Outbreak Notice
Guidelines and Recommendations

Avian Influenza A (H5N1) Virus Update: Information for U.S. Citizens Living Abroad
This information is current as of today,

Most recently updated: February 2, 2007
Initially released: March 24, 2005

Current Situation

Visit the official U.S. government website for pandemic influenza

Highly pathogenic avian influenza A (H5N1) (hereafter referred to as “H5N1”) virus has caused serious disease among wild birds and poultry on multiple continents. For a current list of countries reporting outbreaks of H5N1 among poultry and/or wild birds, view updates from the World Organization for Animal Health (OIE). Human infections with H5N1 viruses are still rare, but have occurred in countries in Asia, Africa, Eastern Europe, and the Middle East between 2003–2007. Most cases of H5N1 virus infection in humans are thought to have occurred from direct contact with infected poultry, but in one instance, human cases are thought to have been acquired through close contact with wild swans. Rare occurrences of probable spread (or ‘transmission’) from human to human have been reported. So far, however, this type of transmission has not been sustained. Transmission of H5N1 viruses to two persons through consumption of uncooked duck blood may also have occurred in Vietnam in 2005. Total numbers of confirmed human cases of H5N1 virus by country are available on the World Health Organization (WHO) Avian Influenza website. An assessment of the current situation can be found on the Centers for Disease Control and Prevention (CDC) Avian Influenza website.

Outbreaks of H5N1 virus among bird populations in Asia, parts of Europe, the Middle East and Africa are not expected to diminish significantly in the short term. Consequently, it is expected that human infections resulting from direct contact with infected poultry will continue to occur in countries where poultry flocks are infected. Because no sustained human-to-human transmission of H5N1 virus has been documented anywhere in the world, the current phase of alert, based on the WHO global influenza preparedness plan, remains at Phase 3 (Pandemic Alert). If H5N1 virus were to gain the capacity to spread easily from person to person, an influenza pandemic (worldwide outbreak of disease) could begin. CDC remains in close communication with WHO and continues to monitor the H5N1 virus situation in countries reporting bird outbreaks and human cases.

For more information about pandemic influenza, please see the official U.S. government website for pandemic influenza.

CDC Recommendations

Citizens living in H5N1-affected countries should be aware of the H5N1 situation in their local area and any resulting preventive health recommendations. The following recommendations may be revised as more information becomes available.

Monitor the worldwide situation

• CDC Travelers’ Health
• CDC Avian Influenza
• World Health Organization Avian Influenza

Monitor the local situation

• If H5N1 virus has been isolated in the country where you reside, monitor the announcements of the country’s Ministry of Health and local government. Updates may also be provided at the WHO and OIE websites.
• Follow local public health guidelines, including any movement restrictions and prevention recommendations.

Develop a plan

• If H5N1 virus infections among birds or humans are identified in an area, officials may decide to limit movement of birds and possibly humans to contain the spread of disease. Be prepared to stay in your residence for an extended period of time (“stay in place”) if needed. Have a supply of water, nonperishable food items and other necessities such as an extra supply of medications, especially prescription medications. For preparation guidance, see the Pandemic Flu Planning Checklist for Individuals and Families.
• If you currently live abroad or are preparing to move abroad, you should evaluate how you would receive adequate health care if the situation were to arise.
• Evaluate your plan periodically and update as needed based on new information.

Use Personal hygiene

• As with other infectious illnesses, one of the most important preventive practices is careful and frequent handwashing. Clean your hands often with soap and water (or waterless, alcohol-based hand gels containing at least 60% alcohol, when soap is not available and hands are not visibly soiled) to remove potentially infectious materials from your skin and help prevent disease transmission.

Take precautions regarding birds and poultry

• Avoid all contact with birds, including domestic poultry (such as chickens and ducks) or any wild birds.
• Avoid touching surfaces contaminated with poultry feces or secretions.
• Avoid settings where H5N1 virus-infected poultry may be present, such as commercial or backyard poultry farms and live poultry markets.
• Children should be taught not to touch sick or dead birds. If there has been a verified H5N1 virus infection in birds within the region, make sure that small children are supervised by an adult when they go outside.
• If possible, allow trained workers to dispose of bird carcasses and bird droppings. Contact local health authorities or government officials to determine if trained workers are available.
• If contact with a bird carcass is unavoidable (for example, a cat brings a dead bird into the house), follow the interim guidance below: 

• Under no circumstances should the bird be touched with bare hands. Appropriate personal protective equipment (PPE), as described below, should be worn to avoid direct contact with skin, mucous membranes, and eyes.
• Use an inverted double-plastic bag technique to protect the hands while picking up the carcass. This technique involves taking two plastic bags, placing one inside the other; put hands inside the bags; pick up the carcass, using the bags as a protective barrier; pull the bag up and around the carcass; and tie the bag. Alternatively, use a shovel or other disposable or cleanable utensil and wear disposable impermeable gloves, if possible. Gloves should be changed if torn or otherwise damaged. CDC does not generally recommend latex gloves because a significant proportion of people have latex allergies.  
• For additional protection, safety goggles or glasses and a surgical mask may be worn to protect the mucous membranes of the nose, mouth and eyes against splashes.
• If disposing of the carcass in the absence of other instructions from health or government authorities, place it in a double-plastic bag and bury it or place it in an appropriate trash receptacle in a location where it is unlikely to be disturbed by animals.
• Discard or disinfect* any PPE used. Immediately clean hands with soap and water (or an alcohol-based hand gel with at least 60% alcohol when soap and water are not available).
• Avoid touching face, rubbing eyes, eating, drinking, or smoking before washing hands with soap and water.

*Recommendations for PPE Disinfection:
For machine-washable, reusable PPE: Disinfect PPE in a washing machine with detergent in a normal wash cycle. Adding bleach will increase the speed of viral inactivation as will hot water, but detergent alone in cold water will be effective. Follow manufacturer recommendations for drying the PPE. Non machine-washable, reusable PPE should be cleaned following the manufacturer’s recommendations for cleaning.

 

Take precautions regarding pets

• In addition to humans and birds, it is known that pigs, tigers, leopards, ferrets and domestic cats can be infected with H5N1 viruses. In addition, in early March 2006, Germany reported H5N1 infection in a stone marten (a weasel-like mammal). The H5N1 virus that emerged in Asia in 2003 is evolving and it is possible that other mammals, including dogs, may be susceptible to infection as well. All of the cases of H5N1 infection in domestic cats reported to date have been associated with H5N1 outbreaks among domestic poultry or wild birds and are thought to have occurred by the cat eating raw infected birds. If dogs are susceptible to H5N1, infection might occur by the same route. There is no evidence to date that cats or dogs can spread H5N1 virus to humans. The European Centre for Disease Prevention and Control has issued preliminary recommendations for cat owners living in H5N1-affected areas. (408 KB, 3 pages) Additionally, the Food and Agriculture Organization has produced guidance for areas where H5N1 virus has been diagnosed or is suspected in poultry or wild birds.
• The following measures are recommended if there has been a verified H5N1 virus infection in birds within the region:
• Keep domestic cats inside the house to avoid exposure to potentially infected birds.
• Do not feed your cats raw meat or poultry.
• Avoid all contact with stray cats and keep them outside the house.
• Inform local veterinary authorities if your cat is sick and has possibly been in contact with birds.
• Strictly follow normal hygiene rules for pet care to avoid contracting diseases transmitted by pets. When cleaning cat litter boxes, wear gloves and thoroughly wash your hands with soap and water immediately afterward.

Take precautions regarding food and food preparation

• Eat only poultry or poultry products that have been cooked.
• Do not eat dishes containing uncooked (raw) or undercooked poultry or poultry products such as eggs, and including dishes made with uncooked poultry blood.
• Wash your hands with soap and warm water for at least 20 seconds before and after handling raw poultry and eggs.
• Prevent cross-contamination by keeping raw poultry and its juices away from other foods.
• Clean cutting boards and other utensils with soap and hot water to keep raw poultry from contaminating other foods.
• Use a food thermometer to make sure you cook poultry to a temperature of at least 74˚C (165˚F) . Consumers may wish to cook poultry to a higher temperature for personal preference.
• Even if poultry and eggs were to be contaminated with the virus, safe cooking would kill it.
• Recent studies have shown that the cooking methods that are already recommended by the U.S. Department of Agriculture (USDA) and the Food and Drug Administration (FDA) for poultry and eggs to prevent other infections will destroy avian influenza viruses, as well.
• Cook eggs until whites and yolks are firm.
• For more information about food preparation safety, see the USDA Fact Sheet and the FDA Questions and Answers On Avian Influenza ("Bird Flu") and Food Safety page. Other helpful information can be found at the website of the Partnership for Food Safety Education (PFSE) , as well as the Federal Government’s Consumer Advice pages for Eggs and Meat & Poultry.

If you believe you might have been exposed to ill or dead birds

• Monitor your health more closely for 10 days after your possible exposure to birds infected with avian influenza.
• If you become ill with a fever, cough , sore throat, or have trouble breathing, consult a health-care provider, especially if you think you may have been exposed to birds infected with avian influenza in the past 10 days. Before you visit a health-care setting, tell the provider the following: 1) your symptoms, 2) where you traveled, and 3) if you have had direct contact with poultry or close contact with a severely ill person. The U.S. embassy or consulate also can provide names and addresses of local physicians.
• Do not travel while ill, unless traveling locally for medical care. Limiting contact with others as much as possible can help prevent the spread of an infectious illness. See Seeking Health Care Abroad in Health Information for International Travel for more information about what to do if you become ill while abroad.

  Additional Information

  The U.S. Department of State has decided to provide oseltamivir at its embassies and consulates for eligible U.S. government employees and their families serving abroad who become ill with avian influenza. The Department of State has specifically stated that they cannot provide non-U.S. Government employees traveling or living abroad with antiviral medications even in the event of a pandemic. For more information about this policy, see the Department of State Avian Flu Fact Sheet.

  For more information, including information about vaccine development for H5N1 influenza, please see the Questions and Answers About Avian Influenza (Bird Flu) and Avian Influenza A (H5N1) Virus page.

  For more information about avian influenza, see CDC’s Avian Influenza Web site .

  For more information about commonly used avian influenza terms, see the U.S. Department of Agriculture’s Avian Influenza Low Pathogenic H5N1 vs. Highly Pathogenic H5N1 Latest Update .

  For additional guidance on handling dead birds, see the CDC’s Interim Guidance for States Conducting Avian Mortality Surveillance for West Nile Virus (WNV) and/or Highly Pathogenic H5N1 Avian Influenza Virus .

  Visit the official U.S. government website for pandemic influenza .