EUROPEAN COMMISSION

DIRECTORATE-GENERAL FOR HEALTH AND FOOD SAFETY
Public Health, Cancer and Health security
Health Security

Opinion of the Health Security Committee on
zoonotic avian influenza
December 2023

1. BACKGROUND: AVIAN INFLUENZA IN THE EU/EEA
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Since 2020, highly pathogenic avian influenza (HPAI) belonging to A(H5N1) clade
2.3.4.4b viruses have caused large epidemics in wild and kept birds in the EU/EEA leading
to mass mortality events in wild birds and serious losses to the poultry industry. Moreover,
since October 2022, the virus has more frequently infected mammalian species, in
particular wild carnivores, fur farm animals, marine mammals and pets. In October 2022,
an outbreak of avian influenza occurred in a fur farm in Spain and outbreaks are affecting
farmed foxes, minks and racoon dogs in Finland ( 1). Direct or indirect contact with wild
birds could have initiated these outbreaks, however investigations on the source are still
ongoing. In France A(H5N1) virus was detected in a domestic cat presenting neurological
and respiratory symptoms ( 2) and Italy reported asymptomatic infections among a
domestic cat and five dogs ( 3). These animals were kept in establishments where outbreaks
(1) Lindh E, Lounela H, Ikonen N, Kantala T, Savolainen-Kopra C, Kauppinen A, et al. Highly pathogenic
avian influenza A(H5N1) virus infection on multiple fur farms in the South and Central Ostrobothnia
regions of Finland, July 2023. Euro Surveill. 2023;28(31):2300400. https://doi.org/10.2807/15607917.ES.2023.28.31.2300400 PMID: 37535475
(2) Briand FX, Souchaud F, Pierre I, Beven V, Hirchaud E, Hérault F, et al. Highly pathogenic avian
influenza A(H5N1) Clade 2.3.4.4b virus in domestic cat, France, 2022. Emerg Infect Dis.
2023;29(8):1696-8. https://doi.org/10.3201/eid2908.230188 PMID: 37379514
(3) Moreno Ana, Bonfante Francesco, Bortolami Alessio, Cassaniti Irene, Caruana Anna, Cottini Vincenzo,
Cereda Danilo, Farioli Marco, Fusaro Alice, Lavazza Antonio, Lecchini Pierdavide, Lelli Davide,
Maroni Ponti Andrea, Nassuato Claudia, Pastori Ambra, Rovida Francesca, Ruocco Luigi, Sordilli
Marco, Baldanti Fausto, Terregino Calogero. Asymptomatic infection with clade 2.3.4.4b highly
pathogenic avian influenza A(H5N1) in carnivore pets, Italy, April 2023. Euro Surveill.
2023;28(35):pii=2300441. https://doi.org/10.2807/1560-7917.ES.2023.28.35.2300441
Commission européenne/Europese Commissie, 1049 Bruxelles/Brussel, BELGIQUE/BELGIË – Tel. +32 22991111

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of HPAI were confirmed in poultry (Italy) or in the vicinity of an outbreak in poultry
(France). In Poland, during the summer 2023, an outbreak of respiratory and neurological
symptoms occurred in cats, with 25 cats testing positive to A(H5N1). The source of this
outbreak has not been identified. Simultaneously, in the Republic of Korea another HPAI
outbreak in cats was reported ( 4) and a study conducted in the Netherlands has detected
asymptomatic infections in domestic and stray cats ( 5).

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In the EU/EEA, to date no human infections with avian influenza A(H5N1) have been
detected. In Spain, two asymptomatic poultry farm workers participating in culling
activities tested positive for virus clade 2.3.4.4b virus. However, the lack of symptoms, the
low viral load, and the absence of specific H5 antibodies against the A/H5 virus suggested
that those were environmental contaminations and not productive or systemic
infections ( 6).

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There is an extensive set of EU legislation ( 7) ( 8) ( 9) ( 10) protect workers from risks to
health and safety. This is to be fully implemented by the countries, also in establishments
with risks for HPAI outbreaks. Measures include physical distancing, enhanced
ventilation, dust- and aerosol-avoiding measures (for example, when cleaning and
handling litter), and using appropriate personal protective equipment (PPE).

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2. RATIONALE FOR THE PREPARATION OF THIS OPINION
Although the circulating HPAI viruses are still predominantly adapted to avian receptors,
mutations that are markers of virus adaptation in mammals have been identified mainly in
viruses isolated from infected mammals. In Finland sequencing analyses of avian influenza
viruses isolated from fur farms suggest a possible transmission between mammals at
affected fur farms via contact through animal secretions, feed or contaminated bedding and
care equipment ( 11). To date there have been no human infections detected in Finland nor
in other EU Member States and EEA countries over the course of similar events.
(4)__https://www.mafra.go.kr/home/5109/subview.do?enc=Zm5jdDF8QEB8JTJGYmJzJTJGaG9tZSUyRjc
5MiUyRjU2NzAzMSUyRmFydGNsVmlldy5kbyUzRg%3D%3D
(5) https://afludiary.blogspot.com/2023/11/netherlands-utrecht-university-study-of.html
(6) Aznar E, Casas I, González Praetorius A, Ruano Ramos MJ, Pozo F, Sierra Moros MJ, et al. Influenza
A(H5N1) detection in two asymptomatic poultry farm workers in Spain, September to October 2022:
suspected
environmental
contamination.
Euro
Surveill.
2023;28(8):2300107.
https://doi.org/10.2807/1560-7917.ES.2023.28.8.2300107 PMID: 36820643
(7) Directive 89/391/EEC on the introduction of measures to encourage improvements in the safety and
health of workers at work (the Framework Directive)
(8) Directive 2000/54/EC on the protection of workers from risks related to exposure to biological agents at
work
(9) Directive 89/656/EEC on the minimum health and safety requirements for the use by workers of personal
protective equipment at the workplace
(10) Regulation (EU) 2016/425 on personal protective equipment
(11) Lindh E, Lounela H, Ikonen N, Kantala T, Savolainen-Kopra C, Kauppinen A, Österlund P, Kareinen
L, Katz A, Nokireki T, Jalava J, London L, Pitkäpaasi M, Vuolle J, Punto-Luoma AL, Kaarto R,
Voutilainen L, Holopainen R, Kalin-Mänttäri L, Laaksonen T, Kiviranta H, Pennanen A, Helve O,
Laamanen I, Melin M, Tammiranta N, Rimhanen-Finne R, Gadd T, Salminen M. Highly pathogenic
avian influenza A(H5N1) virus infection on multiple fur farms in the South and Central Ostrobothnia
regions of Finland, July 2023. Euro Surveill. 2023 Aug;28(31):2300400
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ECDC assesses the risk of infection with currently circulating avian H5 influenza viruses
of clade 2.3.4.4b in Europe as low for the general population in the EU/EEA, low to
moderate for occupationally or otherwise exposed people to infected birds or mammals
(wild or domesticated).

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In the context of more frequently identified and reported infections among wild mammals,
high-density mammalian population (i.e. fur farms) and pets, the virus might adapt to infect
more efficiently humans. In addition, with the upcoming influenza season, there is an
increased risk of reassortment between different influenza viruses including zoonotic one,
like the H1N1 subtype that circulates in kept and wild pigs.

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The European Commission has conducted and planned a series of initiatives over the last
months in line with the call for a One Health approach included in the Serious CrossBorder Threats to Health (SCBTH) Regulation 2022/2371.

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This opinion of the Health Security Committee is a call to action to promote prevention
and preparedness in the light of the risks associated with the large circulation of H5N1
virus in the last seasons and the upcoming seasonal human influenza period. The actions
recommended may be also relevant for the prevention of, preparedness for and response to
other subtypes of avian influenza A relevant for public health.

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3. CALL FOR ACTION

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3.1 ONE HEALTH APPROACH

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Ensure that Standard Operation Procedures are in place guaranteeing close cooperation
and swift communication between the human health and veterinary authorities at all levels,
including setting up coordination bodies and relevant joint governance structures when
necessary.

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When possible, set up integrated surveillance systems building on existing networks, legal
frameworks and know-how fostering data exchange and joint assessments. Review and
identify areas where diagnostic pathways to ensure effective surveillance in animals and
humans (including genomic surveillance) might need to be updated.

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Foster joint outbreak investigation and response when human and animal populations are
affected in the outbreak. Encourage joint integrated training activities, workshops and
simulation exercises. Ensure rapid alert of public health authorities by veterinary services
in situations of detection of avian influenza with zoonotic potential (e.g. preferably even
before confirmation by genomic sequencing) and ensure sustained effective bidirectional
communication between animal and human health authorities.

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3.2 HUMAN HEALTH SECTOR ACTIONS
a. Reporting of avian influenza in humans
Laboratory confirmed human infections with avian influenza and other novel influenza
strains are notifiable under the International Health Regulations and through the Early
Warning and Response System, in line with EU Regulation 2022/2371 on serious crossborder threats to health. Use the European alert and response systems (EWRS, EpiPulse)
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and the European Surveillance System (TESSy) for notification, exchange of information
and monitoring of human infections.
b. Strengthening respiratory infections surveillance

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Consider the ECDC proposal on a risk-based targeted approach for testing for avian
influenza viruses in areas with ongoing avian influenza outbreaks in poultry and detections
in wild birds and other animals ( 12). The focus should be on outbreaks and severe
respiratory or unexplained neurological disease cases in humans. Wastewater surveillance
could be considered as an additional monitoring system.

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c. Monitoring humans exposed to infected animals: follow up and testing

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Monitor closely persons exposed to infected animals (either occupationally or through
contact with infected birds, pets, other mammals, etc.) for 10-14 days for the development
of symptoms. The ECDC suggests to consider testing those exposed independently from
symptoms taking into account their level of exposure. If symptoms develop after exposure
to an infected animal, the person should be isolated, tested and public health authorities
should be informed. ECDC provided specific guidance on testing ( 13).

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d. Preventing human exposure and infection

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Consider discussing with National Immunisation Technical Advisory Groups to include
people at risk of occupational exposure to HPAI among those groups for which seasonal
influenza vaccine is recommended and free of charge. Specific national vaccination
programmes against seasonal influenza, will decrease the risk of co-infection with seasonal
and animal influenza viruses and therefore decrease the risk of emergence of a reassortant
influenza virus with pandemic potential.

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In addition, countries should also consider pre- and post-exposure prophylaxis with
antivirals in persons occupationally exposed to infected animals.

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e. Ensuring health and safety at work for farm and other concerned
workers

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Ensure that the relevant EU legislation to protect workers from health and safety risks is
fully implemented, including by ensuring the availability and correct use of personal
protective equipment for professionals working in settings with exposures to HPAI,
including veterinarians, ornithologists, pathologists.

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f. Ensuring availability for and use of personal protective equipment by
healthcare professionals

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Infection Prevention and Control guidance and treatment protocols, including training on
the use of personal protective equipment (PPE) should be in place in referral hospitals for
the management of human avian influenza virus infections. Recommended PPE for
healthcare workers taking care of patients with avian influenza virus infection includes eye
protection, FFP2 respirator, water resistant gown and gloves.

(12) https://www.ecdc.europa.eu/en/publications-data/avian-influenza-infections-surveillance-eu-eea
(13) https://www.ecdc.europa.eu/en/publications-data/zoonotic-influenza-virus-infections-humans-testingand-detection
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g. Preparedness and Medical Countermeasures

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Finalise national preparedness plans against pandemic influenza / respiratory viruses,
including medical countermeasures (MCM) response. Participate in EU-wide exercises on
avian influenza.

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Gather and share with the Health Emergency preparedness and Response Authority
(HERA) information on national capacities, strategies, gaps and needs for MCM response
(including on diagnostics, vaccines, therapeutics and personal protective equipment for
human use), in order to inform EU support to MCM research and development, as well as
the organisation of joint procurement where relevant. The scope and granularity of
information to be shared, and means for sharing this information, will be agreed with MS
within the HERA governance bodies (HERA Board and Advisory Forum).

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h. Raising awareness and pro-active risk communication

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Participate in seminars/webinars organised by ECDC to update and inform animal and
public health experts of different networks working on avian influenza and surveillance.
In these scientific seminars, experts from countries, ECDC, EFSA and the EU Reference
Laboratory share the latest information on outbreaks, investigation protocols or other
ongoing projects.

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Continue to develop and implement actions providing information and raising awareness
on avian influenza and potential human exposure or infection to target health professionals,
particularly in areas with ongoing avian influenza outbreaks in poultry and detections in
wild birds or other animals. Ensure clear advice to the public on avoiding contact with sick
and dead animals. Provide clear instructions regarding contacting and reporting to relevant
health authorities.

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Consider using/adapting the ECDC infographics ( 14) ( 15) and short videos to support
awareness-raising among the public.

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3.3 ANIMAL HEALTH SECTOR ACTIONS
Even if HPAI in Europe is currently only affecting animals with no human cases reported,
public health authorities rely on certain animal health actions – notably the rapid sharing
of information - to inform subsequent public health action (e.g. rapid testing of potentially
infected individuals, quarantine, etc.). Considering that HPAI is now affecting a number
of mammals, that the circulation of viruses in mammals increases their zoonotic potential
and that some mammals can be "mixing virus vessels" potentially leading to the emergence
of new strains of the virus, HPAI surveillance and control measures in animals are crucial
also to help prevention and preparedness action on the human health side.
a) Surveillance and response in animal populations

(14) Poster: Effective hand-washing (europa.eu)
(15) Infographic: Using face masks in the community (europa.eu)
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Explore options to extend and enhance surveillance (including genomic surveillance, in
line with the guidance ( 16) of the EU Reference Laboratory for Avian Influenza) of avian
influenza in animals (birds and mammals), in accordance with the EU legal requirements
(Union surveillance programme in CDR (EU) 2020/689 ( 17) as amended by CDR (EU)
2023/1798) which prompts relevant information sharing if the disease occurs in mammals.

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Countries can explore additional actions or response.in line with art 257 (on the Emergency
measures to be taken by the competent authority of the Member State in the territory of
which an outbreak of a listed disease or emerging disease, or a hazard occurred) or art 171
(on National measures designed to limit the impact of diseases other than listed diseases)
of the Regulation (EU) 2016/429 ( 18).

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Ensure early, regular and consistent availability of information of avian influenza viral
genetic characteristics of virus from infected animals in order to assess timely the potential
zoonotic risk, as well as the results of any epidemiological investigation including also
those regarding asymptomatic animals. This information should be immediately and
efficiently shared with relevant human health authorities in order to allow implementation
of public health measures and development of medical countermeasures.

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Consider preparing national guidance for close involvement and coordination (animal and
human health authorities) in investigation of avian influenza outbreaks including among
mammals when there is potential zoonotic risk, from the predominant strains circulating
in the affected area to allow for early awareness and thus support rapid prevention,
preparedness and response action on the human health and veterinary side (while
respecting the requirements of the EU legislation).

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Where vaccination of poultry and captive birds is planned, according to EU legislation and
considering EFSA recommendations weighting its pros and cons also as a measure to limit
an outbreak of zoonotic avian influenza, ensure surveillance in accordance with EU
legislation, including post-vaccination surveillance in line with Delegated Regulation (EU)
2023/361. The results of this surveillance, especially any detected or suspected
identification of escape mutants, should be communicated to public health authorities,
establishing an effective bidirectional communication flow.

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b) Reinforcing HPAI awareness
Reinforce HPAI awareness in veterinary services, veterinarians, medical doctors, poultry
and captive bird keepers, fur animal keepers, zoos staff, pet animal keepers, hunters,
wildlife organisations and other relevant groups.
c) Continuing preparedness measures
Continue high level HPAI preparedness, prevention including biosecurity in poultry
production systems, and ensure laboratory capacity to investigate zoonotic potential.
Biosecurity should be also ensured in fur animal farms, where protection of farmed
mammals from wild birds (especially seabirds and waterfowl) should be prioritized, as for

(16) https://www.izsvenezie.com/documents/reference-laboratories/avian-influenza/usefulresources/guidance-representative-genomic-avian-influenza-virus.pdf
(17) http://data.europa.eu/eli/reg_del/2020/689/oj
(18) https://eur-lex.europa.eu/eli/reg/2016/429/oj
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EFSA guidance. Reinforce HPAI preparedness in animal species other than birds,
including fur animals.
d) Participating in active surveillance project for wild birds
Consider to participate in active surveillance for wild birds: EFSA is preparing the launch
of a grant to perform pilot project focusing on targeted active wild bird surveillance at
certain relevant areas of Europe to detect which viruses are entering along the most
important wild bird flyways. A pilot project ( 19) done at one location was successful and
in this follow up project the number of sites will be expanded.

(19) https://efsa.onlinelibrary.wiley.com/doi/epdf/10.2903/sp.efsa.2022.EN-7791
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