As avian flu continues to sicken workers across the United States, Migrant Clinicians Network seeks to provide clinicians and health advocates with reliable information so they can best serve migrant and immigrant communities experiencing outbreaks. This FAQ was developed on December 10, 2024. Recommendations and information may change; visit the CDC’s H5 Bird Flu: Current Situation page for the most recent updates.

What is the difference between H5N1, avian flu, bird flu, and HPAI?

Various strains of the H5N1 have circulated over time. The numbers and letters in H5N1 refer to the structure of the flu strain. At this point, the different names – H5 bird flu, H5N1, bird flu, avian flu, Highly Pathogenic Avian Influenza/HPAI – refer to the same Influenza A virus currently in circulation. In this FAQ, we use “avian flu” in most cases for consistency. This is not to be confused with seasonal influenza A which has a different HN number combination.

Where is it spreading?

As of December 10, 2024, avian flu has been detected in dairy cows in 16 states. Not every state tests for avian flu so there may be more undetected and therefore unreported cases in the country. Avian flu remains widespread in wild birds and mammals, and there are additional sporadic outbreaks among  poultry farms and domesticated mammals. No person-to-person spread has been detected. CDC’s H5 Bird Flu: Current Situation regularly updates these figures.

What level of concern should I have at this point?

The risk of avian flu to the general population is low, but the risk for farmworkers on dairies and poultry farms is high. However, even at the highest risk levels, most cases have been mild. Clinicians need to uncover and respond to cases to ensure that avian flu does not spread and mutate. At this time, this work is critical from a public health perspective. With the present variants, patients with avian flu are expected to experience mild symptoms and to recover.

Why is it spreading now? What has changed?

The ability to spread from mammal to mammal is new in recent years as the virus mutated. In 2024, the virus was first identified among dairy cattle. With more encounters with infected cows, farmworkers are contracting avian flu from infected dairy cows.

What are the symptoms?

Symptoms have been mild in most cases and are similar to other viruses and the flu. Symptoms may include:

• Eye redness (conjunctivitis or “pink eye”)
   
• Cough, sore throat, runny or stuffy nose, muscle or body aches, headaches, fatigue
   
• Fever
   
• Shortness of breath or difficulty breathing
   
• Diarrhea, nausea, vomiting, seizures (less common)
   

Fever is not always present in avian flu infection and absence of fever should not reduce the index of suspicion. Occupational or recreational exposure to dairy cows, wild birds, or backyard or industrial poultry is critical to assess.

Does a vaccine against avian flu exist?

While a vaccine against H5N1 has been developed and others matching the current strain are in development, there is no indication that the United States is stockpiling vaccines or preparing to launch a widespread vaccination program against H5N1 (as of December 10, 2024). CDC’s approach at present is to prevent exposure with PPE and other occupational controls, boost vaccination against the seasonal influenza to prevent mutations, and monitor the spread among workers. (See “Why should farmworkers get the season flu vaccine?”, below.)

What do I need to consider if I have an immigrant farmworker patient with compatible symptoms to avian flu, beyond the basic CDC recommendations?

We recommend that clinicians serving farmworker, dairy worker, and poultry worker patients increase their index of suspicion among patients with symptoms of acute respiratory illness or conjunctivitis. Read CDC’s Brief Summary for Clinicians for more. On that CDC page, you can see next steps if a clinician suspects avian flu in a patient, including prescribing Tamiflu. Here, we add some notes for clinicians specifically serving migrant and immigrant farmworker patients:

• Take a sensitive detailed history to assess potential occupational and recreational exposures. Before directly asking about potential exposures, take a full patient history to understand the patient’s occupation, lifestyle, and living situation. Consider whether the patient may be fearful of disclosing exposures. Low-wage workers, immigrants, those with significant financial burdens, those whose housing is associated with their work, and those without immigration authorization may be hesitant to expose their workplace or may do anything they can to avoid missing work or jeopardizing their job. 
   
• Explain the importance of uncovering an outbreak, using an interpreter if necessary. It is important for patients to understand what avian flu is, why we are tracking the spread, what the symptoms are, and – most importantly – what the next steps are for the patient and the farm if a patient is positive. If the patient’s second language is English, use an interpreter to ensure complete understanding. 
   
  • Use MCN’s Avian Flu handout in Spanish and English.
    
     

  • Share CDC’s overview videos in Spanish.
    
     

  • See MCN’s Avian Flu webpage for more resources. 
    
    
     
• Follow CDC recommendations. Workers who are exposed to sick cows or poultry but are not experiencing symptoms should be tested. Local or state health departments are coordinating testing; the process may vary by state. While waiting for test results, clinicians should provide oseltamivir (Tamiflu) to sick patients AND prophylaxis to asymptomatic workers who experienced high-risk exposure, particularly those with insufficient or compromised PPE. CDC recommendations may change; watch the CDC page for clinicians for updates. 
   
• Clinicians have a responsibility to public health to report cases. Do everything you can to build rapport and trust with the patient so the patient can feel comfortable. If a patient is fearful of uncovering illness or of testing when sick:
  • Contact community health workers, outreach workers, or others on the care team who may already have a relationship with the patient or the patient’s community and can build trust.
     
  • Use motivational interviewing techniques.
     
  • Determine the next steps from the local or state health department and provide as much clarity as possible on what the next steps are.
     

How are cases, particularly the few cases where there is no known exposure to animals, being detected?

Routine virus panels include tests for seasonal influenza A and B, RSV, COVID-19. When tests are submitted to labs, they are randomly selected for deeper analysis as part of the United States’ ongoing influenza surveillance system. This includes testing for avian flu.

In cases where patients are very sick, the selection is not random; those patients are tested for a wide range of illnesses. All states participate in this surveillance system.

How do I get my patient tested?

Tests are becoming more widely available. If your patient has suspected occupational exposures and/or compatible symptoms, clinicians can request a test. Contact your local health department. The local department can tell you whether tests are being coordinated at the local or state level.

In areas where H5N1 remains less prevalent, clinicians may choose to rule out other viral pathogens first, by ordering a viral panel which is often available in hospital emergency rooms and urgent care centers.

While waiting for test results, clinicians should provide oseltamivir (Tamiflu) to sick patients.

Why should farmworkers get a seasonal flu vaccine?

It is especially important that seasonal flu vaccines are provided to workers on dairy and poultry farms with a heightened risk of exposure to avian flu.

CDC launched a special program to make seasonal flu vaccines available for farmworkers in states experiencing avian flu outbreak. The seasonal flu vaccine does not protect farmworkers from avian flu, but: 1) will reduce the number of severe seasonal flu cases; 2) may reduce the number of flu-like viruses in circulation to assist in the identification of avian flu; 3) prevents co-infection of flu and avian flu, which may be more severe and may influence virus mutations.

What can health workers do to prepare for future outbreaks in farmworker communities?

Community outreach workers and outreach teams can:

• Prioritize communication and relationships with dairy producers to open lines of communication and trust between industry and local sites of health provision serving the dairy’s workers.
   
• Create open lines of communication with the local or state health department that is responsible for a potential outbreak.
   
• Recognize workers’ anxieties – and address them when you can.
   
• Provide education to workers and the community on what would happen if there’s an outbreak and address concerns over exposure of immigration status and loss of work to get tested.
   
• Send strong messages and provide resources about prevention that are relevant for migrants and immigrants. (See the following question.)
   
• Workers should be encouraged to get the seasonal influenza vaccination.
   
• Workers should be trained on and test-fitted with appropriate PPE. Hand hygiene should also be covered.
   
• Acknowledge and address the fear and anxiety that workers may have in thinking about working with authorities or weighing the cost of missing work because of a future outbreak.
   

How can farmworkers prevent illness from avian flu?

Prevention is key! Prevention messages for workers include:

• Understand how exposure happens: Exposure can come from sick animals or their milk, feces, urine, litter, contaminated materials like bedding and straw, or raw (unpasteurized) milk. Surfaces and water like waterers, troughs, or ponds, may be contaminated with infected animal waste. 
   
• Get vaccinated against the seasonal flu: All dairy and poultry workers, and others with a high exposure potential, are encouraged to get vaccinated against the seasonal flu. This vaccine does not prevent avian flu. It reduces the potential of the patient to be co-infected with avian flu and seasonal flu simultaneously. Contracting both flus simultaneously increases the risk of mutation. (See “Why should farmworkers get the seasonal flu vaccine?”)

• Avoid exposure with PPE: Wear properly fitted PPE that is appropriate for the work at hand. Those working in dairy with high exposure levels are recommended to wear PPE. Employers should provide PPE at no cost to the employee. Donning and doffing PPE should occur during work hours. See the CDC page for more on preventing exposure before, during, and after wearing PPE. Scroll to the bottom for links to PDFs of instructions on how to take on and remove PPE, available in Spanish as well. 
   
• Practice excellent hand hygiene: Properly wash hands often, avoid face touching. 
   
• If working on a dairy farm, the patient can look for illness among the animals: Dairy cows appear lethargic, and farms experience a reduction in milk production. Provide instructions for how to report dairy cow illness to the local health department.
   
• Understand the symptoms and how to report: If a patient feels sick, provide specific instructions for how to report that illness to your clinic or to the local health department, as defined by your health center. 
   
• Do not drink raw milk! Dairy farmworkers sometimes bring milk home. Raw milk consumption from infected cows may cause illness.
   

Clinicians are encouraged to recognize the difficulty in following occupational guidelines for migrant and immigrant workers: Wearing PPE and avoiding exposure in a milking parlor where wet surfaces and milk are ubiquitous are challenging. Acknowledge the difficulties and work with the patient to get the maximum level of protection given their work tasks. Prioritize goggles or face shields, which are more easily used in milk parlors. Determine if work accommodations can be made to reduce potential exposure. Good communication with and support of dairy farm owners is critical.

Our region had confirmed cases of avian flu among dairy cows at a nearby farm. What messages about avian flu should health workers share?

In addition to all the prevention messages above, workers who experienced an exposure or whose PPE has been compromised around a H5N1-positive herd can be provided antiviral chemoprophylaxis under certain circumstances. Consult CDC’s Highly Pathogenic Avian Influenza A(H5N1) Virus: Interim Recommendations for Prevention, Monitoring, and Public Health Investigations.

What should I be looking for when assessing a patient for exposure?

Clinicians should always ask about workplace environmental conditions as part of the history intake, especially if working on or near dairy or poultry farms. Patients may have exposure but not have a job title that indicates exposure – for example, a patient may say that she is an accountant, but not disclose without further questioning that she provides accounting for a local farm and goes to the farm for work.

Patients on farms that haven’t yet tested for avian flu may still have the virus present. Infected cows may be lethargic, may have higher rates of mastitis, or may experience a drop in milk production. Other animals – particularly cats and poultry, who have high mortality rates from avian flu – are better indicators: 80% of dairy farms have cats present, and 50% of avian flu-infected farms with cats observed sick or dead cats. More than 20% of dairy farms have chickens or poultry present.

What is the recent history of avian flu?

In recent years, strains of avian flu have affected numerous species, particularly poultry, but also mammals, including wild mammals, domestic pets, domesticated farm animals, and, now, humans.

One human case of avian flu was reported in 2022 in a poultry worker. In March 2024, avian flu began being detected among dairy herds, and, since then, 57 additional human cases have been confirmed in seven states.  Among those cases, 34 were related to exposure to cattle, 21 to poultry exposure, and 2 had unknown exposures. Most were workers. Many others may have been infected but did not seek treatment or testing, and/or were asymptomatic. Most people with recent confirmed cases experienced mild symptoms. Recent human infections continue to be rare and the overall risk to the public remains low – but those at highest risk are dairy and poultry workers, many of whom are migrants or immigrants.

Are children at greater risk?

In recent weeks, one child in Canada with a confirmed severe case of avian flu was followed by one confirmed case in a child in California and a third possible case in a child in California. Initial investigations could not confirm routes of exposure. Both California cases were detected through influenza testing and surveillance and the children experienced mild symptoms. However, given the evolving situation and limited information, no conclusions can be taken from these very few cases on how the current strain of avian flu affects children.  CDC’s risk assessment for all people in the general public not working with potentially infected animals, including children, remains low.

What resources are out there?

• MCN’s Avian Flu page includes links to our bilingual resources, archived webinars, blogs, and more.
   
• CDC’s extensive avian flu resources including:
  • Brief Summary for Clinicians
  • Current H5N1 Bird Flu Situation in Dairy Cows
  • H5N1 Bird Flu: Current Situation Summary
  • Raw Milk: Know the Facts
     
• National Center for Farmworker Health’s H5N1 Bird Flu Response
   
• Upper Midwest Agricultural Safety and Health Center’s Safeguard Your Farm: Protect You and Your Livestock from HPAI
   
• Western Center for Agricultural Health and Safety’s Limiting Farmworker Exposure To Bird Flu