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Volume 24, Number 10—October 2018
Online Report

Protective Measures for Humans against Avian Influenza A(H5N8) Outbreaks in 22 European Union/European Economic Area Countries and Israel, 2016–17

Cornelia AdlhochComments to Author , Gavin Dabrera, Pasi Penttinen, Richard Pebody, on behalf of Country Experts
Author affiliations: European Centre for Disease Prevention and Control, Stockholm, Sweden (C. Adlhoch, P. Penttinen); Public Health England, London, UK (G. Dabrera, R. Pebody)

Main Article

Table 1

Levels of exposure, groups for active and passive follow up and recommendations for antiviral prophylaxis, by country, European Union/European Economic Area and Israel, 2016–17*

Country Definition of level of exposure Groups for active follow up Groups for passive follow up Antiviral treatment recommendations and other measures
Czech Republic None None Cullers People in close contact with infected birds and experiencing relevant health problems are advised by public health authorities to seek medical care. General practitioners/clinicians are responsible for the next therapeutic and prophylactic steps.
Denmark Sporadic contact with birds and their droppings; workers who collect dead wild birds suspected for avian influenza; farmers, veterinarians and workers involved in handling of outbreaks with confirmed highly pathogenic avian influenza in poultry None Groups 2 and 3 Antiviral prophylaxis is only recommended for persons exposed at risk level 3
Estonia None In accordance with occupational risk analysis results In accordance with occupational risk analysis results For exposed persons, mostly for occupationally exposed persons
Finland Depending on type of exposure Exposed humans without PPE and those taking part in culling and cleaning Others For severe cases and risk groups, outbreak control
France None None; started active surveillance in 2015 but was rapidly overloaded and stopped Exposed persons No prophylaxis
Germany (28) A) Persons in direct contact to animals possibly infected with A/H5 virus (mainly poultry workers and veterinarians); increasing risk for exposure related to duty. B) Persons in direct contact with persons possibly infected with A/H5 virus. B1) Family members or persons in the same household with a probable or confirmed case if infection with A/H5 virus. B2) Medical personnel in practices and hospitals with <1 possible, probable, or confirmed human case of infection with A/H5 virus. C) Personnel in laboratories analyzing samples suspected to contain A/H5 viruses It is the responsibility of local health authorities to decide on the measures taken; RKI recommends using a monitoring instrument (29) The decision to use antiviral drugs s up to the respective Federal State. RKI recommends to offer antiviral postexposure prophylaxis. Recommended measures for groups: A) 1. Minimize number exposed, 2. Use personal protective clothing, 3. Use measures when leaving the site, 4. Antiviral prophylaxis, 5. Vaccination; B1) 1. Antiviral prophylaxis, 2. Active follow up of contact persons, 3. Investigation and differential diagnostics of acute respiratory symptoms; B2) 1. Hygiene, 2. Antiviral prophylaxis, 3. Active follow up of contact persons, 4. Investigation and differential diagnostics of acute respiratory symptoms; C) Work performed under safety cabinet level 2 for diagnostic work; virus culture under BSL-3 conditions
Greece Setting (exposure to wild birds/domestic poultry/occupationally exposed); type of exposure All persons in contact with birds with high suspicion of or confirmed influenza A(H5N8( virus infection are monitored by public health professionals from the local prefecture Local veterinary services should provide a list of those exposed to the local public health officials who are involved in active surveillance As a general recommendation, antiviral prophylaxis is offered to persons exposed to infected birds. A risk assessment is conducted for each incident by local public health authorities and the Hellenic Center for Disease Control and Prevention, including the need for antiviral drugs. If relevant clinical symptoms develop in a person within the 10 d follow-up period, after exposure to infected birds, he or she should be given antiviral drugs at treatment dose for 5 d. Other measures include minimize number of persons exposed, use of full PPE, and vaccination
Hungary None Persons exposed to animals with confirmed avian influenza virus, such as influenza A(H5N8) virus None Exposed persons should be provided oseltamivir antiviral prophylaxis for 10 d
Ireland Category A: Occupational persons who are exposed to avian influenza before identification of an incident who were not wearing appropriate PPE at all times during exposure. This category could include farm workers, other exposed workers, owners of backyard flocks or other persons resident at the premises who have had exposure to birds or infected materials and veterinary staff. Category B: Persons who will be occupationally exposed during the response to the incident, while wearing appropriate PPE. This category could include anyone involved in culling, disposal, and clean-up operations at a premises or rendering facilities or rangers/veterinarians capturing wild birds. Category C: Nonoccupational exposures: might include members of the public (or others) inadvertently handling sick or dead birds, or their fecal matter that is confirmed to be infected with avian influenza virus. These persons are unlikely to have been using appropriate PPE. Category D: Members of the public or others outside of occupational settings, inadvertently handling sick or dead birds, or their fecal matter for which avian influenza status cannot be confirmed (e.g., single or large bird die-off). These persons will generally be managed under the standard approach, unless information or risk assessment suggests a different approach. Depending on risk assessment, a strict or standard approach is undertaken with regard to active surveillance. Strict Approach, Category A: Active follow up is required for every day up to 10 d from the last date when exposure occurred without complete PPE. This active follow up consists of daily contact between healthcare personnel and the person to check whether symptoms compatible with human avian influenza (including conjunctivitis) have developed in the person. The person should also receive standard information on potential symptoms and emergency contact instructions for healthcare personnel (for instances when symptoms develop between daily contacts). If PPE were started at a later date after an unprotected exposure, then the contact should be reassigned to passive follow up after the end of the active follow up period. Passive follow up should be continued for 10 d after the last exposure. Category B: If the person has been exposed to the incident while wearing complete PPE during all exposures, the person should undergo passive follow up until 10 d after the last exposure to the infected site. Passive follow up involves provision of information on human avian influenza symptoms for persons to be aware of and emergency contact instructions for healthcare personnel. Any person who has not worn complete PPE during all exposures will require active follow up according to Category A from the date of the last exposure without full PPE. In situations in which a person has unprotected exposure, followed by protected exposure with complete PPE, then the person should have 10 d of active follow up from the date of last exposure without complete PPE. The person should then be given instructions for passive follow up for a period <10 d after the last exposure with complete PPE. Category C: To be considered for active follow up for 10 d from the date of exposure. Category D: Not usually applicable to the strict approach. Standard Approach, Categories A–C: All persons exposed to infected site or birds should undergo passive follow up for 10 d after the last exposure. Category D: On the basis of risk assessment by public health or occupational health personnel; possible approaches might include consideration of passive follow up for a 1 bird without avian influenza confirmation. Active follow up might be considered for a large bird die-off in which avian influenza has not been confirmed. Incidents regarding poultry: the decision of using chemoprophylaxis is dependent on whether a strict or standard approach is deemed appropriate. Chemoprophylaxis: Chemoprophylaxis should be started <7 d after the last exposure, the dose for oseltamivir is 75 mg. 1×/day. The minimum course for oseltamivir is usually for 10 d. For influenza A(H7N9), 75 mg of oseltamivir, 2×/d, is recommended for prophylaxis. Because of concerns over potential resistance to oseltamivir. If any persons are unable to take oseltamivir, this situation should be discussed with the NVRL.
Strict approach (categories A–C). For all avian influenza incidents considered to require a strict approach, antiviral chemoprophylaxis is advised. This decision is likely to include all incidents in which the subtype of avian influenza virus is H5, H7, or H9. However, chemoprophylaxis of responders to incidents should be considered on a case-by-case basis, taking into account the evidence of the ability of the virus to cause human infection or severe disease. If in doubt, discuss with the NVRL and HPSC. The exception to the recommendations above would be for persons in Category B (wearing full PPE) who have responded to a wild bird incident, which requires a risk assessment on an individual incident basis. For only occupational contacts, prophylaxis should be started before persons have contact with birds and should be given daily while in contact and for 10 d after last exposure. If exposure has already occurred, prophylaxis should be started <7 days of the last exposure. The maximum recommended duration of prophylaxis is 42 d, and advice should be sought if it is likely to be required for longer than this period. Standard approach (all categories): Antiviral chemoprophylaxis is not routinely advised as long as all onditions for use of the Standard Approach are met. The standard and strict approaches were outlined in previous questions.
Israel Protected and unprotected exposure Unprotected exposure Protected workers Not recommended
Italy None None. Potentially exposed persons are requested to seek care by a general practitioner in case of ILI/ARI/conjunctivitis onset. In case of suspected and confirmed human ILI or ARI cases, active surveillance for close contacts is immediately activated for >10 d All persons exposed (farmers, veterinarians, cullers) Treatment and prophylaxis during influenza A(H5N8) outbreaks
Liechtenstein Professional contact with poultry or wild birds; accidental contact with poultry or wild birds None Diagnosis of avian influenza must be reported to the healthcare system regardless of outbreak situation or group Usual hygienic measures. No specific antiviral medication
Malta None All those whose work involves direct close contact with live or dead poultry/wild birds Healthcare workers taking care of confirmed case-patients who wore PPE, and family members/friends/work colleagues who had close contact with exposed persons For treatment of suspected and confirmed cases of avian influenza
Netherlands 1) Persons with prolonged exposure to infected animals (farmers and family, workers on the farm); 2) Persons with short period of intensive exposure to infected animals or products of infected animals (veterinarians, cullers); 3) Persons with one-time or short presence on infected farm without direct exposure to infected animals or their products; 4) Municipal Health Service personnel involved in taking specimens from patients suspected for infection with avian influenza virus. None Groups 1 and 2 Restrictive antiviral treatment depending on the level of exposure prophylaxis is offered alone or combined with seasonal Influenza vaccine or monitoring
Norway 1) Sporadic contact with wild birds and their droppings; 2) Close contact with sick or dead wild birds where avian influenza infection is suspected; 3) Close contact with poultry holdings where avian influenza infection is suspected or confirmed. None The municipality doctor is responsible for logging the name and address of exposed persons and the period of exposure.
Self-monitoring for ILI, ARI, conjunctivitis, or general signs of infection should be performed for 10 d postexposure by persons at risk level 3. If symptomatic, they should contact their general practitioner and inform him or her about the exposure. In general, antiviral prophylaxis is not recommended. Antiviral drugs are only used for influenza patients, in particular those who have an increased risk for severe illness. Neuraminidase inhibitors should be given as soon as possible and <48 h of symptom onset. Treatment for hospitalized patients should always be considered, also after 48 h of symptom onset. For avian influenza, oseltamivir is recommended for all persons at risk level 3 from first exposure to >7 d postexposure. This treatment should also be considered for persons at risk level 2.
Romania None Exposed persons with occupational risk and exposed persons living in/near the households where the outbreak was identified. No particular group (general population) Antiviral prophylaxis is not recommended. Antiviral drugs are used only for treatment when needed.
Slovak Republic Direct contact to poultry with influenza A(H5N8) confirmation; contact with wild birds with influenza A(H5N8) confirmation; stay in environment with influenza A(H5N8) detection;
contact with a person with confirmed influenza A(H5N8) Farmer, culler, veterinarian, public directly exposed to birds None Public health recommendations on antiviral prophylaxis as per ECDC rapid risk assessment
Slovenia Accidental contact with dead or diseased wild bird; professional contact with dead or diseased wild bird; professional contact with diseased poultry (no cases so far in this country) Only for those who had intensive unprotected contact with poultry that had confirmed avian influenza infection There is no passive surveillance in place. Nevertheless, National Influenza Centre would test any specimen positive for influenza A virus but negative for seasonal H1 or H3 subtype avian influenza viruses Antiviral prophylaxis has not been recommended for influenza A(H5N8) and A(H5N5), but for unprotected close contact with wild birds or poultry with confirmed HPAI A(H5N1), antiviral prophylaxis would be given to exposed persons
Spain None None If exposed persons have symptoms <7 d after the last contact with infected birds, they should inform public health authorities Generally not recommended
Sweden Exposed without protective equipment None For influenza A(H5N8); only passive surveillance Not relevant for influenza A(H5N8). Antiviral treatment only for confirmed cases or during the time it takes for a diagnosis if a person has severe illness.
United Kingdom Highest risk: culling, swabbing, direct contact with carcasses, fecal materials; other exposures are also considered to be at lower risk but still require PPE to be used. All exposed persons (not just highest risk). However, previous recommendations had active surveillance only for those without both PPE and antiviral during exposures. Not applicable for current recommendations. Previously for those had used PPE and antiviral drugs during all exposures. In February 2016, interim recommendations were adopted whereby only persons with the highest risk exposures (culling, handling carcasses, direct contact with infected materials, swabbing) and had a breach in the recommended PPE required postexposure antiviral prophylaxis for 10 d.

*ARI, acute respiratory infection; BSL-3, Biosafety Level 3; ECDC, European Centre for Disease Prevention and Control; HPAI, highly pathogenic avian influenza; HPSC, Health Protection Scotland; ILI, influenza-like illness; NVRL, national virus reference laboratory; PPE, personal protective equipment; RKI, Robert Koch Institute.

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1Members of this group are listed at the end of this article.

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Page updated: September 16, 2018
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The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
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