DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health

Protecting Poultry Workers

from Avian Influenza (Bird Flu)
This document is in the public domain and may be freely copied 

or reprinted.

DISCLAIMER

Mention of any company or product does not constitute endorsement by the National 

Institute for Occupational Safety and Health (NIOSH). In addition, citations to Web sites 

external to NIOSH do not constitute NIOSH endorsement of the sponsoring organizations 

or their programs or products. Furthermore, NIOSH is not responsible for the content of 

these Web sites.

ORDERING INFORMATION

This document is in the public domain and may be freely copied or reprinted. To receive 

NIOSH documents or more information about occupational safety and health topics, 

contact NIOSH at

1–800–CDC–INFO (1–800–232–4636)

TTY: 1–888–232–6348

E-mail: cdcinfo@cdc.gov

or visit the NIOSH Web site at www.cdc.gov/niosh

For a monthly update on news at NIOSH, subscribe to 

NIOSH eNews by visiting www.cdc.gov/niosh/eNews

DHHS (NIOSH) Publication Number 2008–128 (supersedes 2008–113)

May 2008

Safer • Healthier • PeopleTM
Protecting Poultry Workers from Avian 

Influenza (Bird Flu)

WARNING!

During an outbreak of avian influenza (bird flu), poultry workers* may become 

seriously ill or die after contact with infected poultry or contaminated materials.

All poultry workers and all owners and operators of poultry operations should take the following steps to protect themselves from avian 

influenza.

Take the following steps BEFORE an 

outbreak of avian influenza:

1. Make sure that an avian influenza response 

plan has been developed to complement regional, State, and industry plans.

 Use the CDC guidance presented in the full 

Alert to develop a response plan.

 Select a response plan manager.

 Coordinate your avian influenza response 

plan with appropriate State animal and 

public health agencies.

 Make sure that workers are aware of the 

avian influenza response plan and their responsibilities.

2. Follow biosecurity practices to keep avian influenza and other diseases out of your poultry 

flock:

 Keep your poultry flock isolated from outside environments.

 Prevent flocks from contacting wild birds 

and water sources that might be contaminated by wild birds.

 Allow only essential workers and vehicles to 

enter the farm and poultry houses.

 Provide clean protective clothing, equipment, and disinfection facilities for workers.

 Thoroughly clean and disinfect equipment 

and vehicles entering and leaving the farm. 

Include tires and undercarriage.

 Do not borrow equipment or vehicles from 

other farms and do not lend yours.

 Avoid visiting other poultry farms.

 If you do visit another farm or a live-bird 

market, change footwear and clothing before contacting your own flock again.

*

Poultry workers include all workers who may contact poultry 

or materials or environments contaminated by poultry.
 Do not bring birds from slaughter channels 

(especially live-bird markets) back to the 

farm.

3. Know the signs of avian influenza in poultry.

 Be aware of the signs of avian influenza 

infection with the highly pathogenic H5N1 

virus in poultry:

— Sudden death without clinical signs or 

symptoms

— Lack of coordination

— Lack of energy and appetite

— Soft-shelled or misshapen eggs

— Decreased egg production

— Purple discoloration of the wattles, 

combs, and legs

— Swelling of the head, eyelids, combs, 

wattles, and hocks

— Diarrhea

— Nasal discharge

— Coughing and sneezing

4. Report sick or dying birds immediately!

 Immediately report any sick or dying birds 

in your poultry flock to the proper authorities:

— Call the U.S. Department of Agriculture 

(USDA) toll free at 1–866–536–7593.

— Or contact your State veterinarian or local extension agent.

 Don’t wait to report sick birds! Early detection of avian influenza is essential to prevent its spread.

5. Know the possible signs and symptoms of 

avian influenza in humans infected with the 

highly pathogenic H5N1 virus:

 Fever

 Cough

 Shortness of breath

 Sore throat

 Muscle aches

 Conjunctivitis (redness, swelling, and pain 

in the eyes and eyelids)

 Diarrhea

6. Consider getting the current season’s flu 

shot. 

7. Train workers in all guidance and recommendations presented in this Alert.

Take the following steps DURING an 

outbreak of avian influenza:

1. Follow the avian influenza response plan.

2. Ask your doctor about taking antiviral medication.

3. Wear personal protective clothing.

 Wear the following personal protective 

clothing if you may be exposed to an avian 

influenza virus:

— Outer garments (aprons or coveralls)

— Gloves

(Over)
— Foot protection (boots or boot covers)

— Head protection (head cover or hair 

cover)

 Choose disposable, impermeable, lightweight protective clothing.

 Wear disposable, lightweight, waterproof 

gloves (8- to 12-mil nitrile or vinyl, for example) or heavy-duty, 18-mil rubber gloves 

that are reusable after disinfection.

 Use disposable boot covers or boots that 

can be reused after disinfection.

 Use disposable head covers or hair covers. 

4. Wear eye protection.

 When working with poultry, wear unvented 

or indirectly vented safety goggles, a respirator with a full facepiece, or a powered, 

air-purifying respirator (PAPR) with a loosefitting hood or helmet and face shield.

 Remove eye protection carefully to prevent 

contaminated equipment from contacting 

eyes, nose, or mouth.

5. Wear respirators.

 Wear a NIOSH-approved, air-purifying respirator with a particulate filter whenever 

you are working in poultry barns or may be 

exposed to infected poultry or virus-contaminated materials or environments.

 Use a particulate filter that is rated N–95 

or better.

6. Follow a written respiratory protection program. To make sure that respirators protect 

workers adequately from avian influenza, do 

the following:

 Designate a qualified person to oversee the 

program and answer workers’ questions.

 Provide workers with respirator training and 

fit-testing to assure a safe and comfortable 

seal for the respirator facepiece.

 Include all workers who may be at risk of 

exposure to avian influenza virus.

7. Protect yourself when removing personal protective clothing or equipment.

 With your respirator, goggles, and gloves on, 

remove all personal protective clothing.

— Place disposable clothing in a secure 

container†

 for disposal.

— Place reusable clothing in labeled or 

color-coded bags or containers‡

 for 

cleaning and disinfection.

 Remove gloves and discard them in a secure container.

— Thoroughly wash hands with soap and 

water.

— If no hand-washing facilities are available, 

use waterless soaps or alcohol-based 

sanitizers provided by your employer.

†

NIOSH recommends the use of secure containers such as 

those described in the Code of Federal Regulations [29 

CFR 1910.1030(d)(4)(iii)(B)]. Such containers should 

therefore be (1) closable, (2) constructed to contain all 

contents and prevent leakage of fluids during handling, 

storage, transport, or shipping, (3) labeled or color-coded, 

and (4) closed before removal. 

‡

NIOSH recommends the use of labeled or color-coded bags 

such as those described in the Code of Federal Regulations [29 CFR 1910.1030(d)(4)(iv)(A)(2)].
— Be careful about using waterless soaps 

or alcohol-based sanitizers too often, 

as they can be very harsh to the skin.

 Next, carefully remove your goggles and 

then your respirator.

— Thoroughly wash hands again with soap 

and water.

— If no hand-washing facilities are available, 

use waterless soaps or alcohol-based 

sanitizers provided by your employer.

8. Use good hand hygiene (proper use of gloves, 

hand-washing, and waterless hand sanitizers) 

and the decontamination procedures outlined 

here to prevent infection, avoid taking viruses 

home, and keep them from spreading to other 

farms. 

9. Shower at the end of the work shift and leave all 

contaminated clothing and equipment at work.

 Shower at the worksite or at a nearby decontamination station.

 Never wear contaminated clothing or equipment outside the work area.

10. Participate in health surveillance and monitoring programs.

 Make sure a surveillance program has been 

established to identify symptomatic workers for 10 days after exposure to infected 

birds or virus-contaminated materials or 

environments.

 Seek immediate medical care for workers 

who develop any of the following symptoms 

within 10 days of exposure to infected or 

exposed birds or to virus-contaminated 

materials or environments:

— Fever

— Cough

— Shortness of breath

— Sore throat

— Muscle aches

— Conjunctivitis (eye infections)

— Diarrhea

 Tell the health care provider about the possible avian influenza exposure before the ill 

person arrives.

 Promptly report suspected human cases to 

supervisors and to local health authorities.

For additional information, see NIOSH Alert: Protecting Poultry Workers from Avian Influenza 

(Bird Flu) [DHHS (NIOSH) Publication No. 2008–128 

(supersedes 2008–113)]. To request single copies of 

the Alert, contact NIOSH at

1–800–CDC–INFO (1–800–232–4636)

TTY: 1–888–232–6348

E-mail: cdcinfo@cdc.gov

or visit the NIOSH Web site at 

www.cdc.gov/niosh

For a monthly update on news at 

NIOSH, subscribe to NIOSH eNews by 

visiting www.cdc.gov/niosh/eNews

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health
Proteja de la gripe aviar a los 

trabajadores de las granjas avícolas

¡ADVERTENCIA!

Durante un brote de gripe aviar (también conocida como “gripe del pollo”), los trabajadores 

avícolas*

 podrían enfermarse gravemente o morir tras el contacto con aves de corral infectadas 

o materiales contaminados.

Todos los trabajadores avícolas y los propietarios 

y operadores de procesos avícolas deben tomar 

las siguientes medidas para protegerse de la gripe 

aviar.

Tome las siguientes medidas ANTES de 

un brote de gripe aviar:

1. Asegúrese de que se ha elaborado un plan para enfrentar la gripe aviar como complemento a los planes 

regionales, estatales, e industriales.

 Para elaborar este plan de respuesta, utilice las 

instrucciones presentadas por los CDC en el 

documento completo de la Alerta.

 Designe a un encargado del plan de respuesta.

 Coordine su plan de respuesta ante la gripe aviar 

con las correspondientes agencias estatales de 

control animal y salud pública.

 Asegúrese de que los trabajadores estén al tanto de este plan y de sus responsabilidades.

2. Siga las prácticas de bioseguridad que se presentan a continuación para mantener a su plantel avícola libre de gripe aviar y de otras enfermedades:

 Mantenga a su plantel avícola aislado de los 

ambientes externos.

 Evite el contacto de las aves de corral con 

las aves silvestres y con fuentes de agua que 

pueden haber sido contaminadas por las aves 

silvestres.

 Permita que solamente entren a la granja y a las 

jaulas el personal y los vehículos esenciales.

 Proporcione a los trabajadores ropa protectora 

limpia, equipo e instalaciones para la desinfección.

 Limpie y desinfecte a fondo los equipos y los 

vehículos (incluidos neumáticos y debajo de los 

vehículos) que entran y salen de la granja.

 No utilice equipo ni vehículos de otras granjas, 

y no preste los suyos.

 Evite visitar otras granjas avícolas.

 Si usted visita otra granja o un mercado de aves 

vivas, cámbiese de ropa y de calzado antes de 

volver a acercarse a su plantel avícola.

 No lleve a la granja las aves de los canales de 

matanza, en especial de los mercados de aves 

vivas.

*

Los trabajadores avícolas son todos aquellos que pueden 

entrar en contacto con aves de corral, materiales, o ambientes contaminados por éstas.
3. Conozca los signos de la gripe aviar en las aves de 

corral.

 Manténgase atento a los signos de la infección 

por gripe aviar en las aves de corral causada por 

el virus altamente patógeno H5N1:

— Muerte repentina sin signos ni síntomas 

clínicos

— Falta de coordinación

— Falta de energía y apetito

— Producción de huevos con cáscaras blandas o deformes

— Disminución en la producción de huevos

— Manchas moradas en la barbilla, la cresta, 

o las patas

— Inflamación de la cabeza, párpados, cresta, 

barbilla, o patas

— Diarrea

— Secreción nasal

— Tos y estornudos

4. ¡Reporte inmediatamente los casos de aves enfermas o moribundas!

 Reporte inmediatamente todo caso de aves enfermas o que se estén muriendo en su plantel 

avícola a las correspondientes autoridades:

— Llame al Departamento de Agricultura de 

EE.UU. (USDA, por sus siglas en inglés) a través 

de su línea gratuita 1–866–536–7593.

— O comuníquese con su veterinario estatal 

o el agente local del Servicio de Extensión 

Agrícola.

 ¡No espere para reportar las aves enfermas! La 

detección temprana de la gripe aviar es esencial para prevenir su transmisión.

5. Conozca los posibles signos y síntomas de la gripe 

aviar en seres humanos que han sido infectados 

por el virus H5N1 altamente patógeno:

 Fiebre

 Tos

 Dificultad para respirar

 Dolor de garganta

 Dolores musculares

 Conjuntivitis (dolor, inflamación, o enrojecimiento de ojos y párpados)

 Diarrea

6. Piense en ponerse la vacuna contra la gripe de la 

actual temporada.

7. Enseñe a los trabajadores a seguir todas las instrucciones y recomendaciones presentadas en 

esta Alerta.

Tome las siguientes medidas DURANTE 

un brote de gripe aviar:

1. Siga el plan de respuesta ante la gripe aviar.

2. Pregúntele a su médico si debe tomar medicamentos antivirales.

3. Utilice ropa protectora.

 Utilice las siguientes prendas protectoras si 

hay probabilidad de exposición a un virus de 

la gripe aviar:

— Prendas exteriores (delantales y overoles)

— Guantes

— Protección para los pies (botas o fundas 

para botas)

— Protección para la cabeza (sombreros o 

pañoletas)

(más al reverso)
 Utilice prendas protectoras ligeras, desechables e impermeables.

 Utilice guantes desechables, ligeros y de material impermeable (p. ej., de vinilo o de nitrilo 

de 8 a 12 mils) o guantes de goma gruesos de 

18 mils, que se puedan volver a usar después 

de una desinfección.

 Utilice fundas de botas desechables o botas que se puedan volver a usar después de 

desinfectarlas.

 Utilice sombreros o pañoletas desechables 

para cubrir la cabeza.

4. Utilice equipo protector de ojos.

 Cuando trabaje con aves de corral, utilice gafas 

de seguridad que no tengan orificios de ventilación o que tengan ventilación indirecta, un 

respirador con una máscara de cara completa, 

o un respirador con purificador de aire motorizado (PAPR) que tenga una capucha holgada 

o casco y visera protectora.

 Retírese el equipo protector de los ojos con 

mucha precaución para evitar que las partes 

contaminadas hagan contacto con los ojos, la 

nariz o la boca.

5. Utilice respiradores.

 Utilice un respirador de aire purificado con filtro 

para partículas, aprobado por NIOSH, cuando trabaje en granjas avícolas o si hay una exposición 

potencial a aves de corral infectadas o materiales y ambientes contaminados por el virus.

 Utilice un filtro de partículas de una graduación 

igual o mayor a N–95.

6. Siga las instrucciones de un programa de protección respiratoria. Para asegurarse que los trabajadores cuentan con respiradores adecuados para 

protegerse de la gripe aviar, siga estas recomendaciones:

 Designe a una persona calificada que supervise el programa y responda a las preguntas de 

los trabajadores.

 Proporcione capacitación a los trabajadores en 

el uso del respirador y haga que se lo prueben, 

para asegurar que el respirador que cubre la 

cara se ajusta de manera cómoda y segura.

 Incluya a todos los trabajadores que pueden 

estar en riesgo de exposición al virus de la 

gripe aviar.

7. Protéjase de una posible contaminación cuando 

se quite las prendas y el equipo protector.

 Comience por quitarse la ropa protectora, sin 

retirarse el respirador, las gafas y los guantes.

— Coloque las prendas desechables en un 

recipiente†

 de seguridad para depositar estos desechos.

— Coloque las prendas reutilizables en recipientes‡

 con etiquetas o códigos por color 

para la limpieza y la desinfección.

 Quítese los guantes y deposítelos en un recipiente de seguridad.

— Lávese otra vez minuciosamente las manos con agua y jabón.

— Si no hay instalaciones accesibles para 

lavarse las manos, utilice lociones o 

†

NIOSH recomienda el uso de envases seguros como aquellos 

descritos en el Código de Regulaciones Federales (Code of 

Federal Regulations) [29 CFR 1910.1030(d)(4)(iii)(B)]. Dichos envases por lo tanto deberán (1) poder cerrarse bien, 

(2) estar diseñados para guardar todo tipo de materiales y 

evitar la fuga de líquido durante su manejo, almacenamiento, 

transporte o envío, (3) estar identificados con etiquetas o 

códigos de color y (4) ser cerrados antes de su traslado. 

‡

NIOSH recomienda el uso de bolsas con etiquetas o códigos 

de color como aquellas descritas en el Código de Regulaciones Federales [29 CFR 1910.1030(d)(4)(iv)(A)(2)].
desinfectantes a base de alcohol provistos 

por su empleador.

— No utilice de manera excesiva las lociones 

o desinfectantes para las manos a base de 

alcohol, ya que pueden resecar la piel.

 A continuación, retírese cuidadosamente las 

gafas y al final el respirador.

— Lávese minuciosamente las manos con 

agua y jabón.

— Si no hay instalaciones accesibles para lavarse las manos, utilice lociones o desinfectantes a base de alcohol provistos por 

su empleador.

8. Practique una buena higiene de las manos (uso 

de guantes, lavado de las manos con agua y 

jabón, o uso de desinfectantes para las manos) 

y aplique los procedimientos para la descontaminación que se han descrito arriba a fin de prevenir 

infecciones, evitar llevarse los virus a casa, y no 

permitir su propagación a otras granjas.

9. Dúchese al final de su jornada laboral y deje en el 

trabajo todas las prendas y equipo contaminado.

 Dúchese en el lugar de trabajo o en una instalación cercana designada para la descontaminación.

 Nunca utilice ropa o equipo protector contaminado afuera de su área de trabajo.

10. Participe en programas de monitorización y vigilancia de la salud.

 Asegúrese de haber establecido un programa 

de vigilancia para identificar a los trabajadores 

sintomáticos en los 10 días siguientes a la 

exposición a aves infectadas o a materiales y 

ambientes contaminados por el virus.

 Solicite atención médica inmediata para los 

trabajadores que presenten alguno de los síntomas siguientes en los 10 días posteriores a 

la exposición a aves infectadas o expuestas, 

o a materiales y ambientes contaminados por 

el virus:

— Fiebre

— Tos

— Dificultad para respirar

— Dolor de garganta

— Dolores musculares

— Conjuntivitis (infecciones de los ojos)

— Diarrea

 Notifique al proveedor de atención médica que 

hubo una posible exposición a la gripe aviar 

antes de que la persona vaya a la consulta.

 Reporte inmediatamente a los supervisores 

y las autoridades locales de salud los casos 

sospechosos de gripe aviar.

Para más información, sírvase leer la Alerta de 

NIOSH: Proteja de la gripe aviar a los trabajadores 

de las granjas avícolas [Publicación No. 2008–128 

de DHHS (NIOSH) (reemplaza 2008–113)]. Obtenga 

copias gratuitas de esta Alerta a través de

1–800–CDC–INFO (1–800–232–4636)

TTY: 1–888–232–6348

Correo electrónico: cdcinfo@cdc.gov

o visite la página Web de NIOSH: 

www.cdc.gov/spanish/niosh

Para recibir boletines mensuales 

actualizados de NIOSH visite el sitio 

Web www.cdc.gov/niosh/eNews y 

suscríbase a NIOSH eNews.

DEPARTMENTO DE SALUD Y SERVICIOS HUMANOS

Centros para el Control y la Prevención de Enfermedades

Instituto Nacional para la Seguridad y Salud Ocupacional
1

Protecting Poultry Workers from 

Avian Influenza (Bird Flu)

WARNING!

During an outbreak of avian influenza (bird flu), poultry workers* may become 

seriously ill or die after contact with infected poultry or contaminated materials.

The National Institute for Occupational 

Safety and Health (NIOSH) requests 

help in protecting poultry workers from 

infection with viruses that cause avian 

influenza (also known as bird flu). Although human infection with avian influenza viruses is rare, workers infected 

with certain types of these viruses may 

become ill or die.

Some types of avian influenza viruses 

can cause serious illness or death in 

poultry and other birds. These viruses 

are referred to as highly pathogenic 

viruses. Rarely, these viruses may be 

passed to humans who contact infected 

poultry or virus-contaminated materials 

or environments.

The following workers are at risk of infection with highly pathogenic avian influenza viruses:

 Poultry growers and their workers

 Service technicians of poultry growers

 Workers at egg production facilities 

(caretakers, layer barn workers, and 

chick movers)

 Veterinarians and their staff who work 

with poultry

 Disease control and eradication workers on poultry farms (State, Federal, 

contract, and poultry farm workers)

This Alert describes the following:

1. Avian influenza in humans

2. Avian influenza outbreaks in chickens

3. Recommendations for protecting poultry workers from avian influenza

Remember these facts:

 No avian influenza epidemic now exists in humans.

 Scientists are currently most concerned about the highly pathogenic 

*Poultry workers include all workers who may contact 

poultry or materials or environments contaminated 

by poultry.
2 Avian Influenza

avian influenza A virus known as 

H5N1. As of April 8, 2008, all human 

cases of influenza caused by this virus have occurred outside the United 

States.†

 The avian influenza virus rarely infects humans.

 The avian influenza virus does not 

pass easily from person to person.

NIOSH requests that owners and operators of poultry operations follow the recommendations in this Alert and use the 

controls presented here.

NIOSH also requests that safety and 

health officials, editors of trade journals, labor unions, and employers bring 

the recommendations in this Alert to 

the attention of all poultry workers and 

poultry farm operators.

BACKGROUND

What is avian influenza?

Avian influenza is caused by influenza A viruses and occurs worldwide in many species 

of birds. For this reason, avian influenza is 

often referred to as “bird flu.”

Avian influenza viruses normally reside in the 

intestinal tracts (guts) of water and shore 

birds, and they usually cause little if any disease. Only a few of these viruses can cause 

disease in other animals and in humans—

for example, the highly pathogenic H5N1 

and H7N7 viruses.

Influenza A viruses are divided into two 

groups based on their pathogenicity (capacity to cause disease) to poultry:

 Low-pathogenic avian influenza viruses, which cause a mild disease or no 

noticeable signs of disease

 Highly pathogenic avian influenza viruses, which cause serious disease and 

high rates of death

Scientists are currently most concerned 

about the highly pathogenic avian influenza 

A virus known as H5N1.‡Although the H5N1 

virus causes serious illness in birds, it has

rarely infected humans.

The first known cases of human infection with H5N1 avian influenza occurred in 

1997 in Hong Kong. Outbreaks of H5N1 

avian influenza in poultry and some cases 

in humans began again in Asia in late 2003 

and continue to be reported there. In addition, outbreaks in birds and humans have 

been reported in Africa, and outbreaks in 

birds have occurred in Europe. As of April 

8, 2008, no outbreaks in birds or humans 

have been reported in North, Central, or 

South America.

Avian influenza outbreaks from the H5N1 

virus have occurred in birds in more than 

50 countries and in humans in 12 countries (see WHO [2008] at www.who.int/csr/

disease/avian_influenza/en/).

Important avian influenza facts

Remember the following facts about the 

highly pathogenic H5N1 virus:

†

For current information about outbreaks of avian 

influenza around the world, see www.cdc.gov/flu/

avian/outbreaks/current.htm.

‡

In this document, H5N1 always refers to the highly 

pathogenic form of avian influenza virus.
Avian Influenza 3

 Most human infections with this virus 

have resulted from contact with infected 

poultry or virus-contaminated materials 

or environments.

 H5N1 virus rarely infects humans.

 When this virus does infect humans, it 

does not pass easily from person to person—that is, transmission between humans has not been efficient or sustained 

[DHHS 2006].

 As of April 8, 2008, the H5N1 virus has 

not been detected in the United States.

 H5N1 virus can be spread from one location to another through

— migrating birds (which may not show 

symptoms of disease) and

— legal and illegal trade in poultry and 

other birds as well as their products.

 If the virus changes so that it can be easily passed from one person to another, 

it could cause a pandemic (worldwide)

influenza outbreak in humans.

FREQUENTLY ASKED QUESTIONS

1. How are poultry affected by 

avian influenza?

Domestic poultry may be infected with either low-pathogenic or highly pathogenic 

viruses through contact with infected 

poultry, wild birds, or virus-contaminated 

materials or environments:

 Highly pathogenic avian influenza viruses spread quickly and may kill an 

entire poultry flock in 48 hours.

 Low-pathogenic avian influenza viruses may go unnoticed or cause only 

mild symptoms (such as ruffled feathers or a drop in egg production).

2. What is the risk of infection to 

humans?

Avian influenza viruses do not usually 

infect humans. However, 379 human 

cases of avian influenza A (H5N1) were 

reported to the World Health Organization 

(WHO) between late 2003 and April 8, 

2008 [WHO 2008]. About 63% of these 

cases (239) were fatal. No human cases 

have been reported within North, Central, 

or South America.

H5N1 virus can be transmitted to people 

who contact infected poultry or viruscontaminated materials or environments. 

This type of transmission has not been 

frequent or sustained from one human to 

another.

Health risks related to human exposure 

to the low-pathogenic avian influenza viruses are poorly understood, but they are 

thought to be minimal. Only rare cases of 

human infection with low-pathogenic viruses have been reported. Nonetheless, 

anyone likely to have prolonged exposure 

to any avian influenza virus should take 

protective measures.

Photograph courtesy of U.S. Department of Agriculture.
4 Avian Influenza

 Litter

 Egg flats

 Cages

For more information about human infection with avian influenza viruses, see 

www.cdc.gov/flu/avian/gen-info/avian-fluhumans.htm.

4. Why are scientists concerned 

about the H5N1 virus?

Scientists are concerned about the 

H5N1 virus for the following reasons:

 H5N1 virus causes serious illness and 

death in poultry and therefore threatens 

domestic poultry throughout the world.

 This virus can cause serious illness 

and death in humans.

 If a strain of H5N1 changes so that 

it is highly infectious to humans and 

spreads easily from person to person, 

it could cause an influenza pandemic.

Public health authorities are monitoring 

outbreaks of human illness linked with 

avian influenza. To date, human infections with highly pathogenic avian influenza viruses identified since 1997 have 

not resulted in continued transmission 

from one person to another.

REPORTED OUTBREAKS

Current news about avian influenza deals 

mostly with human illness caused by the 

H5N1 virus. However, human infections 

have also been caused by other subtypes 

of avian influenza virus such as H7N7 and 

H7N3. The following reports describe outbreaks involving several subtypes of highly 

Examples of workers at risk include the 

following:

 Poultry growers and their workers

 Service technicians of poultry growers

 Caretakers, layer barn workers, and chick 

workers at egg production facilities

 Veterinarians and their staff who work 

with poultry

 Workers involved in disease control 

and eradication on poultry farms 

(Federal, State, contract, and poultry 

farm workers)

3. How is the virus passed to 

humans?

Avian influenza virus is excreted in the 

droppings, saliva, and nasal secretions 

of infected birds. The virus is believed to 

enter humans through the mouth, nose, 

or eyes. Scientists believe that the virus 

is most often passed to humans from 

contact with infected poultry that was 

sick or dead. Contact with the following 

materials or equipment may also be a 

source of infection:

 Droppings

 Feathers

Photograph copyright © Getty Images.
Avian Influenza 5

pathogenic avian influenza virus. One report 

describes an outbreak in poultry alone, with 

no reported human cases.

Report 1—Eighteen H5N1 human 

cases in Hong Kong, 1997

An outbreak of H5N1 avian influenza occurred in humans and poultry in Hong Kong 

during 1997. This outbreak involved 18 confirmed human cases, including six deaths 

[Chan 2002].

The first human case occurred in May, soon 

after outbreaks in poultry were reported at 

three farms. Seventeen more human cases 

occurred in November and December after 

infected poultry were found in wholesale 

and retail markets. Many of the infected humans had visited either a retail poultry stall 

or a live poultry market before becoming ill 

[Mounts et al. 1999]. All chickens and other 

poultry in Hong Kong were culled (destroyed) 

to stop the outbreak. No additional human 

cases were detected during this outbreak 

after the culling operation was complete.

Commercial poultry cullers and workers were 

not included among the 18 cases described 

here. However, laboratory tests showed that 

about 3% of poultry cullers and 10% of poultry workers showed evidence of earlier infection with H5N1 virus [Bridges et al. 2002].

Report 2—Eighty-nine H7N7 

human cases in the Netherlands, 

2003

In February 2003, a large outbreak of avian 

influenza was caused by the highly pathogenic H7N7 virus in commercial poultry 

farms in the Netherlands [Koopmans et al. 

2004]. The infection spread to approximately 255 farms and resulted in the culling of all 

infected flocks (about 30 million chickens). 

The virus may have been introduced to the 

commercial flocks by infected wild ducks.

At the time of the outbreak, local authorities 

believed the risk to humans was low. However, 89 human infections were identified, 

with health complaints primarily consisting 

of conjunctivitis. Mild, influenza-like illness 

was associated with the conjunctivitis in a 

few cases.

However, one human fatality occurred in a 

veterinarian who had not received antiviral medication but had spent a few hours 

screening flocks that were later confirmed to 

be infected with the H7N7 virus. The highest risk of infection was in veterinarians and 

workers who culled infected poultry.

The outbreak was brought under control in 

about 2 months by culling infected flocks. 

An outbreak-management response team 

advised all workers who screened and 

culled poultry to wear goggles and respirators to reduce their exposures to the avian 

influenza virus. The team recommended 

that vaccination with the current flu vaccine 

be made mandatory for all poultry farmers 

and their families within a 3-kilometer radius of infected farms. They stressed the 

importance of hand washing and personal 

hygiene at home. Immediate treatment with 

oseltamivir (Tamiflu®) was recommended for 

all new conjunctivitis cases and a preventive 

dose (75 mg daily) was started for all persons handling potentially infected poultry. 

This dose was continued for 2 days after the 

last exposure.

Report 3—Two H7N3 human cases 

in Canada, 2004

On February 19, 2004, the Canadian Food 

Inspection Agency announced an outbreak 
6 Avian Influenza

of avian influenza in poultry from highly 

pathogenic H7N3 virus in the Fraser Valley region of British Columbia [Tweed et 

al. 2004; CDC 2006b]. Health Canada reported two cases of laboratory-confirmed 

H7N3 infections in humans. Both patients 

were poultry workers; one was involved in 

culling operations on March 13−14, 2004, 

and the other had close contact with poultry on March 22−23, 2004. Both patients 

developed conjunctivitis and other flu-like 

symptoms. Their illnesses resolved after 

treatment with antiviral medication (oseltamivir). Ten other poultry workers developed 

conjunctivitis symptoms and/or upper respiratory symptoms after contacting poultry. 

However, these infections were not laboratory-confirmed as H7N3 infections.

Culling operations by Federal workers and 

other measures were undertaken to control 

the spread of the virus. Authorities required 

personal protective equipment for all persons 

involved in culling activities. This equipment 

included N–95 respirators, gloves, goggles, 

biosafety suits, and footwear. Authorities 

also monitored compliance with prescribed 

safety measures. Epidemiologic, laboratory, 

and clinical surveillance was done for signs 

of avian influenza in exposed persons. However, no person-to-person transmission was 

detected during this outbreak.

Report 4—H5N2 in poultry, Texas, 

2004: no human cases

In February 2004, an outbreak of avian influenza from highly pathogenic H5N2 virus 

was detected in a flock of 7,000 chickens 

in south-central Texas [Lee et al. 2005]. 

The chickens at the affected farm were being sold to live-bird markets in Houston. Approximately 1,700 chickens had been sold 

to the live-bird markets about a week before 

the laboratory confirmed avian influenza in 

the flock. The flock was culled on February 

21, 2004. No human infections were reported.

Report 5—Eight H5N1 human 

cases in Indonesia, 2006

Poultry in Indonesia and other nearby countries have suffered continuing outbreaks of 

illness from the H5N1 virus in 2006 and 

2007. This virus is considered to be entrenched in poultry throughout much of Indonesia. This widespread presence of the 

virus and local conditions have resulted in 

a substantial number of human cases (102 

cases since 2005).

In June 2006, Indonesia became the focus 

of media attention when H5N1 was identified in an outbreak involving eight members 

of an extended family in northern Sumatra 

[Butler 2006]. No samples were taken from 

the first patient, a 37-year-old woman who 

became ill on April 24 and died on May 4. 

However, samples from seven other family 

members confirmed the presence of H5N1 

virus. Investigators assumed that the first 

patient was also infected with H5N1 virus 

(which she is thought to have contracted from infected poultry). In all, seven of 

the eight infected family members died. A 

25-year-old brother of the first patient survived.

The outbreak was considered to be controlled on June 12, 2006—3 weeks after 

the death of the last victim—with no new 

cases reported. This cluster of H5N1 cases 

is the first instance in which WHO reported 

that human-to-human transmission may 

have occurred. Concerns over the cluster of 

cases have eased since no other large clusters of human cases have been identified.
Avian Influenza 7

CONCLUSIONS

Outbreaks in Birds

In birds, outbreaks of the H5N1 virus continue 

to spread in Europe, Asia, and Africa. These 

outbreaks are on a scale that has not been 

seen before. Continued worldwide spread of 

this virus will place poultry and poultry workers at increased risk of infection.

Human cases

Since January 2003, WHO has published the 

numbers of confirmed human illnesses and 

deaths from the H5N1 virus. Between January 2003 and April 8, 2008, WHO reported 

379 confirmed human cases of infection 

with H5N1 virus in 14 countries—Azerbaijan, 

Cambodia, China, Djibouti, Egypt, Indonesia, Iraq, Laos, Myanmar, Nigeria, Pakistan, 

Thailand, Turkey, and Vietnam [WHO 2008]. 

Of these cases, 239 (63%) were fatal.

In 2007, Indonesia reported 42 new human cases of avian influenza, followed by 

Egypt (25), Vietnam (8), China (5), Laos 

(2), Cambodia (1), Myanmar (1), Nigeria 

(1), and Pakistan (1) [WHO 2008].

Human cases of avian influenza have most 

often been linked to close human contact 

with sick or dying poultry from backyard operations. Such contact is common in countries where poultry are numerous and birds 

are not generally confined by enclosures.

Continued sporadic infections of humans 

with H5N1 could increase the chances that 

the virus will change so that it can pass more 

easily from human to human. This change 

could result in an influenza pandemic.

Preventive steps

Additional efforts are needed to prevent new 

cases of avian influenza in humans. In Thailand, public health education campaigns and 

media reports about avian influenza have 

reached rural people at greatest risk [Olsen 

et al. 2005]. However, this information has 

not resulted in changed behavior to control 

risks for many Thai people. Culling flocks of 

ill birds has been highly effective in controlling 

some avian influenza outbreaks. But this preventive measure may not be effective in areas 

of Southeast Asia, where backyard flocks are 

common and poultry movement is difficult to 

control [CDC 2004; Olsen et al. 2005].

Poultry producers in the United States and 

around the world should take preventive steps 

to protect their workers and poultry flocks. 

Poultry producers can substantially reduce the 

risk to workers if they follow the recommendations listed in the following section.

RECOMMENDATIONS FOR PROTECTING POULTRY WORKERS 

NIOSH recommends the following preventive 

steps for protecting poultry workers who are 

at risk of exposure to avian influenza viruses. These recommendations are discussed 

in more detail in the following subsections. 

Recommendations are intended for both 

poultry producers (owners and operators of 

poultry farms) and poultry workers.

Summary of recommendations

Take the following steps BEFORE an 

outbreak of avian influenza:

1. Make sure that an avian influenza response plan has been developed.
8 Avian Influenza

2. Follow the biosecurity practices presented in this Alert.

3. Know the signs of avian influenza in 

poultry.

4. Report sick or dying birds immediately.

5. Know the possible signs and symptoms 

of avian influenza in humans.

6. Consider getting the current season’s 

flu shot.

7. Train workers in all guidance and recommendations presented in this Alert.

Take the following steps DURING an 

outbreak of avian influenza:

1. Follow the avian influenza response plan.

2. Ask your doctor about taking antiviral 

medication.

3. Wear personal protective clothing:

— Outer garments (impermeable aprons 

or coveralls)

— Gloves

— Footwear (boots or boot covers)

— Disposable head cover or hair cover 

4. Wear eye protection (goggles or a fullfacepiece respirator).

5. Wear a NIOSH-certified, air-purifying respirator with a particulate filter (N–95 or 

better).

6. Follow a written respiratory protection 

program.

7. Protect yourself when removing personal protective equipment and clothing.

8. Use good hand hygiene (proper use of 

gloves, hand-washing, and waterless 

hand sanitizers) and decontamination 

procedures.

9. Shower at the end of the work shift and 

leave all contaminated equipment and 

clothing at work.

10. Participate in health surveillance and 

monitoring programs.

Detailed recommendations

Take the following steps BEFORE an 

outbreak of avian influenza:

1. Make sure that an avian influenza 

response plan has been developed 

to complement regional, State, and 

industry plans.

 Use the following guidance to develop 

an avian influenza response plan:

— CDC guidance in this Alert and at 

the following Web site: www.cdc.

gov/flu/avian

— The USDA national plan for responding to an outbreak of highly 

pathogenic avian influenza in the 

Photograph copyright © Getty Images.
Avian Influenza 9

United States [APHIS 2007b]: 

www.aphis.usda.gov/newsroom/

hot_issues/avian_influenza/avian_influenza_summary.shtml. This 

plan is intended to complement regional, State, and industry plans.

 Select a response plan manager.

 Coordinate your avian influenza response plan with appropriate State 

animal and public health agencies.

 Make sure that workers are aware 

of the avian influenza response plan 

and their responsibilities.

2. Follow biosecurity practices to keep 

avian influenza and other diseases out of your poultry flock [APHIS 

2007a]:

 Keep your poultry flock isolated from 

outside environments.

 Prevent flocks from contacting wild 

birds and keep them away from water sources that might be contaminated by wild birds.

 Allow only essential workers and vehicles to enter the farm and poultry 

houses.

 Provide clean protective clothing, 

equipment, and disinfection facilities 

for workers.

 Thoroughly clean and disinfect equipment and vehicles entering and 

leaving the farm. Include tires and 

undercarriage.

— Use detergents and disinfectants 

(avian influenza viruses are sensitive to most).

— Use EPA-registered disinfectants 

that are labeled as effective 

against influenza viruses.

— Use heating and drying (which inactivate the viruses).

 Do not borrow equipment or vehicles 

from other farms and do not lend 

yours.

 Avoid visiting other poultry farms. 

 If you do visit another farm or a livebird market, change footwear and 

clothing before contacting your own 

flock again.

 Do not bring birds from slaughter 

channels (especially live-bird markets) back to the farm.

3. Know the signs of avian influenza in 

poultry.

Be aware of the signs of avian influenza 

infection in poultry so that you can do 

the following:

 Recognize sick birds

 Quarantine the farm to prevent the 

spread of disease

 Protect workers from infection

In domestic poultry, signs of infection 

with the highly pathogenic H5N1 virus 

may vary depending on the viral strain, 

age and species of bird, other existing 

diseases in the poultry, and environment. 

The signs may include the following: 

 Sudden death without clinical signs 

or symptoms 

 Lack of coordination 

 Lack of energy and appetite
10 Avian Influenza

 Soft-shelled or misshapen eggs

 Decreased egg production

 Purple discoloration of the wattles, 

combs, and legs

 Swelling of the head, eyelids, combs, 

wattles, and hocks

 Diarrhea

 Nasal discharge

 Coughing and sneezing

Some birds may be infected with avian 

influenza but appear to be healthy. 

4. Report sick or dying birds immediately.

 Immediately report any sick or dying birds in your poultry flock to the 

proper authorities: 

— Call the U.S. Department of Agriculture (USDA) Veterinary Services toll free at

1–866–536–7593

— Or contact your State veterinarian or local extension agent.

 Don’t wait to report sick birds. 

Early detection of avian influenza is 

essential to prevent its spread.

5. Know the possible signs and symptoms of avian influenza in humans.

Know the signs and symptoms of avian 

influenza in humans infected with the 

highly pathogenic H5N1 virus so that ill 

persons can be treated immediately:

 Fever

 Cough

 Shortness of breath

 Sore throat

 Muscle aches

 Conjunctivitis (redness, swelling, and 

pain in the eyes and eyelids)

 Diarrhea 

Watch for these signs and symptoms of 

avian influenza for up to 10 days after 

exposure to infected or exposed birds 

or to virus-contaminated materials or 

environments.

So far, conjunctivitis has been extremely 

rare in humans infected with the highly pathogenic H5N1 virus—but it is a 

common symptom in humans infected 

with the highly pathogenic H7N7 virus. 

Avian influenza can also lead to pneumonia, acute respiratory distress, and 

other life-threatening complications. 

6. Consider getting the current season’s flu shot.

CDC recommends the current season’s 

flu shot for workers involved in avian influenza control activities. Other poultry 

workers should also consider getting the 

current flu shot. Although a flu shot will 

not prevent infection with avian influenza, it could prevent dual infection—that 

is, infection with both an avian influenza virus and a human influenza virus 

at the same time. Such dual infection 

might result in the formation of new viral strains. If one of these new strains 

passes easily from person to person, an 

influenza pandemic could result.

For information about dual infection, use 

of antiviral medications, and vaccination 

of poultry workers, see the CDC Web site 
Avian Influenza 11

on avian influenza at www.cdc.gov/flu/

avian/index.htm.

7. Train workers in all guidance and 

recommendations presented in this 

Alert.

Take the following steps DURING an 

outbreak of avian influenza: 

1. Follow the avian influenza response 

plan.

2. Ask your doctor about taking antiviral medication.

Before you begin disease control activities during an outbreak of avian influenza, ask your doctor about taking antiviral medication. The Centers for Disease 

Control and Prevention (CDC) recommends that workers receive an influenza 

antiviral drug daily for the entire time they 

are in direct contact with infected poultry 

or with virus-contaminated materials or 

environments [CDC 2006a]. In addition, 

the Occupational Safety and Health Administration (OSHA) recommends that 

workers take the antiviral drug for 1 week 

following exposure [OSHA 2006].

Oseltamivir is currently the antiviral drug 

most often used for influenza. This drug 

is preferred because the avian influenza 

virus is less likely to be resistant to it 

than to amantadine or rimantadine (two 

other drugs used to prevent or treat 

influenza A). A fourth drug, zanamivir, 

may be considered as an alternative to 

oseltamivir for prophylaxis when available [Hayden and Pavia 2006].

3. Wear personal protective clothing.

Personal protective clothing is clothing 

that protects the torso (aprons, outer 

garments, or coveralls), hands (gloves), 

feet (boots or boot covers), and head 

(head covers or hair covers) from exposure to harmful agents. Many poultry 

workers routinely wear personal protective clothing. 

Poultry workers should be required to 

wear personal protective clothing whenever they may be exposed to avian influenza viruses. Such clothing will prevent 

skin contact with virus-contaminated 

materials or environments. It will also 

reduce the chances of carrying contaminated material outside the poultry barn 

or worksite.

Outer garments. When selecting protective outer garments such as aprons 

or coveralls, take the following steps:

 Select impermeable, disposable protective clothing when possible.

 Select lightweight clothing when appropriate to protect workers from 

heat stress. For example, choose a 

lightweight impermeable coverall instead of a chemical-resistant suit if 

possible.

Gloves. Gloves may be lightweight and 

disposable (8- to 12-mil nitrile or vinyl, 

for example), or they may be heavy duty 

rubber (18 mils thick or greater) and reusable after disinfection. Gloves should 

be waterproof. When selecting gloves, 

consider the following:

 Activities performed by the worker

 Dexterity requirements

 Need for glove durability and resistance to tearing and abrasion
12 Avian Influenza

Regardless of the type of gloves selected, make sure they do not make existing dermatitis worse or damage healthy 

skin from prolonged exposure to water 

or sweat. Wearing a thin cotton glove 

under a protective outer glove may prevent dermatitis. 

Foot protection. Select disposable 

boot covers or boots that can be disinfected. These will protect workers from 

contact with harmful agents and will 

prevent them from being carried from 

one location to another. 

Head protection. Select disposable, 

lightweight head covers or hair covers.

Sources of personal protective cloth -

ing and equipment. For sources and 

manufacturers of personal protective 

clothing or other personal protective 

equipment, see the Buyer’s Guide of 

the International Safety Equipment 

Association [www.safetyequipment.org].

4. Wear eye protection.

Eye protection is important to prevent 

eye contact with virus-contaminated 

dusts, droplets, and aerosols and to 

keep workers from touching their eyes 

with contaminated fingers or gloves. 

 When working with poultry, wear unvented or indirectly vented safety 

goggles, a respirator with a full facepiece, or a powered, air-purifying 

respirator (PAPR) with a loose-fitting 

hood or helmet and face shield. 

 If you wear safety goggles, make 

sure they are either 

— unvented (eyecup goggles, for 

example) or

— indirectly vented.

If indirectly vented goggles are properly fitted and have a good antifog 

coating, they may be used by poultry 

workers with a low risk of exposure to 

avian influenza. However, such goggles are not airtight and will not prevent exposures to airborne material.

 Do not use directly vented goggles 

or safety glasses for working with 

infected birds. They do not protect 

workers from fine particles, splashes, or aerosols.

 If you need prescription lenses, 

use

— protective eyewear with built-in 

prescription lenses,

— lens inserts,

— protective eyewear that fits snugly 

over prescription glasses without changing their position or 

obstructing vision (such as fullfacepiece respirators, PAPRs with 

hoods or helmets, and some 

styles of goggles), or

— contact lenses with goggles, a 

respirator with a full facepiece, or 

a PAPR with a loose-fitting hood 

or helmet and face shield.

 Fit eye protection and respirators at 

the same time:

— Some goggles can change the fit 

of a full-facepiece respirator.

— Eye protection may interfere with 

the seal of a half-facepiece respirator.

 Wear your eye protection or prescription glasses when you check the 

seal of a respirator before each use. 
Avian Influenza 13

Glasses should not protrude into the 

seal area of a full-facepiece respirator.

 Remove eye protection carefully to 

prevent contaminated equipment from 

contacting eyes, nose, or mouth.

For more information about eye safety, 

see www.cdc.gov/niosh/topics/eye.

5. Wear a NIOSH-certified, air-purifying 

respirator with a particulate filter 

(N–95 or better).

In agricultural environments, respirators 

are important to prevent exposures to 

viruses as well as to other agents such 

as bacteria, fungi, and endotoxins.

 Wear a NIOSH-certified, air-purifying 

respirator with a particulate filter (N–95 

or better) whenever you are working in 

poultry barns or may be exposed to 

infected poultry or virus-contaminated 

materials or environments. These are 

the most practical and appropriate 

respirators for such use.

 See Table 1 to compare the costs 

and advantages of the five types of 

air-purifying respirators.

 See NIOSH Respirator Selection 

Logic 2004 [NIOSH 2005] and Histoplasmosis—Protecting Workers at 

Risk [NIOSH 2004] for more information about selecting and using 

respirators for infectious agents.

6. Follow a written respiratory protection program.

To make sure that respirators protect 

workers from avian influenza, do the 

following:

 Designate a person trained in the selection, use, and fitting of respirators 

to oversee the program and answer 

workers’ questions.

 Provide workers with respirator training and fit testing to assure a safe 

and comfortable seal for the respirator facepiece.

 Include all workers who may be at risk 

of exposure to avian influenza virus.

 See Safety and Health Topics: Respiratory Protection [OSHA 2007] at www.

osha.gov/SLTC/respiratoryprotection/

index.html for more information about 

respiratory protection programs and 

respirators.

7. Protect yourself when removing personal protective clothing and equipment.

Protect yourself and prevent the avian 

influenza virus from spreading to other 

areas by taking these steps when removing protective clothing and equipment:

 With your respirator, goggles, and 

gloves on, remove all personal protective clothing.

— Place disposable clothing in a secure container.§

— Place reusable clothing in labeled or color-coded bags or 

§

NIOSH recommends the use of secure containers such as those described in the Code of Federal Regulations [29 CFR 1910.1030(d)(4)(iii)(B)]. 

Such containers should therefore be (1) closable, 

(2) constructed to contain all contents and prevent 

leakage of fluids during handling, storage, transport, or shipping, (3) labeled or color-coded, and 

(4) closed before removal.
14 Avian Influenza

containers** for cleaning and disinfection.

 Remove gloves and discard them in 

a secure container.

— Thoroughly wash your hands with 

soap and water.

— If no hand-washing facilities are 

available, use waterless soaps or 

alcohol-based sanitizers provided 

by your employer.

 Next, carefully remove your goggles 

and then your respirator.

 Thoroughly wash your hands again 

with soap and water. If no handwashing facilities are available, use 

waterless soaps or alcohol-based 

sanitizers provided by your employer. 

8. Use the good hand hygiene and decontamination procedures outlined 

here to prevent infection, avoid taking viruses home, and keep them 

from spreading to other farms: 

 Wear gloves whenever you may be 

exposed to infected poultry.

 Remove your gloves immediately after work and after removing protective clothing. Dispose of gloves in a 

secure container. 

 Wash your hands thoroughly with 

soap and water.

 If no hand-washing facilities are 

available, use waterless soaps or 

alcohol-based sanitizers provided by 

your employer.

 Be careful about using waterless 

soaps or alcohol-based sanitizers 

too often. They can be very harsh to 

the skin.

9. Shower at the end of the work shift 

and leave all contaminated clothing 

and equipment at work.

 Shower at the worksite or at a nearby 

decontamination station.

 Never wear contaminated clothing or 

equipment outside the work area.

10. Participate in health surveillance 

and monitoring programs.

 Make sure a surveillance program 

has been established to identify 

workers who develop symptoms of 

avian influenza.

 Seek immediate medical care for 

workers who develop any of the following symptoms within 10 days of 

exposure to infected or exposed birds 

or to virus-contaminated materials or 

environments:

— Fever

— Cough

— Shortness of breath

— Sore throat

— Muscle aches

— Conjunctivitis (eye infections)

— Diarrhea

 Tell the health care provider about 

the possible avian influenza exposure before the ill person arrives.

**NIOSH recommends the use of labeled or colorcoded bags such as those described in the Code 

of Federal Regulations [29 CFR 1910.1030(d)(4)

(iv)(A)(2)].
Avian Influenza 15

 Promptly report suspected human 

cases to supervisors and to local 

health authorities.

ACKNOWLEDGMENTS

The principle contributors to this Alert were 

Greg Kullman, Ph.D., C.I.H.; Lisa J. Delaney, 

M.S., C.I.H.; John Decker, M.S., C.I.H.; Kathleen MacMahon, M.S., D.V.M.; and Anne 

Hamilton. Gino Fazio and Vanessa Becks 

provided desktop design and production.

Please direct comments, questions, or requests for additional information to the following:

David Weissman, M.D. 

Director, Division of Respiratory Disease 

 Studies

National Institute for Occupational Safety 

 and Health

1095 Willowdale Road

Morgantown, WV 26505–2888

Telephone: 304–285–5749

Or call 1–800–CDC–INFO (1–800–232–

4636) (TTY: 1–888–232–6348)

We greatly appreciate your assistance in 

protecting the health of U.S. workers.

John Howard, M.D.

Director, National Institute for 

 Occupational Safety and Health

Centers for Disease Control and 

 Prevention

REFERENCES CITED

APHIS [2007a]. Biosecurity for the birds. 

Washington, DC: Animal and Plant Health 

Inspection Service, United States Department of Agriculture [www.aphis.usda.gov/

vs/birdbiosecurity/hpai.html].

APHIS [2007b]. Draft summary of the national avian influenza (AI) response plan, 

August 2007. Washington, DC: Animal and 

Plant Health Inspection Service, U.S. Department of Agriculture [www.aphis.usda.

gov/newsroom/hot_issues/avian_influenza/

avian_influenza_summary.shtml].

Bridges CB, Lim W, Hu-Primmer J, Sims L, 

Fukuda K, Mak KH, Rowe T, Thompson WW, 

Conn L, Lu X, Cox NJ, Katz JM [2002]. Risk 

of influenza A (H5N1) infection among poultry workers, Hong Kong, 1997–1998. J Infect Dis 185:1005–1010.

Butler D [2006]. Family tragedy spotlights 

flu mutations. Nature 44(13): 114–115.

CDC (Centers for Disease Control and 

Prevention) [2004]. Cases of influenza A 

(H5N1)—Thailand, 2004. MMWR 53:100–

103.

CDC (Centers for Disease Control and Prevention) [2006a]. 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].

CDC (Centers for Disease Control and Prevention) [2006b]. Past avian influenza outbreaks [www.cdc.gov/flu/avian/outbreaks/past.

htm#h7n3canada].

CFR. Code of Federal regulations. Washington, DC: U.S. Government Printing Office, 

Office of the Federal Register.
16 Avian Influenza

Chan PKS [2002]. Outbreak of avian influenza A (H5N1) virus infection in Hong Kong in 

1997. Clin Infect Dis 34(Suppl 2):S58–S64.

DHHS (U.S. Department of Health and Human Services) [2006]. Indonesia situation 

update—May 31 [www.pandemicflu.gov/

news/indonesiaupdate.html].

Hayden F, Pavia A [2006]. Antiviral management of seasonal and pandemic influenza. J 

Infect Dis 194(Suppl 2):S119–S126.

Koopmans M, Wilbrink B, Conyn M, Natrop 

G, van der Nat H, Vennema H, Meijer A, van 

Steenbergen J, Fouchier R, Osterhaus A, 

Bosman A [2004]. Transmission of H7N7 

avian influenza A virus to human beings during a large outbreak in commercial poultry 

farms in the Netherlands. Lancet 363:587–

593.

Lee CW, Swayne DE, Linares JA, Senne DA, 

Suarez DL [2005]. H5N2 avian influenza 

outbreak in Texas in 2004: the first highly 

pathogenic strain in the United States in 20 

years? J Virol 79:11412–11421.

Mounts AW, Kwong H, Izurieta HS, Ho Y, Au 

T, Lee M, Buxton Bridges C, Williams SW, 

Mak KH, Katz JM, Thompson WW, Cox NJ, 

Fukuda K [1999]. Case-control study of 

risk factors for avian influenza A (H5N1) 

disease, Hong Kong, 1997. J Infect Dis 

180(2):505–508.

NIOSH [2004]. Histoplasmosis—protecting 

workers at risk. Cincinnati, OH: U.S. Department of Health and Human Services, Centers 

for Disease Control and Prevention, National 

Institute for Occupational Safety and Health, 

DHHS (NIOSH) Publication No. 2005–109 

[www.cdc.gov/niosh/docs/2005-109].

NIOSH [2005]. NIOSH respirator selection 

logic 2004. Cincinnati, OH: U.S. Department 

of Health and Human Services, Centers for 

Disease Control and Prevention, National Institute for Occupational Safety and Health, 

DHHS (NIOSH) Publication No. 2005–100 

[www.cdc.gov/niosh/docs/2005-100/default.html].

Olsen SJ, Laosiritaworn Y, Pattanasin S, Prapasiri P, Dowell SF [2005]. Poultry-handling 

practices during avian influenza outbreak, 

Thailand. Emerg Infect Dis 11:1601–1603. 

OSHA [2006]. Protecting employees from 

avian flu (avian influenza) viruses. Washington, DC: U.S. Department of Labor, Occupational Safety and Health Administration [www.osha.gov/OshDoc/data_AvianFlu/

avian_flu_guidance_english.pdf].

OSHA [2007]. Safety and health topics: respiratory protection. Washington, DC: U.S. 

Department of Labor, Occupational Safety 

and Health Administration [www.osha.gov/

SLTC/respiratoryprotection/index.html].

Tweed SA, Skowronski DM, David ST, Larder 

A, Petric M, Lees W, Li Y, Katz J, Krajden M, 

Tellier R, Halpert C, Hirst M, Astell C, Lawrence D, and Mak A [2004]. Human illness 

from avian influenza H7N3, British Columbia. Emerg Infect Dis 10:2196–2199.

WHO [2008]. Cumulative number of confirmed human cases of avian influenza A/

(H5N1) Reported to WHO [www.who.int/csr/

disease/avian_influenza/country/en/].
Avian Influenza 17

Appendix A

Advantages, Disadvantages, and Costs of Air-purifying Respirators

for Protecting Poultry Workers*

Respirator type† and APF‡ Advantages Disadvantages

Cost

(2004 dollars)

Filtering-facepiece respirator

(disposable; dust mask); APF = 10

Is lightweight. Needs no maintenance or cleaning.Has no effect on mobility. 

Provides no eye protection. Provides no protection against irritant gases such as ammonia.Can add to heat burden. Permits inward leakage at gaps in face seal. Does not have adjustable head straps on many models.Is difficult for a user to do a seal check. Varies greatly in level of protection provided by dif- ferent models.May make communication difficult. Requires fit testing to select proper facepiece size. May not fit properly when used with some eye- wear. 

$0.70 to $10

Elastomeric half-facepiece 

respirator; APF = 10

Requires low maintenance. Has reusable facepieces and replaceable filters and cartridges.Permits use of dual cartridges to protect workers from exposures to particles, gases, and vapors.Has no effect on mobility. 

Provides no eye protection. Can add to heat burden. Permits inward leakage at gaps in face seal. Requires cleaning and disinfection of facepiece before reuse and thus poses a contact exposure risk.May make communication difficult. Requires fit testing to select proper facepiece size. May not fit properly when used with some eye- wear.

Facepiece: $12 to $35Filters: $4 to $8 each

(Continued)

See footnotes at end of table.
18 Avian Influenza (Continued). Advantages, Disadvantages, and Costs of Air-purifying Respirators for Protecting Poultry Workers* Respirator type† and APF‡ Advantages Disadvantages Cost (2004 dollars) Powered, air-purifying respira- tor (PAPR) with hood, helmet, or loose-fitting facepiece; APF = 25 Provides eye protection.  Provides protection for people  with beards, missing dentures, or facial scars. Has low breathing resistance.  Has combination cartridges  that can be used for expo- sures to particles, gases, and vapors. Creates a cooling effect with  flowing air. Has face seal leakage that is  generally outward. Requires no fit testing.  Permits wearing of prescription  glasses. Permits better communication  than rubber half-facepiece or full-facepiece respirators. Has reusable components and  replaceable filters. Has added weight from battery and blower.  Is awkward to wear for some tasks.  Requires cleaning and disinfection of components  before reuse and thus poses a contact exposure risk. Requires battery charging.  Requires air-flow testing with flow device before  use. Unit: $400 to $1,000 Filters: $10 to $30 Elastomeric, full-facepiece respirator with N–100, R–100, or P–100 filters; APF = 50 Provides eye protection.  Requires low maintenance.  Has reusable facepieces and re-  placeable filters and cartridges. Can add to heat burden.  Has reduced field of vision compared with a half-  facepiece respirator. Permits inward leakage at gaps in face seal.  Facepiece: $90 to $240 Filters: $4 to $8 Each nose cup: $30 (Continued)

See footnotes at end of table.
Avian Influenza 19 (Continued). Advantages, Disadvantages, and Costs of Air-purifying Respirators for Protecting Poultry Workers* Respirator type† and APF‡ Advantages Disadvantages Cost (2004 dollars) Has combination cartridges  that can be used for expo- sures to particles, gases, and vapors. Has no effect on mobility.  Has a more effective face seal  than a filtering-facepiece or rubber half-facepiece respira- tor. Requires cleaning and disinfection of facepiece  before reuse and thus poses a contact exposure risk. Requires fit testing to select proper facepiece size.  May require nose cup or lens treatment to prevent  fogging of facepiece lens. Requires spectacle kit for users who wear pre-  scription glasses. Powered, air-purifying respira- tor (PAPR) with tight-fitting half facepiece or full facepiece; APF = 50 Provides eye protection with  full facepiece. Has low breathing resistance.  Has face seal leakage that is  generally outward. Creates a cooling effect with  flowing air. Has reusable components and  replaceable filters. Has combination cartridges  that can be used for expo- sures to particles, gases, and vapors. Has added weight from battery and blower.  Is awkward to wear for some tasks.  Provides no eye protection with a half facepiece.  Requires cleaning and disinfection of components  before reuse and thus poses a contact exposure risk. Requires fit testing to select proper facepiece size.  Requires charging of battery.  May make communication difficult.  Requires spectacle kit for people who wear  prescription glasses with full-facepiece respirators. Requires air-flow testing with flow device before  use. Unit: $500 to $1,000 Filters: $10 to $30 *All respirator types mentioned here meet the minimum requirements for N–95 respirators. †Alternative filter types may be obtained for each type of respirator described here. ‡APF = assigned protection factor.
20 Avian Influenza

NOTES
Avian Influenza 21

NOTES
to 

For a monthly update on news at NIOSH, subscribeor visit the NIOSH Web site at www.cdc.gov/nioshE-mail: cdcinfo@cdc.govTTY: 1–888–232–63481–800–CDC–INFO (1–800–232–4636)health topics, contact NIOSH atmore information about occupational safety andTo receive NIOSH documents orthrough research and prevention.Safety and health at work for all peopleDelivering on the Nation’s promise:Cincinnati, Ohio 45226–19984676 Columbia ParkwayNational Institute for Occupational Safety and HealthCenters for Disease Control and PreventionDEPARTMENT OF HEALTH AND HUMAN SERVICES

NIOSH eNews by visiting www.cdc.gov/niosh/eNews

3!&%2s(%!,4()%2s0%/0,%©(supersedes 2008–113)DHHS (NIOSH) Publication No. 2008–128