The Rural Clinician's Role in Influenza A(H5N1) Surveillance This Summer: Practical Strategies for Assessing Patient Risk and Implementing Influenza Testing and Treatment

Date: Tuesday, June 18, 2024
Duration: approximately 60 minutes

Featured Speakers

	Sarah Heppner, MS, Associate Director, Federal Office of Rural Health Policy (FORHP)
	Tim Uyeki, MD, MPH, MPP, Chief Medical Officer, Influenza Division, National Centers for Immunization and Respiratory Diseases (NCIRD), Centers for Disease Control and Prevention (CDC)
	Laszlo Madaras, MD, MPH, Chief Medical Officer, Migrant Clinicians Network (MCN)

Join to hear experts from the Centers for Disease Control and Prevention (CDC) and in the field discuss clinical features of influenza A(H5N1), recommendations and considerations for influenza testing and treatment, and strategies for culturally competent patient evaluations for possible exposure to influenza A(H5N1).

Additional CDC Resources

From This Webinar

Transcript

Kristine Sande: I'm Kristine Sande, and I'm the program director of the Rural Health Information Hub. I'd like to welcome you to today's webinar, The Rural Clinician's Role in Influenza A (H5N1) Surveillance This Summer: Practical Strategies for Assessing Patient Risk and Implementing Influenza Testing and Treatment. It is my pleasure to introduce our speakers for today's webinar.

First, we'll hear from Sarah Heppner. Sarah serves as the Associate Director of the Federal Office of Rural Health Policy in the Health Resources and Services Administration of the U.S. Department of Health and Human Services. In this role, Sarah provides programmatic policy and operational support for the office. Sarah has been with FORHP since 2012 serving as the research coordinator, the deputy director of the Office for the Advancement of Telehealth, as well as the director of the Policy Research Division.

Next, we'll hear from Dr. Tim Uyeki who has worked at CDC on the clinical aspects, epidemiology, prevention and control of influenza in the United States and worldwide since 1998. He has been a consultant to the World Health Organization for many years on clinical and epidemiological issues related to seasonal, zoonotic and pandemic influenza, SARS-CoV, MERS-CoV and Ebola virus diseases.

Lastly, we'll hear from Laszlo Madaras. As the chief medical officer for the Migrants Clinicians Network or MCN, Dr. Madaras is responsible for the oversight of MCN clinical activities. He also serves as a subject matter expert for various topics in migrant and immigrant health, including COVID-19 clinical education. Since the first weeks of the SARS-CoV-2 pandemic, Dr. Madaras treated thousands of patients sick enough to need hospitalization and sometimes intensive care. Over the last 30 years in parts of Africa, Latin America, South America, the Pacific Islands and the United States, Dr. Madaras has served thousands for wide-ranging ailments including newly emerging diseases such as Zika and most recently COVID-19.

With that, I'll turn it over to Sarah Heppner. Sarah?

Sarah Heppner: Thanks so much for the invitation to join you all today, and thank you for taking time out of your day. Whether you're listening or watching this live or if you're catching this on the recording, we recognize how busy everyone is, and thank you for taking the time to join us. As Kristine said, my name is Sarah Heppner, and I'm the associate director for the Federal Office of Rural Health Policy. Our office has coordinated activities related to rural healthcare within the U.S. Department of Health and Human Services for more than 30 years.

As part of that role, we're thrilled to be able to work with our CDC colleagues through their rural public health office. Together we'll continue to be the voice for rural across the department, sharing rural relevant resources and information about H5N1 and making sure that we're communicating those information and resources to you as quickly as we can and through the easiest mechanisms that we are able to. Thank you again for taking the time to join us. Please ask any questions that are on your mind. We will make sure that we get information to you as quickly as we have it.

Tim Uyeki: Thanks, Sarah. So, I'm going to give an overview on a highly pathogenic avian influenza A (HN51) virus and give a historical perspective. So just to start out, just to talk about this virus, highly pathogenic avian influenza, A (H5N1) virus, actually, the first time we ever heard about this virus or it was first identified was in 1959 in an outbreak in poultry in Scotland. But one of the points is that like all influenza A viruses, this virus has the propensity and continues to evolve, and it evolves into different groups that we classify into clades. Now the first time this virus really came to public health attention was in 1997 in Hong Kong. This is the first time that an influenza A virus was known to come from infected poultry to infect people directly and actually to cause a fatal outcome. During that outbreak there were 18 cases identified with six deaths, and this is pretty alarming. Since 1997 to date, there are 24 countries that have reported human cases of H5N1.

To date, it's about 912 cases, and what's alarming is that more than 50% of these cases actually have died. It's about 51.5% to date. But I just want to point out that these are uncommon events. These are sporadic cases. Again, this goes back since 1997, and many different countries have reported human cases. Now starting at about 2020, this particular group of H5N1 viruses that we call clade 2.3.4.4b viruses emerged in wild birds. It actually was wild migratory birds that spread this virus all over the world. It's in many regions of the world now, and it was first detected in wild birds in North America at the very end of 2021. Since then, there have been many infections of a wide range of wild bird species as well as causing many poultry outbreaks starting in about February 2022 in the U.S. and ongoing. In addition, there have been many, many different mammal species that have been infected, not just in the U.S. and North America, but in all over the world.

This has included both marine as well as terrestrial mammals, anywhere from very small scavenger animals all the way up to a Kodiak brown bear in Alaska and as well as a polar bear. This is an epidemic curve of human cases of H5N1 have been reported since 1997. What you see in the middle of the graph is different colors on this bar graph chart, these are different countries that have reported human cases. You can see there's some periodicity in these cases, and particularly in 2015, there was a big epidemic in Egypt. This is representing poultry-to-human transmission for the most part, but since 2015 you can see cases have really dropped off. Then you can see towards the very bottom right of the graph a trickling of sporadic human cases, and that will include some of the cases in the U.S. that I'll talk about next. If we look at from 2022 to date, there have been 29 cases reported from several different countries you can see in the top right, and this includes four cases in the U.S.

One case in the U.S. was reported in April of 2022 was in an individual who was actually depopulating poultry at a confirmed poultry outbreak of H5N1 and a very, very low level of virus was detected in a single upper respiratory tract specimen. I personally don't believe that this person was actually infected. I think this just represented a detection of virus contamination, and I think that holds true for actually about seven or eight other cases that were asymptomatic. But clearly, what we've seen is this virus can cause severe and critical illness, typically severe pneumonia and can cause fatal outcomes. So these viruses bind to receptors that we have that are most prevalent in our lower respiratory tract. These receptors for the virus are also found on conjunctiva. This is different than seasonal influenza A and B viruses that are transmitted very well among people all over the world, and These seasonal influenza A viruses and B viruses typically bind best to receptors in our upper respiratory tract.

So there is a difference between these viruses in terms of human infections that these H5N1 viruses really bind best to receptors in our lower respiratory tract, so the virus pretty much has to get down into the lower airways. Now, among those who are symptomatic, there's a really wide clinical spectrum, so there are cases of mild disease, and this is predominantly manifested by acute respiratory illness, mild, uncomplicated, what we say, uncomplicated influenza-like illness. There have been a few cases of conjunctivitis alone that I'll talk about, but more commonly, this virus causes severe pneumonia, can progress to critical illness, respiratory failure, sepsis, multi-organ failure, and as I mentioned, very high mortality in those who are hospitalized. Now, how do people get infected with this virus? Well, historically, it's been predominantly through unprotected exposure to sick or dead poultry. It's either direct or very close exposure to sick or dead poultry.

Typically, in many countries this has occurred in rural areas, people raising backyard poultry that then became infected and died. Now visiting a live poultry market has also been reported both in rural areas as well as some urban areas. You can see on the top figure on the right, this just represents some of the ways that we think people can be infected from poultry to human transmission of this virus either through direct contact, so touching virus that's something, surfaces or touching poultry that are infected. You get virus on your hands and then touching your mucus membranes, that could lead to infection, or somehow virus is aerosolized and then that gets deposited either on conjunctiva or in the upper respiratory tract or is inhaled down into the lower airways. Now the other way most recently that we've learned about is that this can occur through direct or very close exposure to other infected animals such as dairy cows. I'll talk about this in a second. At the bottom right you see a figure that depicts how people might be infected by closer direct contact with dairy cows.

Now, the virus infects the respiratory tract of cows, but is very much concentrated in the mammary, sorry, in raw, cow milk, it infects the mammary tissues. So if one were to get exposed to respiratory secretions being up very, very close, for example, giving oral gastric fluid resuscitation to a cow, you're right in the cow's face close with nasal secretions. Or if you were to get splashed by raw cow milk or get cow milk contaminated on your hands and then touch your mucus membranes, that could lead to infection.

In terms of wild birds, a lot of wild birds have been infected and died. We know historically there was a small cluster back in 2006 in Europe in Azerbaijan in which there were two different clusters of people that found dead wild swans. They took the feathers off. There probably was aerosolization of virus and then inhalation of virus into the lower airways, and actually seven cases in four of them died.

Then very uncommonly, you could have limited non-sustained human-to-human transmission. This has been reported in about five countries, but the last time it was reported was in 2007. This has typically occurred through unprotected prolonged exposure to a symptomatic H5N1 patient. When people are progressing in their illness, the sicker you become, the higher the levels of virus in your respiratory tract and the more infectious you are. If you're taking care of someone, you're exposed to their respiratory secretions. If they're coughing, there could be aerosolization and then inhalation of virus. This has typically occurred in households from one blood-related family member to another. But it's also occurred in the healthcare setting, a blood-related family member taking care of another symptomatic patient in the hospital. This is why we want to recommend, particularly for healthcare personnel, that you've got to be wearing recommended personal protective equipment and following infection prevention and control recommendations when you're caring for a patient who's suspected or confirmed with H5N1.

So, signs and symptoms of H5N1 virus infection range from very mild to very severe. So initially, the most common symptoms are acute respiratory illness symptoms, upper respiratory tract symptoms. So people may have non-productive cough, may have runny nose, nasal congestion, sore throat, headache. They may have fever. Not everyone has a fever at symptom onset, but as they progress, they typically have fevers. They may have malaise, they may have myalgia.

Now in H5N1 patients that are confirmed historically, there are definitely some that have had gastrointestinal complaints such as abdominal pain as well as vomiting and diarrhea. That's more common with H5N1 than it is with seasonal influenza.

Then conjunctivitis, so symptoms of eye discomfort, redness, eye discharge, maybe some ocular swelling have been reported. It's typically been very uncommon. But as you can see from the photo, the figure in the top right, that's actually a patient that was diagnosed in Texas, and this patient only manifested bilateral conjunctivitis. So, it's uncommon, but it has been reported in of the three cases associated with dairy cattle exposure, two of the three had conjunctivitis.

Now in patients who then progressed to lower respiratory tract disease, that typically occurs around days five to seven after symptom onset. So, what you see, the patient will manifest signs and symptoms of lower respiratory tract disease, so difficulty breathing, shortness of breath, chest pain, and tachypnea.

At hospital admission you typically find signs of pneumonia, hypoxia. Laboratory findings, some of the most common classically are leukopenia, lymphopenia and mild to moderate thrombocytopenia. But clearly not all patients have these classic laboratory findings. Then most commonly, those who have pneumonia have bilateral pneumonia, so chest x-ray findings are typically patchy, interstitial low bar or diffuse infiltrates in opacities and sometimes consolidation, sometimes pleural effusions.

So, to date, and since it was first reported March 25th by U.S. Department of Agriculture is the first time actually that this virus, H5N1, has been shown to infect dairy cattle. We've only seen this in the U.S., not outside the U.S. to date. As of this morning, there are 102 farms confirmed by USDA in 12 states, and you can see the states that are shaded there. Then the particular clade virus has been this 2.3.4.4b virus. It's the same clade that we've seen in wild birds and other mammals in the U.S. and causing poultry outbreaks. As I mentioned, there are high levels of this virus that are found in the raw milk of infected cows, dairy cows.

There's a wide range of other animal species, some of these have been associated in the vicinity of some of these dairy farms, but not necessarily. There are other livestock including baby goats, so alpacas, but then probably those of you have heard from the news that there have been these cats reported. Many mammals, including cats, when they're infected, they manifest both respiratory as well as neurological signs, so they may have seizures or behave abnormally. There have been some actually suspected with rabies, but tested negative for rabies and were positive for H5N1, and there's high mortality in infected mammals. Now, poultry outbreaks I mentioned have started since February 2022, and we're basically at 97 million commercial poultry or backyard bird flocks that have either died or been depopulated to control the spread of this virus. So it's almost every state, 48 states since February 2022.

So in the U.S., as I mentioned, we've had three human cases associated with dairy cow exposures. This year, one in Texas. That person, you saw the figure on the other slide, it was bilateral conjunctivitis only. We had a case in Michigan only had unilateral conjunctivitis. Then the most recent case in Michigan had upper respiratory tract symptoms without fever, did report about 10 days into the illness some watery eyes for a couple of days. I think that was actually due to allergies, and the household contact also had seasonal allergies. So none of these individuals were hospitalized. They were all recommended for home isolation to be away from their household contacts. Oseltamivir was recommended for antiviral treatment and post-exposure prophylaxis of household cases. There were no secondary illnesses in household members, so there was no evidence of human-to-human transmission. My colleagues at CDC isolated H5N1 virus from both the Texas case and the first Michigan case. These viruses were virtually identical, and they're basically the same virus that's circulating in cows, but the origin is actually in wild birds and it's the same virus that's causing these poultry outbreaks.

So potential exposures to H5N1 virus, those who are most at risk of exposure and then potential infection are those who have occupational exposure, people with close, prolonged or unprotected exposures to infected animals. So it could be to any infected animal including infected poultry, could be wild birds, but also any other infected mammal, especially the ongoing multi-state outbreak in dairy cattle. So people could be exposed directly or very close to infected animals or to the environments contaminated by infected animals. These include dairy farm workers, slaughterhouse workers. Now slaughterhouse workers is more of a theoretical risk, certainly if any animals that are infected go to slaughter; milk processing facility employees because of the high levels of H5N1 virus in the raw milk from infected dairy cows; poultry farm workers; and then anyone that's working on these poultry farms or with dairy cows, and that includes veterinary personnel.

So in those individuals particularly, so it's really important when you're seeing a patient that it might have acute respiratory illness or conjunctivitis, whether or not they have a fever or not, even if they appear to have clinically mild illness, you should ask them what they do. What kind of work do they do? Do they have potential occupational exposure to an infected animal? And definitely don't drink raw milk. You should also ask the patient if they consume raw milk or consume products that are made from raw milk.

We do recommend healthcare personnel not only to wear recommended personal protective equipment if you're evaluating a person with suspected or confirmed H5N1, but also frequent hand washing. So, if you do suspect a patient on the basis of the history, it's not the clinical findings because the clinical findings are very nonspecific, acute respiratory illness or conjunctivitis or both. So we do recommend trying to elicit a history of recent exposure to infected animals. Then you should use the recommended personal protective equipment, and that includes a National Institute of Occupational Safety and Health or NIOSH-approved N95 respirator. It includes eye protection with goggles or a face shield as well as a disposable gown and gloves.

Now in those who only present with acute respiratory symptoms and they have a history of exposure to potentially affected animals or definitely infected animals in the prior 10 days, you should collect the nasopharyngeal swab as well as a combined nasal and throat swab and put the combined nasal and throat swab in the same tube of viral transport media that is separate from the nasopharyngeal swab into a different tube of viral transport media. The testing for this virus must be done at a public health laboratory. So influenza tests that are available in clinical settings cannot specifically identify H5N1 virus. There are many, many different kinds of influenza tests available in the outpatient setting, in emergency departments and also for hospitalized patients. But they either detect influenza A or influenza B, and they can't tell you that a positive result for influenza A is H5N1 virus.

So, if you get a positive result for influenza A, it could be seasonal influenza A virus infection, right? So right now, seasonal influenza A and B virus activity in the U.S. is low, but it's not zero. We do have cases of seasonal influenza during the summer months, and occasionally there are people who are hospitalized with pneumonia due to seasonal influenza.

So, there are also people particularly in rural areas, particularly in children, but not only children who have close contact with infected pigs. So pigs can be infected with swine influenza A viruses. Particularly people who visit these agricultural fairs, either a county fair or state fair, they might be exposed to infected pigs and they could acquire swine influenza virus infection. If you tested them, you would get a positive result for influenza A, but it wouldn't distinguish between seasonal influenza, swine influenza, or H5N1 influenza virus infection, so you need to get those specimens. If you suspect H5N1, you need to get them to a public health laboratory. If the patient only has conjunctivitis, you should collect a conjunctival swab and a nasopharyngeal swab. Those are separate. Put them in separate tubes of viral transport media. Again, get those to a public health laboratory.

You should notify your state or local health department or both if that you have a patient with suspected H5N1 because public health needs to follow that patient up, follow up the testing results, make sure the specimens are routed to a public health laboratory for appropriate testing. The patient needs to be isolated. So even before you get testing results, you should prescribe empiric oseltamivir treatment, because early treatment is associated with a better clinical outcome. Actually, in observational studies, it's associated with survival. So, we want to start empiric oseltamivir treatment for suspected H5N1 even before you get testing results back.

Then if H5N1 virus infection of the patient is confirmed, we do recommend that household and close contacts should receive oseltamivir for post-exposure prophylaxis. Because of H5N1 I mentioned is associated with very high mortality in infected patients, we do recommend post-exposure prophylaxis with oseltamivir at treatment dosing. So, it's essentially treat the patient as well as treat the household contacts and any other non-household contacts who had close exposure to the case when they were symptomatic.

So, the other things just to say that we'd like, we're working with our public health partners, local and state health department partners this summer is ongoing monitoring of symptomatic workers, particularly at dairy farms. But we also continue to monitor along with our local and state health department partners workers who are exposed to infected poultry because there continue to be poultry outbreaks of H5N1. To enhance national surveillance for H5N1 virus infections of people, we are asking for all influenza A viruses... sorry, all influenza A positive tests, those respiratory specimens, we want those to be subtyped. So we want those to be sent to a public health laboratory for subtyping, both outpatients as well as hospitalized patients with a positive influenza A test. We're doing enhanced surveillance for lab-confirmed influenza associated hospitalizations.

We will continue to do provider outreach to encourage influenza testing throughout the summer. Even though seasonal influenza activity is low, we do want influenza testing to go on for patients with acute respiratory illness symptoms and/or conjunctivitis, especially if they have a recent history of animal exposures that are relevant. Then as part of all of our different surveillance systems, so we're looking at lab-confirmed influenza surveillance, we're looking at syndromic surveillance for influenza-like illness or acute respiratory illness as well as conjunctivitis. We have many, many different surveillance platforms that we're looking at outpatients, emergency department visits as well as hospitalized patients. We're also looking at wastewater data, and if we see a signal for wastewater data for influenza A, then we're getting in contact with our local and state health department partners to find out if that signal might indicate an increase in infections in humans. But what we found to date is that actually what it reflects is either wild birds, poultry or more raw milk that's being discharged into wastewater runoff.

So, I just want to stop there. I'll hand it over to Dr. Madaras, and I just want to thank you and look forward to questions. Thanks so much.

Laszlo Madaras: Great, thank you, Dr. Uyeki. That was very thorough, and it covered many of the things that I was going to cover anyway, so that makes my job a little bit easier. So good afternoon, everybody. I'm Dr. Madaras, and I'm a family physician in South Central Pennsylvania. I work with farm workers, and we do have dairy and poultry farms in our area. I work part-time as a hospitalist physician also, and I work very closely with our ER physicians as well. So I'm going to give you a perspective of the role of the primary care physician and what we can do in our communities. So my other hat is I'm Chief Medical Officer for Migrant Clinicians Network, and we have been working with populations who are migrants, immigrants on the move, and we are a force for health justice. Our mission is to create practical solutions at the intersection of vulnerability, migration, and health, and we envision a world based on health, justice and equity where migration is never an impediment to well-being. I'll get into some of the work that we do with our farm worker populations here in just a minute.

So the clinician, when I use the word clinician here, I'm going to talk about family physicians, primary internists, nurse practitioners and physician assistants. So the role of the clinician in rural communities is basically one of trust. We are hopefully a trusted source of knowledge and information. We know the community very well. I've worked in this area for about 30 years. I delivered many of the babies here. I know most of the workforce in many parts of the community here. It's important for the primary care clinician to know their rural community and what's going on at any time. As Dr. Uyeki was saying, are we seeing anything like influenza spreading at an atypical part of the off season? We should be aware of that. We also should be aware of who is at greatest risk. We also need to know what's happening not only locally in our community, but also globally. What the COVID pandemic has taught us in our rural communities is that we cannot be blind to what's going on in the rest of the world because the rest of the world is coming at our doorstep very quickly.

As Dr. Uyeki just mentioned, globally, what's happening in different parts of the world with poultry and now with dairy cattle, we need to be very cognizant of that, not just what's going on with us locally, but what could be coming to our doorstep from any part of the world.

So who is at risk? We already covered much of this, so dairy producers and workers. What is interesting to note, though, is that over 50% of dairy workforce in the United States are immigrants. We have about 150,000 dairy workers, and just over half of them are immigrants. Some of them don't have English as their first language, and communication becomes very crucial when we try to provide trusted information to this patient population. Also, 79% of our milk supply comes from immigrant workers. Again, this is very significant given that much of our concern right now is in dairy farms. So again, workers on poultry farms, we covered that.

Slaughterhouse workers, incidentally, veterinarians and other veterinary assistants, as Dr. Uyeki mentioned, veterinarians will do all sorts of necessary procedures and possibly put nasal gastric tubes into horses and cows. In this case, with cows that puts them at a higher risk for the respiratory type of the H5N1. Workers also caring for sick animals who are destroying sick animals need to be concerned.

Community health workers because they're out with their population, and again, consumers of raw milk. Also, those attending agricultural fairs and farm shows where animals are often petted and they're touched and judged for prizes, so we need to be cognizant of that as well. So these are all various risks that we've already covered to some extent, but this is what the primary clinician needs to know about risk as far as H5N1 is concerned. So again, the role of the clinician is to know your area. Okay, so are there dairies in your community? If so, are herds positive where you are?

I communicate with the Department of Agriculture locally to see what is going on anytime of the year that we have any sort of outbreak of any kind of viral contaminants. So, we need to be cognizant of what's happening in our local areas.

We also need to know our patient population. So again, I spoke to the fact that many of our workers are immigrants for whom English may not be their first language, and also their literacy level may not be very high. So any information that we give out, pamphlets or otherwise, and we tend to do this quite a great deal at Migration Clinicians Network, is to provide trusted source of information to our population in various languages to very basic literacy level. So we need to know the patient population also, and this was our experience during COVID as well. So do they get time off when they're sick? If not, will they be willing to come forward to declare themselves feeling ill? Because lack of work, if they're sick and have to take time off, means that they don't get any payment for that time. They usually don't have FMLA. They don't usually have insurance. So again, being a trusted source in the community is very important to try to overcome these fears.

Also, education-wise, do they have time to wash their hands and change gowns before going off to their lunch break? Do they even have a lunch break? Or if they're so hurried, they try to short circuit some of these important health measures that Uyeki was just mentioning. So, this is where the trusted source of the primary clinician comes to play, because if you can provide this information in the language that they understand at a literacy level that is basic, that may help prevent misinformation from spreading. So again, prevention includes educating our patients.

The other thing that we need to do also is confirmatory lab tests and nowhere to go for the testing. As mentioned, state health departments will do the majority of this type of testing as the nasal swabs that we have in our ER will test for 14 different viruses, but it does not determine, H5N1. It does tell us the influenza A or influenza B but nothing beyond that.

So your community health worker is your ally in this situation. Also, other trusted allies are religious leaders in the community. So we try to engage these people also to help spread the important information of what we were just talking about. The community health workers know the community. They know their workers. They often speak the language of that community and are trusted for the most important information. So what we do at Migrant Clinicians Network often is work with these community health workers. We provide webinars to them to get the information out so that they can provide the proper information so that people can get protected and get treated. Mostly, if we can prevent the illness from starting, that would be the major step right there. But they do encourage the workers to seek care, and they often will remind the workers to tell the clinicians where they work. Again, I try to tell my students and my residents the importance of asking about profession, asking about exposures, environmental exposures. So we have a whole training for our students and also for our community workers.

So what kind of symptoms are we looking at? Again, we'll cover this just really quickly: flu symptoms like fever, chills, runny nose, cough, fatigue, muscle aches. Sometimes, but not always, we have red eyes and conjunctivitis. However, this was the case in most of the United States workers that were ill. But as Dr. Uyeki mentioned, in other parts of the world, there's other presentations, and conjunctivitis does not always indicate that they have H5N1.

So again, it's going to be important to recognize H5N1. Taking the patient history, their work history, the environment in which they live and work and how close they are in proximity to other people who may be sick, this is very important, again, with COVID in recent years as well. So, we know now we talked about the at-risk populations and that, again, the confirmatory lab testing at the state health department.

So, this is a screening tool that we use at Migrant Clinicians Network to teach about occupational health and safety. So, three simple questions which are not hard to remember. Describe what you do for work, and are there any physical activities that you do at work or away from work that you feel are harmful to you? Are you exposed to chemicals, fumes, dust, noise, in this case is ill colleagues, high heat? Do you experience these at your work and away from work, and do you think that these are harming you?

So, these are just basic questions that we ask of all our workers so that we know what environment they are coming from. We can make these questions more specific to the H5N1 viral infections if we see these arising in our area.

So again, this is just a visual of what we already talked about, routes of exposure, so mostly the mammary glands. This often happens as the equipment for the dairy is placed on the teats themselves and it's a suction that gets on to each one. If you're very experienced, and I've tried this before, I'm not that experienced, if it falls off or as you're pulling them off, it can spill and spray into your eye very easily, so this is why eye protection is going to be very important.

Some has been found in manure, but as far as we know right now is not likely airborne. So at this point, when you look at the dairy situation, you see this gentleman here with gloves, eye protection and apron, hopefully, boots as well. So there's very little skin that is not covered. Ideally, you could cover your mouth as well, but the important thing is going to be the hand to eyes and face. To avoid that type of contact is the most important thing.

So, the best thing to do is prevention, so personal protective equipment over the hands and face. When you're done with your work, wash the hands. Hand hygiene is really important, soap and water. Also, try not to touch your face, your eyes with your hands while at work. Even after you've washed your hands it's best to minimize the contact with your eyes. As Dr. Uyeki mentioned, the receptors for the avian flu are in the conjunctiva.

Again, do not drink raw milk. Pasteurized milk has been shown to have portions of the virus, but not able to do any damage, but raw milk is not pasteurized and the virus can be alive and well in raw milk. So, I would not recommend drinking any raw milk. So, these are another things that we can do as primary care clinicians in our community is to spread the word.

So personal protective equipment, PPE, ideally face shields or masks. Now, I wore all this during COVID for three years. I can tell you even in the environment of fairly well air-conditioned or negative pressure rooms, it's very easy to get foggy face shields and foggy masks. So, we have to work on getting the right equipment in a dairy barn. There's often a very humid environment and a very cool environment. Disposable gloves are ideal. Most dairy workers work with nitrile gloves, and that was always to prevent mastitis. So I think gloves are still part of that culture and should be continually worn, then safety glasses or goggles that do not fog. Then again, overalls and gowns or an apron, which is often worn as well.

So these are the things that would be an important part of the personal protective equipment. So, the combination of prevention and protection is going to be very important if we are to prevent the transfer of H5N1 from cows or poultry to humans.

So, in summary, we are going to have emerging and reemerging viruses. We have to be vigilant, and we have to keep watching what is happening in our communities and in our world. We do have to know our community very well. I think communication between veterinarians, state health departments, the Department of Agriculture is one of the things that primary care clinicians are well versed in doing as we are known in our communities, and we have a curiosity about what's going on in the health of our community. We have to know who is at most risk, and I think we've covered that pretty well here now.

Then we have to ask our patients what they do for work. What is their profession? What is their exposure? Prevention is important, and then getting updates and partnering with your local and state health departments is going to be very key.

Again, just to say thank you for the CDC because keeping up to date with CDC guidelines is also something that has helped us through COVID, and I'm hoping will help us through whatever's coming next year. But I think the vigilance, the information and communication from the primary care clinician is going to be very, very important. Knowing that if you're starting to see a unusual outbreak of influenza A in your community during the summer, notify and test and talk with your state health department.

We at MCN are already working on information to be given out to primary care clinicians, both in English, Spanish, and we're hoping to get something in Haitian Creole as well. We do have this information packet, and we're working on other pamphlets. We're hoping to give those out to community health workers, to dairy owners, to milk haulers, and so everybody that's involved in our local dairy farms and in poultry farms as well. So, we do have this, and we are working on putting together information packets like comic books in local languages in basic literacy level that is easy to understand.

There's more information here also on avian flu and safety, the pamphlets I was talking about, Avian Flu and Your Safety Guidance to Dairy Workers, a one-page, downloadable resource is English and Spanish. We also have Avian Flu on Dairy Farms: What Clinicians and Dairy Worker's Patients Need to Know, Q&A with Jeff Bender, who is a veterinarian on the latest outbreak and also a pamphlet Avian Flu on Dairy Workers, a video playlist on YouTube. So we have very many different forms of communication to get to our clinicians on the ground who are going to be the eyes and ears for us as we go through this.

I don't want to talk too much here about languages and network organization, but we do have a publication fairly recently in one of the journals of the Medical Association, Championing Health Equity. I put the link there if you're interested in reading more about the kinds of work that we do with farm workers, this is a good place to go to get that information. This is our website. Again, we have comic books that talk about pesticides, heat exposure, various vector-borne illnesses. These comic books are beautifully illustrated by one of our illustrators. They're in basic Spanish, and we're getting them in other languages now as well. So this helps prevent disinformation, gets the correct information out on farm worker health and safety. We'll be working on one of these for H5N1 as well in the future here. We also have other virtual trainings and updates at our website, which I mentioned here. So, thank you again.

Thanks very much. It was a pleasure to be here with you, and I'm ready to entertain questions with Dr. Uyeki and others on the panel here. Thank you.

Kristine Sande: Thanks so much. Yes, it's time for questions. So we do have a couple already here. So the first one, "Could you please distinguish when farm workers should wear masks and when they should wear N95?"

Tim Uyeki: I can take that, and then Dr. Madaras might want to comment as well. So the recommendation for dairy farm workers working with dairy cattle that are confirmed with H5N1 virus infection, there's many different elements of PPE. But in terms of respiratory protection, the recommendation is an N95 respirator, not a surgical face mask. Definitely the recommendation is for eye protection. As I mentioned, we've had two cases of workers with conjunctivitis and so goggles or a face shield. But as Dr. Madaras recommended, this may not necessarily be practical given the environmental condition. So, throughout the U.S., every day it's only getting warmer and more humid, and Dr. Madaras mentioned even for healthcare personnel the challenges of wearing goggles or face shield and fogging up and so forth.

So, what we can say is what the recommendations are. We can post all of the PPE that are recommended. We can post the guidance from CDC and NIOSH in there, but we also realize the reality is that workers may not comply. So I think that we all have to work closely together, including with farm workers and farm owners and the dairy industry to see what might actually be possible and who are those at most highest risk of exposure to this virus and infection. It may be that it is people who are definitely working with cows that are symptomatic that are sick, and that those who are doing milking in the milking parlor. The reason is, again, we've had two cases of conjunctivitis. One of those cases was splashed in the eye with raw cow milk, and that resulted in conjunctivitis. We believe that was how transmission occurred. So I think we can make these recommendations, but I think all of us realize that this may be a bit challenging for workers to comply with that. I don't know if Dr. Madaras wants to add anything to that.

Laszlo Madaras: Yeah. So I agree with that. I think in practical purposes, we need to work with the dairy industry to see what is doable and what is practical. Nobody wants to have sick cows. You lose the milk, you still have to milk, you lose... the industry does not want to have that happen. So if we don't have a, what I would call maybe a hot zone at this point in your local area, do everything you can to cover your mouth and eyes. But if you have confirmed sick cows, by all means, use the N95 as long as you have them.

I am concerned sometimes that the availability based, again, on our experience with COVID. We didn't ramp up fast enough and we were trying to use masks and autoclaving them and reusing them, so it's a challenging thing to have enough for everybody. But I would say definitely as Dr. Uyeki said, in a hot zone where there's sick cows, use the N95. Protect yourself because as we've seen globally, this is not a light illness. This can really be very severely life threatening and life ending, so I'd agree usually N95s in the hot zones for sure. Then whatever's practical in the other parts, as much protection as you can get that seems to be working. Thank you.

Kristine Sande: All right, thank you. Another question is, "While there is an assumption that county and state health departments will provide PPE, there's quite a bit of confusion at the local level about who would provide and pay for such PPE. Do you have any information regarding that?"

Tim Uyeki: Yeah, I think it's a little bit challenging for me to specifically answer this depending on the state and the county. What I can say is that this is something where local and state health departments need to work together closely. There is the potential to request PPE supplies from the Strategic National Stockpile. So this is the assistant secretary for Preparedness and Health, ASPR, HHS ASPR that controls the stockpile. There are regional emergency medical coordinators that states work with to make a request for PPE. So in the absence of that, it's a very good question. I don't have the answer to every specific situation, but I think at the local county health department level, it's really just clarify this with your state health partners.

Kristine Sande: All right. Another question is, "How do we counter the already circulating verbiage that H5N1 is just another hoax by the government to just go ahead and enjoy your raw milk and everything will be fine?" Thoughts about how to do that, Dr. Madaras?

Laszlo Madaras: I can address that a little bit here, yeah. So again, the counter of the misinformation and the disinformation misinformation comes from the trusted primary care clinicians. If you work the community for a long time and you're noted as somebody who is reasonable and knowledgeable and tries give you the best information, these are the things that I think are going to be at that level. They may not hear whatever the government says on TV. That's unfortunate, but that's the post-COVID world that we're living in right now. But it is going to be an uphill battle. But that's why we produce information in several different languages to the core people who are working so English speakers, Spanish speakers, whoever's working on the dairy farms get the right information.

We're going to try to put out that out very quickly so that the right information goes out. Unfortunately, disinformation travels very fast, and so it is a challenge to get it out there. But hopefully, the people who have survived COVID realize many of those people came back to me later and said, "Thank you for the information you gave. I wasn't ready to hear it at one point, but we'll listen to you from here on in." Now, that's small cases like that, but it's really important to be as knowledgeable and up to date as possible with the correct information and fight the disinformation.

Kristine Sande: Great, thanks. So another question is, "So would the same information be what we would share with community members who have livestock at home, so maybe a small number of livestock rather than large herds of dairy or flocks of birds?"

Tim Uyeki: It's a great question. So I don't have animal expertise. I'm a physician and epidemiologist, but what I would say is that there's no question that dairy cattle are susceptible to this virus. So how it got established, it's likely to have been wild bird introductions that got into dairy cattle, but it is pretty clear it's going dairy cow to dairy cow and now extensively in more than 100 dairy herds in 12 farms to date. So any kind of dairy cattle could potentially be infected.

It raises the question about other kinds of cattle such as beef cattle, but this issue as Dr. Madaras was getting at about milk, cow milk, and there is some question about lateral transmission through milk machines or fomites, we don't fully understand the transmission. But could it be possible that you could have wild bird or let's say poultry that are infected that could then somehow transmit to dairy cows on a small farm? I think it is potentially possible. These dairy cows are susceptible. So, the focus has been on large dairy herds, dairy farms, but I don't think we know enough, and there hasn't been enough testing to know if this is a wider problem.

Laszlo Madaras: Yeah. One other thing I wanted to add is that what I hear from the dairy farmers who know this much better than I do also is that if your cow is not producing as much milk as it did fairly recently, and it's not having any good appetite, just like when we're sick, we don't feel like eating much, so anyway, these are signs that even if you have a small herd or just a couple of cows that you should be cognizant of what's going on if they just are not eating and just feeling not right. So many people who are in tune with what their animals are experiencing should watch for that. Then I would say consult your veterinarian.

I think good discussion between the veterinarian and the physician is also important. I believe that one of the cases of conjunctivitis was good communication between the human medical team and the veterinary team to say, "Hey, this person came from a situation where we found some sick cows." That's how they were able to jump to the idea of conjunctivitis, because many of us clinicians who have been doing this for years have not been able to just say, "Oh, this is conjunctivitis, or this must be avian flu." But because there's good communication between different community leaders there, that did happen and we got the information out there.

Kristine Sande: Who would do the fit testing for dairy farms?

Tim Uyeki: Well, that's a great question. I don't think either Dr. Madaras or I have the answer to that, and I think that that's getting at the practical issues. Now, ideally for healthcare personnel, the recommendation is you want to be fit, tested, and actually it is annual fit testing for N95, because there are many, many different models of N95 respirators. There are many different sizes, and one model and one size does not fit all. However, the reality is that we've never made this recommendation for workers at dairy farms before. My understanding is that typically on these dairy farms, nobody wears any kind of personal protective equipment, at least that's recommended until very recently. So when you implement that, that raises a good question. Now, I think most people in the U.S. are pretty familiar with the last four years of the COVID-19 pandemic, and many of us could purchase, or actually you could receive these KN95 respirators.

So it's not formal fit testing, but you mold it to your face and you get a proper fit. So that is much better you get a proper fit, some kind of fit, maybe it's not formal fit testing compared to using no mask or using a surgical mask that maybe is not so well fitting. It's a very good question because formal fit testing is not done in the farm setting. It's not done with a portable fit testing equipment, so I don't have the answer. That's another thing where NIOSH can make these recommendations, but the practical implications of the reality at the farm setting level may not actually be conducive to doing the formal fit testing. So some kind of good approximate seal, I think, is going to be better than no seal. Dr. Madaras may have some further comments.

Laszlo Madaras: No, it is a very challenging question. I can say that at our hospital, the ER nurses are really expert now over the many years of COVID. Every year, like Dr. Uyeki said, we are fit tested, but we just don't have enough nurses to go around. I can't offer those services to the whole community. But if we did, if we had a training program, again, this would take some money, government money to train... our nurses could teach other nurses and community health workers how to do fit testing, I could see that being a solution.

But we don't have enough personnel right now, and I don't think there's government funding for teaching this to everybody. But our nurses know what to do, and they've kept us safe for these many years, but it's just a smaller... we don't have enough nurses to go around. If I offered our services, they'd be really upset with me if I told them they should go out there and do extra work, which they can't do at this point. But it is a good question, and I think we need to work on those practical solutions, and hopefully, we'll get some government money at some point to get that fit testing done. Thank you.

Kristine Sande: So, on behalf of the Rural Health Information Hub, I'd like to thank our speakers for the great information and insights that you've shared with us today. Thank you also to all of our participants for joining us. The slides used in today's webinar are currently available at www.ruralhealthinfo.org/webinars. In addition, a recording and transcript of today's webinar will be made available on the RHIhub website. Thank you again for joining us, and have a great day.