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.

This publication is in the public domain and may be

reproduced, fully or partially, without permission.

Source credit is requested but not required.

This information is available to sensory impaired

individuals upon request. Voice phone: (202) 693-

1999; teletypewriter (TTY) number: (877) 889-5627.
U.S. Department of Labor

Occupational Safety and Health Administration

OSHA 3323-10N

2006

OSHA Guidance Update on 

Protecting Employees from

Avian Flu (Avian

Influenza) Viruses
2

Contents

Purpose . . . 3 

Introduction . . . 4

Guidance for Poultry Employees . . . 7

Guidance for Animal Handlers other 

than Poultry Employees . . . 16

Guidance for Laboratory Employees . . . 17

Guidance for Healthcare Workers Who Treat 

Patients with Known or Suspected AI . . . 20

Guidance for Food Handlers . . . 25

Guidance for Airport Personnel Exposed to 

Passengers Suspected of Being AI-infected . . . 26

Guidance for Travelers on Temporary Work 

Assignment Abroad . . . 29 

Guidance for U.S. Employees Stationed Abroad . . . 33

Guidance for Other Employee Groups that May Be at Risk . . . 36

Employee Training . . . 37

Appendix A Worldwide Occurrence of the H5N1 Virus . . . 38

Appendix B Background on the Biology of Influenza 

Viruses . . . 41 

Appendix C Genetic Variations in H5N1 Strains and 

Implications for Human Health . . . 44

Appendix D Survival and Inactivation of Influenza A 

Viruses, Including H5N1 . . . 46

Appendix E Transmission of the H5N1 Virus . . . 48

Appendix F Symptoms and Outcomes of H5N1 Infection 

in Hospitalized Patients . . . 51

Appendix G Importation Ban on Birds from Countries 

Affected by the H5N1 Virus . . . 53

Appendix H History of Human Influenza Pandemics and 

Concern About a New Pandemic . . . 56

Appendix I Additional Sources of Information . . . 59

Appendix J References . . . 61

OSHA Assistance . . . 66
Purpose

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.

3

This guidance is advisory in nature and informational

in content. It is not a standard or a regulation, and it

neither creates new legal obligations nor alters existing

obligations created by OSHA standards or the

Occupational Safety and Health Act (OSH Act). Pursuant

to the OSH Act, employers must comply with hazardspecific safety and health standards as issued and

enforced either by OSHA or by an OSHA-approved State

Plan. In addition, Section 5(a)(1) of the OSH Act, the

General Duty Clause, requires employers to provide

their employees with a workplace free from recognized

hazards likely to cause death or serious physical harm.

Employers can be cited for violating the General Duty

Clause if there is a recognized hazard and they do not

take reasonable steps to prevent or abate the hazard.

However, failure to implement any recommendations in

this guidance is not, in itself, a violation of the General

Duty Clause. Citations can only be based on standards,

regulations, or the General Duty Clause.
Introduction

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

4
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 AIinfected

■ Travelers on temporary work assignment abroad

5
■ 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. 

Notes:

As much as possible, each section of this document is designed as a

stand-alone reference and, therefore, portions of the document are

redundant.

The website URLs cited in this document were effective as of October

2006. Be aware that URLs are often changed. If the website URL does

not work, go to the home page of the organization. This can usually be

done by deleting all of the URL characters after the first forward slash.

For instance, if the site is www.cdc.gov/od/oc/media/pressrel/fs021025.

htm, the home page would be located at www.cdc.gov. You may then

be able to find the web page of interest by following links on the home

page.

The appendices are current as of October 2006. Since information is

constantly changing, consult the web sites in Appendix I; many of these

are updated regularly. 

6
Guidance for Poultry Employees 

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

7
■ 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.

8
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.

Consult CDC’s website (Hand Hygiene Guidelines Fact Sheet at:

www.cdc.gov/od/oc/media/pressrel/fs021025.htm) for specific

details about effective hand hygiene practices. 

■ 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

9
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. 

10
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.).

11
• 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).

• For information on respirators, see the following:

www.osha.gov/SLTC/etools/respiratory/index.html, and

www.cdc.gov/niosh/npptl/topics/respirators.

Removal of Personal Protective Equipment (PPE)

■ Employees should always remove protective clothing (except

for gloves) first and discard or secure the clothing for disinfection before removing their respirators and goggles.

12
■ 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 outbreakresponse 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.

13
14

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 lifethreatening 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:

• Cover Your Cough (www.cdc.gov/flu/protect/covercough.htm)

• Hand Hygiene Guidelines Fact Sheet

(www.cdc.gov/od/oc/media/pressrel/fs021025.htm). 

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)

15
• 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 EPAregistered 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. 

Guidance for Animal Handlers 

other than Poultry Employees 

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

16
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.

Guidance for Laboratory Employees 

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.

17
18

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. 
19

• 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:

• www.osha.gov/SLTC/etools/respiratory/index.html, and

• www.cdc.gov/niosh/npptl/topics/respirators/.

Medical Monitoring

■ 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 lifethreatening 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. 
■ 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:

• Cover Your Cough (www.cdc.gov/flu/protect/covercough.htm)

• Hand Hygiene Guidelines Fact Sheet

(www.cdc.gov/od/oc/media/pressrel/fs021025.htm). 

Guidance for Healthcare Workers 

Who Treat Patients with Known or

Suspected AI 

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:

• Respiratory Hygiene/Cough Etiquette in Healthcare Settings

(see: www.cdc.gov/flu/professionals/infectioncontrol/

resphygiene.htm); and 

• questioned regarding their recent travel history. 

■ Patients with a history of travel within 10 days to a country with

AI activity and who are hospitalized with a severe febrile

20
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.

21
■ 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:

• www.osha.gov/SLTC/etools/respiratory/index.html, and

• www.cdc.gov/niosh/npptl/topics/respirators.

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 pre22
cautions 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

23
respiratory distress syndrome), and other severe and lifethreatening 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:

• Cover Your Cough

(www.cdc.gov/flu/protect/covercough.htm)

• Hand Hygiene Guidelines Fact Sheet

(www.cdc.gov/od/oc/media/pressrel/fs021025.htm).

24
Guidance for Food Handlers 

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.

25
■ 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: 

• Hand Hygiene Guidelines Fact Sheet

(www.cdc.gov/od/oc/media/pressrel/fs021025.htm). 

Guidance for Airport Personnel Exposed to 

Passengers Suspected of Being AI-infected 

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

26
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

Influenza8 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: 

■ Cover Your Cough (www.cdc.gov/flu/protect/cover cough.htm). 

■ Hand Hygiene Guidelines Fact Sheet

(www.cdc.gov/od/oc/media/pressrel/fs021025.htm).

27
Procedures for Protecting Airport Personnel in Close

Proximity to Passengers Suspected of Having an AIinfection

■ 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).

■ For additional information on respirators, see the following:

www.osha.gov/SLTC/etools/respiratory/index.html, and

www.cdc.gov/niosh/npptl/topics/respirators.

■ 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 AI28
infected person to immediately seek medical care but, prior to

arrival, notify their healthcare provider that they may have

been exposed to AI.

For more information about avian influenza, see 

www.cdc.gov/flu/avian/facts.htm, and 

www.cdc.gov/flu/avian/index.htm.

Guidance for Travelers on Temporary 

Work Assignment Abroad 

Geographic Applicability of OSHA Requirements: Private

sector employers are required to comply with OSHA

standards and other requirements with respect to work

performed in a workplace within the U.S., defined by section

4(a) of the OSH Act as the states, the District of Columbia, and

various listed U.S. territories. Federal agencies are required

by Executive Order 12196 to comply with all OSHA standards

with respect to working conditions of Federal employees

without regard to their location.

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

Czech Republic 29
East Asia Europe, Siberia, Central Asia Africa

South Korea Denmark

(Republic of Korea) France

Thailand Georgia

Vietnam 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.

30
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.

31
■ 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 officer can 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

32
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:

H5N1 infections in humans

■ World Health Organization (WHO) website

(www.who.int/topics/avian_influenza/en/), and

■ CDC website (www.cdc.gov/flu/avian/index.htm). 

Recommendations for enhanced surveillance and infection

control precautions for H5N1

■ CDC website

(www.cdc.gov/flu/avian/professional/han081304.htm).

Health recommendations for travel to Asia

■ CDC website (www.cdc.gov/travel/seasia.htm), and 

■ CDC website (www.cdc.gov/travel/eastasia.htm).

Guidance for U.S. Employees 

Stationed Abroad 

Geographic Applicability of OSHA Requirements: Private

sector employers are required to comply with OSHA

standards and other requirements with respect to work

performed in a workplace within the U.S., defined by section

4(a) of the OSH Act as the states, the District of Columbia, and

various listed U.S. territories. Federal agencies are required

by Executive Order 12196 to comply with all OSHA standards

with respect to working conditions of Federal employees

without regard to their location.

33
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:

■ CDC’s Avian Influenza (Bird Flu) web page

(www.cdc.gov/flu/avian/index.htm).

■ CDC’s Travelers’ Health web page (www.cdc.gov/travel). 

■ WHO website (www.who.int/en). 

Precautions

■ 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. 

34
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. 

For more information on good hand hygiene, consult Hand

Hygiene Guidelines Fact Sheet (www.cdc.gov/od/oc/media/

pressrel/fs021025.htm). 

35
Precautions If You Become Ill

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.

Guidance for Other Employee Groups that 

May Be at Risk 

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:

■ Border/Customs Officials

■ Employees of Retail/Wholesale Facilities

■ Fish and Wildlife Personnel

■ USDA Inspectors

■ FDA Inspectors

■ Department of Corrections Personnel

36
■ Live Bird Market Employees

■ Bird Fighting Industry Employees

■ Animal Control Employees

■ Taxidermists

■ Employees Handling Poultry Feces (Crop farmers, landfill

employees, landscapers)

■ Hotel/Motel Industry Employees 

■ Commercial Hunting Industry Employees

■ Wildlife Biologists Studying Wild Birds 

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 I.

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.

Employee Training 

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.

37
Appendix A

Worldwide Occurrence of the H5N1 Virus 

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, transmis368
sion 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

39
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

40
Appendix B

Background on the Biology of 

Influenza Viruses 

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

41
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

42
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.

43
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 sub44
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.

45
Appendix D

Survival and Inactivation of Influenza A 

Viruses, Including H5N1 

Environmental Survival

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 strainspecific, 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

46
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. 

• Use only disinfectants registered by EPA specifically for inactivating influenza A viruses and follow all label safety and use

directions (see: www.epa.gov/pesticides/factsheets/avian_flu_

products.htm). 

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.

47
Appendix E

Transmission of the H5N1 Virus 

The information in this appendix has largely been condensed

from reference 45 (see Appendix J at pg. 64).

Animals to Animals (Poultry to Poultry)

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.

48
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.

49
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. 

50
Appendix F

Symptoms and Outcomes of H5N1 

Infection in Hospitalized Patients 

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 2004-

2005, 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. 

51
Outcomes

H5N1 – 1997 Hong Kong Strain

■ Time from onset of illness to death: median 23 days (range 8-

29);

■ 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

only46 or severe diarrhea followed by seizure, coma and death.47

Respiratory symptoms were not evident in these cases.

52
Appendix G

Importation Ban on Birds from Countries 

Affected by the H5N1 Virus 

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 South Europe & Africa Near East

the Pacific Asia Eurasia 

Burma Afghanistan Albania Burkina Faso Gaza and

(Myanmar) India Azerbaijan Cameroon West Bank***

Cambodia* Kazakhstan Denmark** Djibouti Israel 

China* Pakistan France** Egypt Jordan

Indonesia* Germany** Ivory Coast

Japan* Hungary** Niger

Laos* Romania Nigeria

Malaysia* Russia Sudan

South Korea* Sweden**

Thailand* Turkey

Vietnam* 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 

53
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.

The bans are enforced by:

■ the CDC (see www.cdc.gov/flu/avian/outbreaks/embargo.htm),

■ the Animal and Plant Health Inspection Service (APHIS) of the

USDA (see www.aphis.usda.gov/vs/ncie/country.html#HPAI). 

■ The U.S. Fish and Wildlife Service under U.S. Customs and

Border Protection of the Department of Homeland Security (see

www.fws.gov/le/PubBulletins/PBImpRestrictionsBirdsH5N1

Update.htm). 

Modifications to the Ban

■ 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. 

54
■ 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

55
Appendix H

History of Human Influenza Pandemics 

and Concern About a New Pandemic 

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-tohuman 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

56
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

Increasing concern over the possibility of a pandemic has led

the World Health Organization (WHO) to develop a Global Influenza

Preparedness Plan.53 The U.S. Department of Health and Human

Services (HHS) developed a National Strategy for Pandemic

Influenza (www.whitehouse.gov/homeland/nspi.pdf). The main

stages of a pandemic as defined by WHO have been summarized

below by CDC:54

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.

57
58

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 humanto-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.
59

Appendix I

Additional Sources of Information 

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.

■ Food and Agriculture Organization of the United Nations (FAO).

This website provides regular bulletins on avian flu.

(http://www.fao.org/ag/againfo/home/en/home.html).

■ 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-todate 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
60

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 Health Organization (WHO) has information on avian flu

online. (www.who.int/csr/disease/avian_influenza/en). 

■ 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:

■ On-Site Consultation 

■ Compliance Assistance 

■ Small Business Assistance 

■ Training and Education 
61

Appendix J

References 

1 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).

2 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).

3 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).

4 Simeonsson, K. et al. 2004. Influenza vaccination of healthcare

workers: institutional strategies for improving rates. N.C. Med. J.

65:323-329.

5 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.

6 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. 

7 Centers for Disease Control and Prevention, Update: Guidelines

and Recommendations Interim Guidance about Avian Influenza A

(H5N1) for U.S. Citizens Living Abroad.

(www.cdc.gov/travel/other/avian_flu_ig_americans_abroad_032405.

htm). 

8 Centers for Disease Control and Prevention, Interim Guidance

for Airline Flight Crews and Persons Meeting Passengers Arriving

from Areas with Avian Influenza.

(www.cdc.gov/travel/other/avian_flu_ig_airlines_021804.htm).

9 Centers for Disease Control and Prevention, Outbreak Notice -

Update: Human Infection with Avian Influenza A (H5N1) Virus in

Asia. (www.cdc.gov/travel/other/avian_influenza_se_asia_2005.htm).
62

10 Infectious Diseases Society of America (IDSA), Avian Influenza

(Bird Flu): Agricultural and Wildlife Considerations. Last updated

May 12, 2006. (www.cidrap.umn.edu/cidrap/content/influenza/

avianflu/biofacts/avflu.html).

11 World Health Organization, Avian influenza – fact sheet. 

15 January, 2004. (http://www.who.int/csr/don/2004_01_15/en).

12 Enserink, M. 2005. Veterinary scientists shore up defenses

against bird flu. Science 308:341. 

13 Avian Influenza Technical Task Force, FAO – Rome & Bangkok.

2005. Update on the avian influenza situation (as of 12/11/2005) –

Issue no. 36. FAOAIDEnews. Avian Influenza Disease Emergency.

(www.fao.org/ag/againfo/subjects/documents/ai/AVIbull036.pdf). 

14 World Health Organization, Avian influenza - Avian influenza

(“bird flu”) and the significance of its transmission to humans. 15

January, 2004. (http://www.who.int/mediacentre/factsheets/

avian_influenza/en/print.html).

15 World Health Organization, Cumulative number of confirmed

human cases of avian influenza A/(H5N1) reported to WHO. 29 May

2006. (www.who.int/csr/disease/avian_influenza/country/cases_

table_2006_05_29/en/index.html).

16 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. 

17 Liem, N.T. and W. Lim. 2005. Lack of H5N1 avian influenza

transmission to hospital employees, Hanoi, 2004. Emer. Infect. Dis.

11:210-215.

18 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.

19 Shortridge, K.F., et al. 1998. Characterization of avian H5N1

influenza viruses from poultry in Hong Kong. Virology 252:331-342.

20 Kuiken, T., et al. 2005. Avian H5N1 influenza in cats. Science

306:241. 

21 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.
63

(www.fao.org/ag/againfo/subjects/documents/ai/AVIbull032.pdf).

22 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. 

23 Liu, J., et al. 2005. Highly pathogenic H5N1 influenza virus

infection in migratory birds. Science, 309:1206. 

24 State of Alaska Epidemiology Bulletin No. 21, Sept. 1, 2005.

H5N1 Avian Influenza: What Alaskans Need to Know.

(http://www.epi.alaska.gov/bulletins/docs/b2005_21.pdf). 

25 USGS National Wildlife Health Center. USDA, DOI and HHS

expand screening for highly pathogenic H5N1 avian influenza in

migratory birds. USDA, DOI and HHS Spotlight Interagency

Readiness Plans. March 20, 2006. (www.nwhc.usgs.gov/disease_

information/avian_influenza/department_of_the_interior_H5N1_

brief.jsp). 

26 Osterholm, M.T. 2005. Preparing for the next pandemic. N.

Engl. J. Med. 352:1839-1842.

27 Cox, N.J. and K. Subbarao. 2000. Global epidemiology of

influenza: Past and present. Ann. Rev. Med. 51:407-421.

28 Crawford, P.C., et al. 2005. Transmission of equine influenza to

dogs. Science 310:482-485. 

29 Suzuki, Y. 2005. Sialobiology of influenza – molecular

mechanism of host range variation in influenza viruses. Biol. Pharm.

Bull. 28:399-408.

30 Normille, D. 2005. Are wild birds to blame? Science 310:426-

428.

31 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.

32 Centers for Disease Control and Prevention, Avian Influenza

Infection in Humans. (www.cdc.gov/flu/avian/gen-info/avian-fluhumans.htm). 

33 Li, K.S., et al. 2004. Genesis of a highly pathogenic and

potentially pandemic H5N1 influenza virus in eastern Asia. Nature

430:209-213.
64

34 Guan, Y., et al. 2004. H5N1 influenza: A protean pandemic

threat. Proc Natl Acad Sci USA. 101:8156-8161.

35 Lee, C.W., et al. 2005. Characterization of highly pathogenic

H5N1 avian influenza A viruses isolated from South Korea. J. Virol.

79:3692-3702.

36 Mase, M., et al. 2005. Characterization of H5N1 influenza A

viruses isolated during the 2003-2004 influenza outbreaks in Japan.

Virology 332:167-176. 

37 World Health Organization, Laboratory study of H5N1 viruses

in domestic ducks: main findings, 29 October 2004.

(www.who.int/csr/disease/avian_influenza/labstudy_2004_10_29/en/

print.html).

38 U.S. Geological Survey National Wildlife Health Center.

Wildlife Health Bulletin #05-02.

(www.nwhc.usgs.gov/research/WHB/WHB_05_02.html).

39 DeMarco, MA, et al. 2003. Long-term monitoring for avian

influenza viruses in wild bird species in Italy. Vet. Res. Comm. 27

Suppl. 1: 107-114. 

40 Smith, GJD, et al., 2006. Evolution and adaptation of H5N1

influenza virus in avian and human hosts in Indonesia and Vietnam.

Virology. In Press.

41 Stallknecht, DE, et al., 1990. Persistence of avian influenza

viruses in water. Avian Dis. 34:406-411. 

42 Lu, et al. 2003. Survival of avian influenza virus H7N2 in SPF

chickens and their environments. Avian Dis. 47:1015-21. 

43 Stallknecht, DE, et al. 1990. Effects of pH, temperature, and

salinity on persistence of avian influenza viruses in water. Avian Dis.

34:412-418. 

44 2005 OIE Terrestrial Animal Health Code. Appendix 3.8.9.

Guidelines for the surveillance of avian influenza. Article 3.8.9.1. 

45 Beigel, J.H., et al. 2005. Current concepts: Avian influenza A

(H5N1) infection in humans. N. Engl. J. Med. 353:1374-1385. 

46 Apisarnthanarak, A., et al. 2004. Atypical avian influenza

(H5N1). Emerg. Infect. Dis. 10:1321-1324.
65

47 de Jong, M.D., et al. 2005. Fatal avian influenza A (H5N1) in a

child presenting with diarrhea followed by coma. N. Engl. J. Med.

352:686-691.

48 Centers for Disease Control and Prevention, Embargo of

Birds from Specified Southeast Asian Countries, General

Information. (www.cdc.gov/flu/avian/outbreaks/embargo.htm).

49 Van Borm, S., et al. 2005. Highly pathogenic H5N1 influenza

virus in smuggled Thai eagles, Belgium. Emerg. Infect. Dis.

11:702-705.

50 USDA Veterinary Services, Highly Pathogenic Avian

Influenza, Outbreak Summary for European Union, March 6,

2006, Impact Worksheet. Available at: http://www.aphis.usda.gov/

vs/ceah/cei/taf/iw_2006_files/foreign/hpaieusum041906_files/hpaie

usum041906.htm). 

51 National Emergency Epidemiology Group. 11 November

2005. Epidemiology report on avian influenza in quarantine

premises in Essex. 9 pp.

(http://www.defra.gov.uk/animalh/diseases/notifiable/disease/ai/pd

f/ai-epidemrep111105.pdf)

52 Centers for Disease Control and Prevention, Key Facts About

Pandemic Influenza. (www.cdc.gov/flu/pandemic/keyfacts.htm).

53 World Health Organization, Global Influenza Preparedness

Plan. The Role of WHO and Recommendations for National

Measures before and during Pandemics. (www.who.int/csr/

resources/publications/influenza/WHO_CDS_CSR_GIP_2005_5.pdf).

54 Centers for Disease Control and Prevention, Stages of a

Pandemic. (www.cdc.gov/flu/pandemic/phases.htm).

55 Larkin, M. 2006. Keeping abreast of avian influenza developments. Lancet Infect. Dis. 6:269-270. 
OSHA Assistance

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 workrelated 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

66
67

health plans. OSHA approves and monitors these plans. Twentyfour 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. 

68
69

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

70
71

OSHA Regional Offices

* 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, OSHAapproved State Plans and OSHA Consultation Projects, please visit us

online at www.osha.gov or call us at 1-800-321-OSHA.

Region I

(CT,* ME, MA, NH, RI, VT*) 

JFK Federal Building, Room E340

Boston, MA 02203

(617) 565-9860

Region II

(NJ,* NY,* PR,* VI*)

201 Varick Street, Room 670

New York, NY 10014

(212) 337-2378

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 IV 

(AL, FL, GA, KY,* MS, NC,* SC,* TN*)

61 Forsyth Street, SW

Atlanta, GA 30303

(404) 562-2300

Region V

(IL, IN,* MI,* MN,* OH, WI)

230 South Dearborn Street 

Room 3244

Chicago, IL 60604

(312) 353-2220

Region VI

(AR, LA, NM,* OK, TX)

525 Griffin Street, Room 602

Dallas, TX 75202

(214) 767-4731 or 4736 x224

Region VII

(IA,* KS, MO, NE)

City Center Square

1100 Main Street, Suite 800

Kansas City, MO 64105

(816) 426-5861

Region VIII

(CO, MT, ND, SD, UT,* WY*)

1999 Broadway, Suite 1690

PO Box 46550

Denver, CO 80202-5716

(720) 264-6550

Region IX 

(American Samoa, AZ,* CA,* HI,* NV,*

Northern Mariana Islands)

71 Stevenson Street, Room 420

San Francisco, CA 94105

(415) 975-4310

Region X

(AK,* ID, OR,* WA*)

1111 Third Avenue, Suite 715

Seattle, WA 98101-3212

(206) 553-5930


www.osha.gov