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NIOSH Publication No. 2008-128:Protecting Poultry Workers from Avian Influenza (Bird Flu) |
May 2008 |
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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. Contents
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Disclaimer Ordering Information |
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Summary of Worker/Employer Recommendations | |
Protecting Poultry Workers from Avian Influenza (Bird Flu) | |
Background |
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Frequently Asked Questions |
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Reported Outbreaks | |
Conclusions | |
Recommendations for Protecting Poultry Workers | |
Acknowledgments | |
References Cited | |
Appendix A | 2008-128app.pdf (3 pages, 116KB) |
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Protecting Poultry Workers from Avian Influenza (Bird Flu)
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:
Take the following steps DURING an outbreak of avian influenza:
* Poultry workers include all workers who may contact poultry or materials or environments contaminated by poultry. † 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)].
Printer friendly version: Summary of Worker/Employer Recommendations 4 pages, 328KB |
Protecting Poultry Workers from Avian Influenza (Bird Flu)
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:
This Alert describes the following:
Remember these facts:
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. * Poultry workers include all workers who may contact poultry or materials or environments contaminated by poultry. † For current information about outbreaks of avian influenza around the world, see www.cdc.gov/flu/avian/outbreaks/current.htm. BACKGROUNDWhat 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:
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 factsRemember the following facts about the highly pathogenic H5N1 virus:
‡ In this document, H5N1 always refers to the highly pathogenic form of avian influenza virus. FREQUENTLY ASKED QUESTIONS1. 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:
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 virus-contaminated 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.
Examples of workers at risk include the following:
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:
For more information about human infection with avian influenza viruses, see
www.cdc.gov/flu/avian/gen-info/avian-flu-humans.htm. 4. Why are scientists concerned about the H5N1 virus?Scientists are concerned about the H5N1 virus for the following reasons:
REPORTED OUTBREAKSCurrent 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 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, 1997An 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 2002]. Report 2—Eighty-nine H7N7 human cases in the Netherlands, 2003In 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, 2004On February 19, 2004, the Canadian Food Inspection Agency announced an outbreak of avian influenza in poultry from highly pathogenic H7N3 virus in the Fraser Valley region of British Columbia [Tweed et al. 2004; CDC 2006a]. 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 casesIn 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, 2006Poultry 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. CONCLUSIONSOutbreaks in BirdsIn 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 casesSince 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 stepsAdditional 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 2004a,b; 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 WORKERSNIOSH 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 recommendationsTake the following steps BEFORE an outbreak of avian influenza:
Take the following steps DURING an outbreak of avian influenza:
Detailed recommendationsTake 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.
2. Follow biosecurity practices to keep avian influenza and other diseases out of your poultry flock [APHIS 2007a]:
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:
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:
Some birds may be infected with avian influenza but appear to be healthy. 4. Report sick or dying birds immediately.
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:
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 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:
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:
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 clothing 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.
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.
6. Follow a written respiratory protection program.To make sure that respirators protect workers from avian influenza, do the following:
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:
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:
9. Shower at the end of the work shift and leave all contaminated clothing and equipment at work.
10. Participate in health surveillance and monitoring programs.
§ 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)]. ACKNOWLEDGMENTSThe 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. 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. REFERENCES CITEDAPHIS [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. 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/].
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