avian influenza in birds and other animals.
Although the types of personal protective equipment that
would be required by each of these groups of employees may
be different from those outlined under Guidance
for Poultry Employees, these PPE recommendations
may serve as a guide for other employees depending on the
risk assessment made by their employers of their possible
level of exposure. A risk assessment can be made by contacting
Federal and State government agencies that will be dealing
with these issues. Many of the agencies that will have up-to-date
information can be found in Appendix A.
Most Federal Agencies
have posted avian influenza guidance for their employees.
Also most states have guidance for employees that would be
most affected if there was an outbreak of avian influenza near them. Consult state health departments for
updates on outbreaks and PPE guidance if and when an outbreak
occurs.
All employees with potential occupational exposure, as described
in this document, should be trained on the hazards associated
with exposure to influenza A (H5N1) and be familiar with the
protocols in place in their facility to isolate and report
cases or reduce exposures.
The first outbreak of highly pathogenic avian influenza (HPAI)
H5N1 virus was reported in Hong Kong in 1997. Hong Kong responded
appropriately by killing its entire poultry population of 1.5
million birds in 3 days. 11 From 2000 through 2004, there were
an additional 15 HPAI outbreaks in Asian countries and 200
million birds were killed. The scale of the problem is enormous,
especially when one considers that in the 40-year period before
2000 there were just 18 HPAI bird flu outbreaks (none due to
H5N1) and only 23 million birds were destroyed. 12 The H5N1
virus was largely confined to several countries throughout
Asia until 2005. Among these were Cambodia, China, Hong Kong,
Indonesia, Japan, Lao PDR (Laos), Malaysia, South Korea (Republic
of Korea), Thailand, and Vietnam. In 2005, different strains
of the virus moved north and westward, first to Russia, Kazakhstan,
and Mongolia in July and to Romania, Turkey and Croatia in
October. 13
Human cases of H5N1 influenza were first reported in Hong
Kong in 1997 with 6 of 18 human infections resulting in death.
14 From December 2003 to November 2005, there have been 126
confirmed human infections resulting in 64 deaths. This is
a case fatality rate of approximately 51%. While no new cases
were reported from Hong Kong during this time period, cases
were reported from Cambodia, Indonesia, Thailand, and Vietnam,
increasing the number of countries affected with human H5N1
infections to five. Vietnam had the highest incidence with
92 reported human cases and 42 deaths. 15 The case fatality
rate in humans may be somewhat inflated because it appears
that many exposed individuals may have had very mild symptoms
or may even have been asymptomatic and, therefore, have not
been counted in epidemiologic surveys. 16 Although there have
been reports that the virus may have been transmitted from
human-to-human, this mode of transmission has not been conclusively
determined and, if it does occur, it currently seems to be
very inefficient. 17 Beyond infecting humans, the H5N1 virus
has been found to infect and kill other mammals. It can be
transmitted from birds to both wild and domestic felids (cats)
that eat infected poultry. However, transmission from birds to pigs does not appear to readily occur, although there is increasing evidence that it is beginning
to occur. Pig-to-pig transmission has not been documented experimentally,
but felid-tofelid transmission does occur. 18, 19, 20
As of October 2006, highly pathogenic avian influenza HPAI
H5N1 viruses have not been reported from North or South America.
However, in 2004, an HPAI H5N2 strain was reported in Texas
and resulted in the culling of chicken stocks in January and
August of that year. 21 During the period from 2004-2005, there
have been low pathogenic avian influenza (LPAI) H5N2 outbreaks
in Italy, Japan, Mexico, the Republic of Korea, and The Taiwan
Province of China and the list of host domestic poultry has
been expanded from chickens to include ducks, turkeys, and
pheasants. 21 The H5N2 subtype has apparently been causing
outbreaks in poultry for quite some time and can readily undergo
genetic change from low to high pathogenicity. During a 1983-1984
epidemic in the U.S., an LPAI H5N2 virus mutated into an HPAI
H5N2 virus within 6 months and resulted in poultry mortality
near 90%. Seventeen million birds had to be destroyed to control
the outbreak. 14 Similarly, an epidemic caused by a LPAI H5N2
strain in Mexico in 1992 underwent genetic change and converted
from an LPAI H5N2 virus to a HPAI H5N2 virus that was not brought
under control until 1995. 14 Although the H5N2 subtype has
now been isolated throughout the world, with some strains being
highly pathogenic to domestic birds, there have not been any
reported cases of human infection.
Wild waterfowl are the natural hosts for influenza A viruses
and when they migrate they can enhance the spread of a particular
viral subtype worldwide. 22 It appears that at least some of
the spread of HPAI H5N1 is also occurring via wild bird migrations.
From its origin in Hong Kong in 1997, it has moved northward
to Lake Qinghai in China, a breeding center for migrant birds
that congregate from Southeast Asia, Siberia, Australia, and
New Zealand. 23 The H5N1 strains that are migrating westward
are genetically almost identical to those that killed wild
birds in Lake Qinghai but distinct from those that have caused
death in humans in Southeast Asia. It is currently believed
that the East Asia/Australian flyway (Pacific Flyway) of migratory
birds may carry HPAI H5N1 to the U.S. via Alaska. The University
of Alaska and the USDA have been alert to this possibility
for some time. From 1998-2004, over 12,000 samples from wild
birds in Alaska were evaluated for influenza viruses but H5N1
was not detected. 24 In addition, since 2000 the USDA has tested
approximately 4000 migratory birds in the Atlantic flyway and
H5N1 was not detected. Since the summer of 2005, the Department
of the Interior (DOI) has been working with the State of Alaska
to strategically sample migratory birds in the Pacific Flyway.
As of March 20, 2006, DOI has carried out more than 1700 tests
on samples from more than 1100 migratory birds. Although twenty-two
HPAI isolates were identified, the HPAI H5N1 was not found.
The USDA, DOI and HHS have developed an Interagency Readiness
Plan to monitor wild birds for the early detection of H5N1
and other HPAI viruses in the United States. The plan is part
of the President's National Strategy for Pandemic Influenza
Preparedness and outlines a prioritized wild bird sampling
system with emphasis on Alaska, followed by other areas in
the Pacific Flyway and the Pacific islands, and finally the
Central, Mississippi and Atlantic Flyways. Emphasis is being
placed on Alaska since it is at the crossroads of bird migration
flyways and scientists believe that if the strains of H5N1
currently affecting Southeast Asia were to spread to North
America via migratory birds they would likely arise first in
Alaska. In 2006, USDA and its cooperators plan to collect between
75,000 and 100,000 samples from live and dead wild birds as
well as 50,000 samples of water or feces from high-risk waterfowl
habitats across the United States. 25
In addition to spreading via migratory birds, the H5N1 virus
may also have been spreading through the legal and illegal
movement of infected birds and contaminated avian-origin products.
The migration of the virus is a matter of great concern, and
the sheer numbers of people, pigs, and poultry in Asia also
offers a significant opportunity for the H5N1 virus to undergo
genetic reassortment (i.e., when two different viruses infect
the same bird, the resulting viruses can reassort their genetic
material into unique combinations) to a form that can be efficiently
transmitted between humans. Since the last pandemic (the Hong
Kong flu) in 1968, the populations of human, pigs and poultry
in China alone have increased 2-, 100- and 1,000-fold respectively.
26
The influenza viruses are 80-120 nanometers in diameter but
they can be ovoid (egg-shaped) to even filamentous (thread-like).
10 There are three major types of the influenza virus: A, B,
and C. Although there are many subtypes of the A virus, there
is only one known subtype of the B and C viruses. Within each
subtype there are many different strains. The subtypes of the
A viruses differ in the combinations of the 16 distinct hemagglutinin
(H1-H16) and 9 distinct neuraminidase (N1-N9) viral surface
proteins. 10 These are the primary antigens of the influenza
viruses against which the human immune system develops antibodies;
the H antigen is significantly more immunogenic than the N
antigen. There are two major ways in which influenza A viruses
can change antigenically: via antigenic drift or shift. During antigenic
drift, a variety of mutations including substitutions,
deletions, and insertions produce genetic variation in the
surface proteins. A second type of variation, antigenic
shift, describes a major antigenic change whereby
a virus with a new H (with or without a new N) is introduced
into the human population. 27 Type A viruses undergo both antigenic
shift and drift, while Type B viruses undergo antigenic drift
only, and type C viruses are relatively stable. Influenza A
viruses cause disease in birds, cats, dogs, ferrets, horses,
humans, swine and marine mammals (seals and whales), while
type B viruses cause disease in humans and rarely, in seals,
and type C occasionally causes a mild disease in humans and
swine. 28, 29
All subtypes of influenza type A viruses can be found in
waterfowl (e.g., ducks, geese, etc.), where they normally reside
in the intestinal tract and cause little, if any, disease.
At times, some of these viruses mutate or reassort (i.e., when
two different viruses coinfect a bird, their genetic components
can recombine to form a new subtype or strain) and cause disease
in poultry (e.g., chickens, turkeys, etc.) that is very contagious
and sometimes deadly. This poultry disease is called avian
influenza (AI) or more commonly “bird” or “avian
flu.” When an AI virus causes high mortality in poultry,
it is referred to as highly pathogenic avian influenza (HPAI)
virus. In the past, the disease caused by HPAI viruses was
more commonly called fowl plague. If an AI virus produces mild
infection in poultry with little mortality, it is referred
to as a low pathogenic avian influenza (LPAI) virus. It should
be noted that the mutation from LPAI viruses to HPAI viruses
has resulted in bird flu epidemics in poultry 19 times since
1959. 30
The genetic material of influenza A viruses is ribonucleic
acid (RNA) and it is arranged in eight separate strands. The
two genes coding for the viral surface proteins as well as
the other genes coding for internal viral proteins can reassort
(recombine with other genes) when a host is infected with more
than one viral subtype. This can lead to the generation of
novel (new) viral subtypes as well as other genetic changes
that affect pathogenicity. The H5N1 virus is an example where
reassortment of genes from three different virus subtypes led
to its development in Hong Kong in 1997. Apparently, the H5
gene of a H5N1 strain present in geese in 1996 was retained
but its remaining genes, including the gene coding for the
N1 surface protein, were obtained from a H6N1 strain from a
green-winged teal and an H9N2 strain from a quail. 31
Although AI viruses do not typically infect humans, confirmed
instances of AI viruses other than H5N1 infecting humans have
been documented since 2002 and include: 32
H7 Subtypes
H7N2, Virginia, 2002: Serologic evidence of infection in one person.
H7N2, New York, 2003: An infected patient presented with respiratory symptoms and recovered. The source of the infection was unknown.
H7N3, Canada, 2004: Infected poultry workers developed eye infections.
H7N7, Netherlands, 2003: Eighty-nine (89) people, mostly poultry workers, were infected. Seventy-eight (78) patients developed conjunctivitis (eye infections) only; five patients developed conjunctivitis along with influenza-like illnesses (ILIs) with cough, fever, and muscle aches; two patients presented with ILI only; and 4 patients had “other” symptoms. There was a single death of an individual that presented with acute respiratory distress syndrome. Three possible instances of transmission from poultry employees to family members were reported.
H9 Subtypes
H9N2, Hong Kong, 2003: An infected child was hospitalized, but recovered.
As of October 2006
HPAI H9 strains have not been reported.
Only certain HPAI strains of H7N7 and H5N1 have killed humans; almost all human deaths have been caused by the latter subtype.
Appendix C Genetic Variations in H5N1 Strains and Implications for Human Health Since the emergence of highly pathogenic avian influenza
(HPAI) H5N1 in 1997 [genotype H5N1/97; different genotypes
(clusters of genetically related strains) had not yet been
recognized], the parent Gs/Gd genotype of H5N1/97 has undergone
additional reassortments with unknown AI viruses. The H5N1/97
genotype did not reappear after the 1997 outbreak. By 2001,
six new genotypes (A, B, C, D, E and X0) had emerged. From
2002 onwards, an additional eight genotypes (V, W, X1, X2,
X3, Y, Z and Z+) were discovered but the Gs/Gd, A, C, D and
E genotypes apparently disappeared. 33 The strain that caused
the 2003 outbreak in Hong Kong that resulted in two human cases,
one of whom died, belonged to the Z+ genotype. 34 The very
similar Z genotype is now dominant in Southeast Asia and was
responsible for the poultry and human outbreaks in Indonesia,
Thailand and Vietnam in late 2003 and early 2004. 33 The viruses
that caused poultry outbreaks in South Korea in 2003 and in
Japan in 2003-2004 were members of the V genotype; a genotype
that has not been associated with human disease. 35,36 It also
appears that the H5N1 viruses from the 2004 Vietnam outbreaks
are environmentally more stable than those from the Hong Kong
1997 outbreak; the former survived at 37ºC for 6 days,
compared with 2 days for latter at 35ºC. 37
HPAI H5N1 has been moving northward. A new H5N1 genotype
emerged at Lake Qinghai in northern China in May of 2005 and
eventually killed more than 6,000 migratory waterfowl. 38 While
it is unusual for an AI virus to kill waterfowl, this is not
unprecedented for the H5 subtype. A H5N3 strain killed 1,300
terns (wild waterfowl) in South Africa in 1961. 39 It is important
to note that the H5N1 genotype that affected wild waterfowl
in northern China appears to be a new reassortant virus, combining
genetic material from at least two other HPAI H5N1 strains.
38 These do not belong to the Z genotype that affected Southeast
Asia. Also it is now known that the strains affecting humans
in Indonesia are of a different sub lineage of the Z genotype
than those that affected humans in Thailand and Vietnam in
2004 and 2005. 40 As of May 29, 2006, there have been no reported
human cases of H5N1 in Thailand or Vietnam in 2006 but the
number of cases of human infection in Indonesia is greater
than for all of 2005 (25 versus 17 total cases in 2005). The
Indonesian sub-lineage is particularly virulent since 25 of
the 31 persons infected in 2006 have died (a case fatality
rate of approximately 80%). 15
While all of these various genetic variants of H5N1 are still
classified as HPAI strains, some appear to be non-infectious
while others are infectious to humans. The strains of H5N1
migrating north and west from Lake Qinghai in China have attacked
poultry and wild waterfowl in many countries but have caused
human disease only in Azerbaijan, Djibouti, Iraq, Turkey, and
Egypt as of October 12, 2006. Of the 54 countries with H5N1
outbreaks in poultry or wild birds, human disease has been
documented in only 10 of them.
Survival of influenza A viruses outside of the host varies
with the virus subtype, the strain, the host bird from which
it was obtained, pH, salinity, temperature and the type of
medium in which the virus is suspended. After excretion by
water birds, strains of avian influenza viruses (AIV) of five
different subtypes (H3N8, H4N6, H6N2, H10N7, and H12N5) remained
infective when suspended in lake water for 30-102 days at 28ºC
and for 126-207 days at 17ºC. 41 In the same study it
was estimated that the strain of subtype H10N7, the only strain
stored at 4ºC, would remain infective for 1333 days. Survival
of a strain of the H7N2 subtype was variable in different types
of chicken manure and ranged from more than 2 days to 6 days
at 15-20ºC, from 24 – 36 hours at 30-37ºC and
from 15 to 20 minutes at 56ºC. 42 Another study using
a strain from each of three different AIV subtypes (H4N6, H6N2,
and H10N7) found that pH, temperature and salinity affected
survival of these viruses differently. 43 It can be seen from
these studies that many variables affect the environmental
survival of AIVs. Therefore, one can only conclude with confidence
that AIV viruses survive less well at higher temperatures and
lower pH levels.
There have been very few studies on the environmental survival
of strains of H5N1. Although the studies cited below were not
totally comparable, these data suggest that like the genetic
data, strains which caused disease in Southeast Asia in 2004-2005
are different from the one that caused disease in 1997. Although
it appears that environmental survival of H5N1 appears to be
somewhat strain-specific, this must be more fully studied.
1997 Hong Kong H5N1 Strains
This strain does not survive complete drying at
room temperature. Not surprisingly, the temperature at which
it is stored affects its survival when in moist feces.
At 4ºC (39ºF) it survives for over 40 days without detectable loss in viability.
At 25ºC (77ºF) it is inactivated after 8 days.
At 35ºC (95ºF) it is inactivated after 2 days.19
2004 Vietnam H5N1 Strains
Interestingly, H5N1 strains from 2004 Vietnam outbreaks are
environmentally more stable than those from the 1997 Hong Kong
outbreak; the former survived at 37ºC for 6 days, compared
with 2 days for the latter at 35ºC. 37
Inactivation
The following provides a list of physical and chemical methods
that are considered effective in the inactivation of influenza
A viruses in general. 44
Physical Methods
Temperatures of 56ºC (133ºF) for 3 hours.
Temperatures of 60ºC (140ºF) for 30 minutes.
Acidic pH conditions.
Complete drying.
Chemical Methods
Exposure to oxidizing agents:
Sodium dodecyl sulphate.
Lipid solvents (e.g., detergents).
Exposure to β-propiolactone.
Exposure to disinfectants: bleach, chlorhexidine, ethanol, formalin, iodine compounds, phenolics, and quaternary ammonium compounds.
Important considerations:
Chemical inactivation is only effective after physical removal of bulk contamination.
The hazards associated with chemical decontaminants can be avoided if instructions for their use are followed closely and appropriate PPE is worn.
Apart from the methods listed above, there are many other
methods that can effectively kill these viruses. However, one
should use the safest method possible when disinfecting areas
known or suspected to be contaminated with the virus.
Infected birds shed virus in respiratory secretions via the
oral or nasal routes and in feces. Fecal-to-oral transmission
is the most common mode of spread between birds.
The movement of the virus between stocks occur mainly via the following modes:
Contaminated equipment;
Egg flats;
Feed trucks; and
Service crew.
Important considerations:
There is documented evidence that cats can become infected with some strains of H5N1 and that the virus can be spread between cats.
It is also possible that cats, dogs, rodents, and other mammals may be able to spread AI viruses by contacting contaminated material with their bodies and thereby transporting it to other poultry stocks.
Contaminated Environment to Humans
Several of the many possible modes of transmission
are:
Self-inoculation of intranasal and conjunctival membranes with contaminated hands.
Exposure during the application of untreated poultry feces as fertilizer.
Exposure to contaminated water.
Ingestion during swimming or drinking.
Direct contact of intranasal or conjunctival (eyelid) membranes.
While the modes of transmission from animal-to-animal and
environment-to-human may be similar for most strains of influenza
virus, there are notable differences in the mode of transmission
from animal-to-human and human-to-human between the 1997 Hong
Kong strains and the 2003-2004 Southeast Asian strains of H5N1.
Animals to Humans
H5N1 1997 Hong Kong Strains
Most infected patients were exposed to:
live poultry within a week before the onset of illness. For this particular outbreak, there was no significant risk related to:
eating or preparing poultry products.
exposure to persons with H5N1 disease.
exposure to ill poultry and butchering of birds. However, this activity was associated with seropositivity (i.e., serum of individuals contained antibodies to the H5 protein) but no signs of disease.
H5N1 2003-2005 Southeast Asian Strains
Most infected patients had engaged in one or more of the
following activities:
direct contact with diseased poultry;
plucking and preparing diseased birds for cooking;
handling fighting male chickens (cocks), in particular making oral contact with the head or beak of the bird;
playing with poultry, particularly asymptomatic ducks; and
consumption of duck's blood or possibly undercooked poultry.
Important considerations:
Although foodborne transmission has been implicated as a route of exposure in a very limited number of cases, it is equally possible that these particular AI-infected individuals may have been exposed to other sources of the virus before consumption of food containing uncooked blood.
Humans to Humans
H5N1 1997 Hong Kong Strains
Did not occur through general social contact, and serologic studies of exposed healthcare workers indicated that the rate of transmission was calculated to be 4% (seroconversion was observed in 25% of these; most were asymptomatic).
Appeared to occur in several household clusters and in one case of apparent child-to-mother transmission. Close personal contact without the use of precautions was implicated.
Transmission by small-particle aerosols was not identified.
H5N1 2003-2005 Southeast Asian Strains
Serologic surveys in Vietnam and Thailand have not found evidence of asymptomatic infections among contacts.
In northern Vietnam, surveillance of contacts of patients using modern molecular assays led to the detection of mild cases and an increased number and duration of clusters in families. Although these findings suggest that H5N1 strains may be adapting to humans in localized environments, more confirmatory studies are needed.
Two studies in Vietnam suggest that H5N1 does not pass from patients to healthcare workers even when infection control measures were not adequate. However, there is one case of severe illness in a nurse exposed to an infected patient in Vietnam.
H5N1 versus Human Influenza
In contrast to strains of H5N1 which are still largely AI
viruses with ineffective transmission between humans, the human
flu viruses can be readily passed from human-to-human via one
of the following routes.
Inhalation of infectious droplets and droplet nuclei.
Direct contact.
Transmission may also occur via contact with contaminated surfaces and subsequent self-inoculation of the nasal or conjunctival (eyelid) mucosa.
The data in this appendix have largely been condensed from
reference 45 (see Appendix J). The type and severity of symptoms
and patient outcomes can vary depending on the properties of
a particular viral strain and the patient's age and medical
status at the time of infection. The following information
is based on a number of studies of H5N1 infected hospitalized
individuals and only lists the most common symptoms (those
expressed in at least 50% of the patients) and lists these
in order of frequency. The number of patients studied that
were infected with the 1997 strain was 18 while the number
infected with 2004/2005 strains was 41.
Symptoms
H5N1 - 1997 Hong Kong Strain
Fever;
Cough;
Rhinorrhea (runny nose).
H5N1 - 2004/2005 Southeast Asian Strains
Fever;
Cough;
Dyspnea (shortness of breath);
Rhinorrhea;
Diarrhea.
The most striking difference in symptoms between those infected
with the 1997 strain and the strains circulating in 20042005,
was the high prevalence of dyspnea (shortness of breath) and
diarrhea in the later patients. Dyspnea was present in only
6% and diarrhea in 17% of patients infected with the 1997 strain.
Outcomes
H5N1 – 1997 Hong Kong Strain
Time from onset of illness to death: median 23 days (range 829);
Respiratory failure: 44%;
Death: 33%;
Age: median 9.5;
Age range: 1-60.
H5N1 – 2004/2005 Southeast Asian Strains
Time from onset of illness to death – median 8-12.8 days (range 4-30);
Respiratory failure: 80%;
Death: 78%;
Age: median was as low as 13.7 in one study and as high as 22 in another;
Age range: 2-58.
These data indicate that the 2004/2005 strains were more
virulent than the 1997 strain. The time from onset of illness
to death was shorter, while respiratory failure and death rate
were higher in patients infected with the former strains. Interestingly,
the death rate was higher in the victims infected with the
2004/2005 strains even though 68% had received some form of
oseltamivir treatment. However, it should be noted that oseltamivir
treatment is most effective when given as soon as possible
after onset of symptoms.
It should also be noted that on rare occasions H5N1-infected
patients in Southeast Asia have presented with fever and diarrhea
only 46 or severe diarrhea followed by seizure, coma and death.
47 Respiratory symptoms were not evident in these cases.
According to the U.S. Fish and Wildlife Service, before 2004
the United States annually imported an estimated 20,000 birds
from countries before they were affected with avian H5N1 influenza
outbreaks. On February 4, 2004, both the CDC and USDA issued
orders banning the importation of all birds whether dead or
alive, and all bird products, such as eggs, originating from
the Asian countries in which H5N1 AI had been documented. 48
These countries have a single asterisk in the table below.
Although the CDC and USDA had bird import restrictions for
nine countries in early 2004, in just over 2 years the list
has almost quadrupled to 36 as of October 2006. The table below
lists the affected countries. This information is constantly
changing and is updated as H5N1 outbreaks in poultry occur
in different countries. The updated lists can be accessed at:
www.cdc.gov/flu/avian/outbreaks/embargo.htm and www.aphis.usda.gov/vs/ncie/country.html#HPAI.
Countries Affected by Current (as of October 2006) CDC and USDA Bird Import Restrictions
East Asia and the Pacific
South Asia
Europe & Eurasia
Africa
Near East
Burma (Myanmar)
Afghanistan
Albania
Burkina Faso
Gaza and West Bank ***
Cambodia *
India
Azerbaijan
Cameroon
Israel
China *
Kazakhstan
Denmark **
Djibouti
Jordan
Indonesia *
Pakistan
France **
Egypt
Japan *
Germany **
Ivory Coast
Laos *
Hungary **
Niger
Malaysia *
Romania
Nigeria
South Korea *
Russia
Sudan
Thailand *
Sweden **
Vietnam *
Turkey
Ukraine
*The first countries to be placed on the list as of February
4, 2004. **USDA has specified defined areas of these countries from which bird imports are restricted. ***Palestinian Autonomous Territories
USDA maintains trade restrictions on the importation of poultry
and poultry products from countries where HPAI H5N1 has been
detected in commercial or traditionally raised poultry, not
in wild or migratory birds (i.e., if HPAI H5N1 has been detected
in wild or migratory birds but not in poultry in a country,
that country would not be placed on the restricted list). Additionally,
USDA has increased its monitoring of domestic commercial markets
for illegally smuggled poultry and poultry products.
All imported live birds must be quarantined for 30 days at
a USDA quarantine facility and tested for HPAI H5N1 before
entering the country. Home quarantine and testing for AI also
is required for returning U.S.-origin pet birds or performing
or theatrical birds returning to the U.S.
As of January 1, 2005 (69 FR 25820) and according to the Code of Federal Regulations (9 CFR 94.6), the ban was modified as follows: “Carcasses, and parts or products of carcasses, of poultry, game birds, or other birds may be imported from a region where HPAI subtype H5N1 exists only if they are imported for scientific, educational or research purposes and the Administrator [of the Animal and Plant Health Inspection Service (APHIS) at the USDA] has determined that the importation can be made under conditions that will prevent the introduction of HPAI subtype H5N1 into the United States.”
On June 23, 2005, a technical amendment was published in the Federal Register (70 FR 36332) in which 9 CFR 94.6(e) was amended to specify that the carcasses specified are “unprocessed.” This was added to remove the restriction on processed poultry products from the affected areas.
The list of Countries/Areas Affected with Highly Pathogenic Avian Influenza subtype H5N1 and therefore included under 9 CFR 94.6 has grown considerably and is continuously updated. The current list is available at: http://www.aphis.usda.gov/vs/ncie/country.html#HPAI.
Illegal Importation of Birds – A Very Real
Threat
Illegal importation of birds from H5N1-affected countries
represents a major threat for the dissemination of H5N1 worldwide.
Countries must be vigilant about this potential problem. For
example, Belgium customs officials recently intercepted asymptomatic
highly pathogenic avian influenza H5N1-infected crested hawk-eagles
that were being smuggled from Thailand. 49 It is interesting
to note that most of the live bird imports into the United
States from the European Union in 2004 and 2005 were pet birds
from Belgium. 50
Legal Importation of Birds
It is of paramount importance that birds be quarantined for
a significant period of time (e.g., the USDA has a 30-day quarantine
period) when they are imported legally from other countries.
For instance, 52 of 101 quarantined birds (Mesias) imported
into the UK from Taiwan died (four were dead on arrival). Thirty-eight
of the 52 dead birds were tested for H5N1. Tissues from these
38 birds were pooled into seven batches, five of which were
positive for H5N1. It was concluded that, although the Mesias
probably died from H5N1 infections, it may not have been the
only cause. As a precaution, the remainder of the Mesias were
euthanized. The H5N1 strain isolated from the Mesias most closely
resembled a 2005 H5N1 isolate from Chinese ducks. 51
Genetic studies indicate that aquatic birds, in particular,
are the probable source of all influenza A virus strains found
in other species. 22 The H5N1 virus is particularly worrisome
because humans have no or little immunity to it. Luckily, not
all novel influenza viruses are able to cause infection or
pass freely from human-to-human. It is when they acquire this
ability that they can cause a pandemic. If
the infection cycle is restricted to bird-to-human transmission,
there is little chance of a pandemic and the spread of the
virus can be contained by eliminating infected birds and avoiding
contact with infected birds.
Currently, only strains of three influenza A viral subtypes
are considered human flu viruses. These refer
to certain strains of H1N1, H2N2,
and H3N2 that can be efficiently transmitted
between humans. There have been three well-documented pandemics
caused by influenza A viruses. The Spanish flu, caused by an
H1N1 virus, struck in 1918-1919 and killed 500,000 in the U.S.
alone. In the second pandemic, the Asian flu caused by an H2N2
virus killed 70,000 in the U.S. and occurred in 1957-1958.
In the most recent pandemic, the Hong Kong flu caused by an
H3N2 virus killed 34,000 people in the U.S. and struck in 1968-1969.
The second and third pandemics were the result of genetic reassortment
whereby the circulating H1N1 virus acquired novel antigens
H2 and N2 in 1957, and H3 in 1968, from avian sources. The
typical annual U.S. flu epidemic (not pandemic) results in
200,000 hospitalizations and approximately 36,000 deaths with
an overall mortality rate of 0.008% for those infected. 52
Since there has not been an influenza A pandemic for over 37
years, the feeling among experts is that we are long overdue.
According to the Centers for Disease Control and Prevention
(CDC):
The severity of the next pandemic cannot be predicted, but
modeling studies suggest that its effect in the United States
could be severe. In the absence of any control measures (vaccination
or drugs), it has been estimated that in the United States
a “medium–level” pandemic could cause 89,000
to 207,000 deaths, between 314,000 and 734,000 hospitalizations,
18 to 42 million outpatient visits, and another 20 to 47 million
people being sick. Between 15% and 35% of the U.S. population
could be affected by an influenza pandemic, and the economic
impact could range between $71.3 and $166.5 billion. 52
Interpandemic Period
Novel influenza subtypes have not been detected in
humans.
Phase 1: An influenza
virus subtype that is known to have caused human infection
may be present in animals but the risk of human infection or
disease is considered to be low.
Phase 2: A circulating
animal influenza virus subtype poses a substantial risk of
human disease.
The distinction between phases 1 and 2 is based on the risk of human infection or disease resulting from circulating strains in animals. The distinction is based on
various factors [e.g., pathogenicity in animals and humans,
occurrence in domestic animals and livestock or only in wildlife,
whether the virus is enzootic (occurs among animals in a certain
area) or epizootic (epidemic among animals), geographically
localized or widespread, and/or other scientific parameters]
and their relative importance according to current scientific
knowledge.
Pandemic Alert Period
Phase 3: Human infection(s)
with a novel subtype have occurred, but no human-to-human transmission,
or at most only rare instances of spread to a close contact.
Phase 4: Small cluster(s)
of human infections with limited human-to-human transmission
but spread is highly localized, suggesting that the virus is
not well adapted to humans.
Phase 5: Larger cluster(s)
of human infections but human-to-human spread still localized,
suggesting that the virus is becoming increasingly better adapted
to humans, but may not yet be fully transmissible. At this
point there is a substantial pandemic risk.
The distinction between phases 3, 4 and 5 is
based on an assessment of the risk of a pandemic. Various factors
[e.g., transmission rate, geographical location and spread,
severity of illness, presence of genes from human strains (if
derived from an animal strain), and/or other scientific parameters]
and their relative importance according to current scientific
knowledge may be considered.
Pandemic Period
Phase 6: Pandemic: Increased and sustained person-to-person transmission in the general population.
According to the WHO plan, as of October 2006, the
world is currently in phase 3, the first phase of the pandemic
alert period.
There are other Federal agencies and international organizations
that have additional resources on avian flu.
Animal and Plant Health Inspection Service (APHIS) of the USDA provides online guidance on avian flu in birds and poultry products (www.aphis.usda.gov/hot_issues/avian_influenza/avian_influenza.shtml). Poultry employees and other farmworkers and pet shop employees should notify APHIS when they suspect birds may be infected with avian flu.
Health and Human Services (HHS) has a website that is regularly updated and provides relevant information about avian influenza and information on pandemic preparedness and response (www.pandemicflu.gov).
Centers for Disease Control and Prevention (CDC) has established avian flu public hotlines: Public: 800-CDC-INFO; TTY: 888-232-6348; and for Clinicians 877-554-4625. The CDC has additional online resources at: www.cdc.gov/flu/avian/index.htm.
Center for Infectious Disease Research and Policy (CIDRAP), University of Minnesota provides continuously updated information on avian flu. (www.cidrap.umn.edu).
The Environmental Protection Agency (EPA) has a website containing an avian influenza fact sheet and a list of registered disinfectant products for use in poultry and other agricultural and veterinary facilities at: www.epa.gov/pesticides/factsheets/avian_flu_products.htm.
ProMED-Mail – This website serves as a central site for news, updates, and discussions of outbreaks of emerging and reemerging diseases that affect human health and provides up-to-date information on disease outbreaks around the world. (www.fas.org/promed/index.html).
U.S. Fish and Wildlife Service, Division of Migratory Bird Management, Avian Influenza in Wild Birds—Sources of Information. This website is very comprehensive and provides numerous links to Federal, state, and local websites concerning avian flu in wild birds. (www.fws.gov/migratorybirds/issues/AvianFlu/WBAvianFlu.htm#StateWildlifeAgencies).
World Organization for Animal Health (OIE). This website has regular animal disease alerts. (www.oie.int/eng/en_index.htm).
Physicians, employers and employees should contact their state or local health department (www.cdc.gov/mmwr/international/relres.html) to notify them of any symptomatic employees or suspected exposure incidents. Numerous other sources of information about avian flu are available. 55 For more information on safety and health resources, you may also want to consult the following:
Directorate of Cooperative and State Programs (DCSP) home page at: www.osha.gov/dcsp/index.html. The site has links to the following:
State Plans
DCSP coordinates OSHA's activities with the OSHA-approved
State occupational safety and health programs.
Outreach and Training
DSCP also provides or coordinates OSHA's outreach, compliance
assistance, and training and education services, including:
Centers for Disease Control and Prevention, Interim Guidance for Protection of Persons Involved in U.S. Avian Influenza Outbreak Disease Control and Eradication Activities. (www.cdc.gov/flu/avian/professional/protect-guid.htm).
Centers for Disease Control and Prevention, Updated Interim Guidance for Laboratory Testing of Persons with Suspected Infection with Avian Influenza A (H5N1) Virus in the United States, June 7, 2006. (www.phppo.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?AlertNum=00246).
Centers for Disease Control and Prevention, Interim Recommendations for Infection Control in Healthcare Facilities Caring for Patients with Known or Suspected Avian Influenza. www.cdc.gov/flu/avian/professional/infect-control.htm).
Simeonsson, K. et al. 2004. Influenza vaccination of healthcare workers: institutional strategies for improving rates. N.C. Med. J. 65:323-329.
Lu, X. et al. 2003. Pathogenicity and antigenicity of a new influenza A (H5N1) virus isolated from duck meat. J. Med. Virol. 69:553-559.
Mase , M.E. et al. 2005. Isolation of a genotypically unique H5N1 influenza virus from duck meat imported into Japan from China. Virology, 339:101-109.
Bridges, C.B., et al. 2002. Risk of influenza A (H5N1) infection among poultry workers, Hong Kong, 1997-1998. J. Infect. Dis. 185:1005-10.
Liem, N.T. and W. Lim. 2005. Lack of H5N1 avian influenza transmission to hospital employees, Hanoi, 2004. Emer. Infect. Dis. 11:210-215.
Choi, Y.K., et al. 2005. Influenza virus infection of pigs by using viruses isolated in Vietnam and Thailand in 2004. J. Virol. 79:10821-10825.
Shortridge, K.F., et al. 1998. Characterization of avian H5N1 influenza viruses from poultry in Hong Kong. Virology 252:331-342.
Kuiken, T., et al. 2005. Avian H5N1 influenza in cats. Science 306:241.
Avian Influenza Technical Task Force, FAO – Rome & Bangkok 2005. Update on the avian influenza situation (as of 31/07/2005) – Issue no. 32. FAOAIDEnews. Avian Influenza Disease Emergency. (www.fao.org/ag/againfo/subjects/documents/ai/AVIbull032.pdf).
Reed, K.D., et al. 2003. Birds, migration and emerging zoonoses: West Nile virus, Lyme disease, influenza A and enteropathogens. Clin. Med. Res. 1:5-12.
Liu, J., et al. 2005. Highly pathogenic H5N1 influenza virus infection in migratory birds. Science, 309:1206.
Osterholm, M.T. 2005. Preparing for the next pandemic. N. Engl. J. Med. 352:1839-1842.
Cox, N.J. and K. Subbarao. 2000. Global epidemiology of influenza: Past and present. Ann. Rev. Med. 51:407-421.
Crawford, P.C., et al. 2005. Transmission of equine influenza to dogs. Science 310:482-485.
Suzuki, Y. 2005. Sialobiology of influenza – molecular mechanism of host range variation in influenza viruses. Biol. Pharm. Bull. 28:399-408.
Normille, D. 2005. Are wild birds to blame? Science 310:426-428
Chin, P.S., et al. 2002. Molecular evolution on H6 influenza viruses from poultry in southeastern China: Prevalence of H6N1 influenza viruses possessing seven A/Hong Kong/156/97 (H5N1)-like genes in poultry. J. Virol. 76:507-516.
OSHA can provide extensive help through a variety of programs,
including technical assistance about effective safety and health
programs, state plans, workplace consultations, voluntary protection
programs, strategic partnerships, training and education, and
more. An overall commitment to workplace safety and health
can add value to your business, to your workplace and to your
life.
Safety and Health Program Management Guidelines
Effective management of employee safety and health protection
is a decisive factor in reducing the extent and severity of
work-related injuries and illnesses and their related costs.
In fact, an effective safety and health program forms the basis
of good employee protection and can save time and money (about
$4 for every dollar spent) and increase productivity and reduce
employee injuries, illnesses and related workers' compensation
costs.
To assist employers and employees in developing effective
safety and health programs, OSHA published recommended Safety
and Health Program Management Guidelines (54 Federal
Register (16): 3904-3916, January 26, 1989). These voluntary
guidelines apply to all places of employment covered by OSHA.
The guidelines identify four general elements critical to
the development of a successful safety and health management
program:
Management leadership and employee involvement.
Work analysis.
Hazard prevention and control.
Safety and health training.
The guidelines recommend specific
actions, under each of these general elements, to achieve
an effective safety and health program. The Federal Register notice is available
online at www.osha.gov
State Programs
The Occupational Safety and Health Act of 1970 (OSH
Act) encourages states to develop and operate their own job
safety and health plans. OSHA approves and monitors these plans.
Twenty-four states, Puerto Rico and the Virgin Islands currently
operate approved state plans: 22 cover both private and public
(state and local government) employment; Connecticut, New Jersey,
New York and the Virgin Islands cover the public sector only.
States and territories with their own OSHA-approved occupational
safety and health plans must adopt standards identical to,
or at least as effective as, the Federal standards.
Consultation Services
Consultation assistance is available on request to employers
who want help in establishing and maintaining a safe and healthful
workplace. Largely funded by OSHA, the service is provided
at no cost to the employer. Primarily developed for smaller
employers with more hazardous operations, the consultation
service is delivered by state governments employing professional
safety and health consultants. Comprehensive assistance includes
an appraisal of all mechanical systems, work practices and
occupational safety and health hazards of the workplace and
all aspects of the employer's present job safety and
health program. In addition, the service offers assistance
to employers in developing and implementing an effective safety
and health program. No penalties are proposed or citations
issued for hazards identified by the consultant. OSHA provides
consultation assistance to the employer with the assurance
that his or her name and firm and any information about the
workplace will not be routinely reported to OSHA enforcement
staff.
Under the consultation program, certain exemplary employers
may request participation in OSHA's Safety and Health
Achievement Recognition Program (SHARP). Eligibility for participation
in SHARP includes receiving a comprehensive consultation visit,
demonstrating exemplary achievements in workplace safety and
health by abating all identified hazards and developing an
excellent safety and health program.
Employers accepted into SHARP may receive an exemption from
programmed inspections (not complaint or accident investigation
inspections) for a period of one year. For more information
concerning consultation assistance, see the OSHA website at
www.osha.gov
Voluntary Protection Programs (VPP)
Voluntary Protection Programs and on-site consultation services,
when coupled with an effective enforcement program, expand
employee protection to help meet the goals of the OSH Act.
The three levels of VPP are Star, Merit, and Star Demonstration
designed to recognize outstanding achievements by companies
that have successfully incorporated comprehensive safety and
health programs into their total management system. The VPPs
motivate others to achieve excellent safety and health results
in the same outstanding way as they establish a cooperative
relationship between employers, employees and OSHA.
For additional information on VPP and how to apply, contact
the OSHA regional offices listed at the end of this publication.
Strategic Partnership Program
OSHA's Strategic Partnership Program, the newest member
of OSHA's cooperative programs, helps encourage, assist
and recognize the efforts of partners to eliminate serious
workplace hazards and achieve a high level of employee safety
and health. Whereas OSHA's Consultation Program and VPP
entail one-on-one relationships between OSHA and individual
worksites, most strategic partnerships seek to have a broader
impact by building cooperative relationships with groups of
employers and employees. These partnerships are voluntary,
cooperative relationships between OSHA, employers, employee
representatives and others (e.g., trade unions, trade and professional
associations, universities and other government agencies).
For more information on this and other cooperative programs,
contact your nearest OSHA office, or visit OSHA's website
at www.osha.gov
Alliance Programs
The Alliance Program enables organizations committed to workplace
safety and health to collaborate with OSHA to prevent injuries
and illnesses in the workplace. OSHA and the Alliance participants
work together to reach out to, educate and lead the nation's
employers and their employees in improving and advancing workplace
safety and health.
Groups that can form an Alliance with OSHA include employers,
labor unions, trade or professional groups, educational institutions
and government agencies. In some cases, organizations may be
building on existing relationships with OSHA that were developed
through other cooperative programs.
There are few formal program requirements for Alliances and
the agreements do not include an enforcement component. However,
OSHA and the participating organizations must define, implement
and meet a set of short- and long-term goals that fall into
three categories: training and education; outreach and communication;
and promoting the national dialogue on workplace safety and
health.
OSHA Training and Education
OSHA area offices offer a variety of information services,
such as compliance assistance, technical advice, publications,
audiovisual aids and speakers for special engagements. OSHA's
Training Institute in Arlington Heights, IL, provides basic
and advanced courses in safety and health for Federal and state
compliance officers, state consultants, Federal agency personnel,
and private sector employers, employees and their representatives.
The OSHA Training Institute also has established OSHA Training
Institute Education Centers to address the increased demand
for its courses from the private sector and from other Federal
agencies. These centers are nonprofit colleges, universities
and other organizations that have been selected after a competition
for participation in the program.
OSHA also provides funds to nonprofit organizations, through
grants, to conduct workplace training and education in subjects
where OSHA believes there is a lack of workplace training.
Grants are awarded annually. Grant recipients are expected
to contribute 20 percent of the total grant cost.
For more information on grants, training and education, contact
the OSHA Training Institute, Office of Training and Education,
2020 South Arlington Heights Road, Arlington Heights, IL 60005,
(847) 297-4810 or see “Outreach” on OSHA's
website at www.osha.gov. For further information on any OSHA
program, contact your nearest OSHA area or regional office
listed at the end of this publication.
Information Available Electronically
OSHA has a variety of materials and tools available on its
website at www.osha.gov. These include e-Tools such
as Expert Advisors, Electronic Compliance Assistance Tools
(e-cats), Technical Links; regulations, directives and
publications; videos and other information for employers and
employees. OSHA's software programs and compliance assistance
tools walk you through challenging safety and health issues
and common problems to find the best solutions for your workplace.
A wide variety of OSHA materials, including standards, interpretations,
directives, and more, can be purchased on CD-ROM from the U.S.
Government Printing Office, Superintendent of Documents, phone
toll-free (866) 512-1800.
OSHA Publications
OSHA has an extensive publications program. For a listing
of free or sales items, visit OSHA's website at www.osha.gov
or contact the OSHA Publications Office, U.S. Department of
Labor, 200 Constitution Avenue, NW, N-3101, Washington, DC
20210. Telephone (202) 693-1888 or fax to (202) 693-2498.
Contacting OSHA
To report an emergency, file a complaint or seek OSHA advice,
assistance or products, call (800) 321-OSHA or contact your
nearest OSHA regional or area office listed at the end of this
publication. The teletypewriter (TTY) number is (877) 889-5627.
You can also file a complaint online and obtain more information
on OSHA Federal and state programs by visiting OSHA's
website at www.osha.gov
OSHA Regional Offices
Region I (CT,* ME, MA, NH, RI, VT*) JFK Federal Building, Room E340 Boston, MA 02203 (617) 565-9860
Region VI (AR, LA, NM,* OK, TX) 525 Griffin Street, Room 602 Dallas, TX 75202 (214) 767-4731 or 4736 x224
Region II (NJ,* NY,* PR,* VI*) 201 Varick Street, Room 670 New York, NY 10014 (212) 337-2378
Region VII (IA,* KS, MO, NE) City Center Square 1100 Main Street, Suite 800 Kansas City, MO 64105 (816) 426-5861
Region III (DE, DC, MD,* PA, VA,* WV) The Curtis Center 170 S. Independence Mall West Suite 740 West Philadelphia, PA 19106-3309 (215) 861-4900
Region VIII (CO, MT, ND, SD, UT,* WY*) 1999 Broadway, Suite 1690 PO Box 46550 Denver, CO 80202-5716 (720) 264-6550
Region IV (AL, FL, GA, KY,* MS, NC,* SC,* TN*) 61 Forsyth Street, SW Atlanta, GA 30303 (404) 562-2300
Region IX (American Samoa, AZ,* CA,* HI,* NV,* Northern Mariana Islands) 71 Stevenson Street, Room 420 San Francisco, CA 94105 (415) 975-4310
Region V (IL, IN,* MI,* MN,* OH, WI) 230 South Dearborn Street Room 3244 Chicago, IL 60604 (312) 353-2220
Region X (AK,* ID, OR,* WA*) 1111 Third Avenue, Suite 715 Seattle, WA 98101-3212 (206) 553-5930
* These states and territories operate their own OSHA-approved
job safety and health programs ( Connecticut, New Jersey, New
York and the Virgin Islands plans cover public employees only).
States with approved programs must adopt standards identical
to, or at least as effective as, the Federal standards.
Note: To get contact information for OSHA
Area Offices, OSHA-approved State Plans and OSHA Consultation
Projects, please visit us online at www.osha.gov or call us
at 1-800-321-OSHA.
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