PUBLIC HEALTH AND

OCCUPATIONAL SAFETY
MODULE PURPOSE

The purpose of this module is to present principles for veterinary, public health, and other animal
control workers to prevent exposure to HPAI, to identify suspect human cases of HPAI, and to provide
guidelines for managing individuals exposed to HPAI. This module also describes some of the practical
implications of personal protection when working in the field and proposes a system of risk
management on infected farm or village sites to reduce the exposure of workers to the HPAI virus.

MODULE OBJECTIVES

At the conclusion of this module, you will be able to:

• Identify risks for transmission to humans;

• Understand basic infection prevention principles;
• Describe the protective measures people in various roles should implement to minimize the risk of
infection from and/or the spread of HPAI;
• List the safety and biosecurity procedures that must be in place on an infected site during outbreak
response and justify the need for strict enforcement of these principles;
• Describe and explain the need for procedures for taking rest breaks, water and food when at an
infected site without compromising worker safety, and
• Explain simple and safe procedures for the immediate replacement of worn or defective PPE.

Prepared by BFC, MSH and UC Davis Avian Flu School

LESSON 1: PUBLIC HEALTH AND OCCUPATIONAL SAFETY

Information for this lesson is contained in the PowerPoint Slides on the following pages.
LESSON 2: SITE MANAGEMENT FOR PROTECTION CONTAINMENT AND
ENFORCEMENT
CURRENT CONTEXT

• Health protection is not simply wearing personal protection equipment (PPE).

• The set up and control procedures on an infected site can significantly reduce exposure to the virus.
• Many of the workers on an infected premise (IP) will not be trained in response and will have to be
instructed.
• Strict enforcement on the proper use of PPE and decontamination stations is essential.
• When there is a shortage of PPE, supervisors should understand the risks and provide practical
alternative solutions.
IMPORTANT POINT
Site control consists of the individual tasks carried out at a place where poultry are infected with avian
influenza virus must be managed in such a way they you do not expose worker to unnecessary health
risks or contribute to spreading the virus beyond the boundaries of the current infected area.

WHY IS SITE CONTROL NEEDED?

An infected site is the largest source of virus contamination during an outbreak. It is essential that
human health is protected and that the virus does not leave the site by virtue of the activities
undertaken. The stamping out of an infectious disease within poultry holdings often requires many
more staff than is needed for cattle and sheep operations because there are significantly more animals
involved. Only essential staff should have direct contact with the birds, supporting staff should be
restricted to areas on the site where they will be exposed to a lower level of virus. With the highly
pathogenic nature of the virus, it is essential to try to contain the virus on the site or in the locality. One
way of containing the virus in the area is to use mostly local people in the operation, however this may
mean that they are not aware of the risk involved and have not been trained in personal protection.
This means that instructions for first responders and culling crews have to be simple and a fully trained
supervisor has to be appointed to ensure compliance with the worker protection procedures. The
supervisor will need to have the authority to correct field workers on any points of personal safety and
remove any worker from the site who fails to comply.

FOUR PRINCIPLES

All activities on an infected site must comply with the 4 principles:

1. Protect people
2. Protect animals
3. Contain the virus
4. Make it a single event
EXERCISE 1: KEY POINTS EXERCISE

1. With reference to the 4 principles, what are the high risk areas and activities on an infected site?

2. What critical control points can you identify on the site?

3. What should you check for when people are entering the site?

4. What can you do to reduce the risk of contamination from the culling area within the site?
PREVENTION OF INFECTION

Viruses are invisible to the naked eye, it would be much easier if they had a color, than you could at
least see it. This is not the case. So you must to ensure that workers in the infected zone maintain their
protection at the highest possible level at all times. By making procedures easy to follow, protection
equipment comfortable to wear and suitable for the conditions you will allow workers the opportunity
for the maximum protection while on site.

Personal protection equipment (PPE) is the first line of defense in preventing viruses from entering the
human body. However, simply wearing PPE is not a guarantee, equally important is the correct use and
the correct behavior of the person wearing it. In reality, people are often reluctant to use PPE,
especially when undertaking physically demanding working in hot and humid conditions. There are
many styles and types of PPE that conform to the standards required for protection against HPAI
viruses, however not all of them are appropriate for the work carried out by first responder teams on
an infected premises. In some cases they could restrict the free movement of the user and become
uncomfortable to wear within a short period of time. Still, the proper use of PPE is one of the most
important weapons to prevent infection and people should be encouraged to use it properly by
adopting procedures that make it easier to comply. For example, people are not inclined to wear face
masks that make it difficult to breathe; masks become damp though heavy respiration and when
working inside closed poultry houses. Masks get clogged rapidly with dust making breathing difficult.
Efficient procedures must be in place to make it easy to change disposable masks regularly when their
effectiveness is reduced; otherwise, workers will remove them in order to breathe more easily. In
practice this may happen within 30 minutes.

Where resources are limited there may not be sufficient PPE available or there may be no PPE at all.
When this is the case, the question is how to create workers protection under these circumstances and
under these conditions? It is essential that operation supervisors are well trained in the risks to which
workers are exposed and can find local solutions to reduce that risk. Keep in mind that the most
important role still is to " prevent people becoming infected and to avoid the virus escaping the infected
area”.

SITE SET-UP

Going back to the original key principles:

• Protect people
• Protect animals
• Contain the virus
• Make it a single event
We need to establish a site by identifying key areas of risk and critical control points to manage the
inflow and outflow of humans and equipment. So you can hand things over the boundaries but NEVER
WALK OVER THEM.
Key principles of defining the site set-up

• Identify risk areas starting from the greatest risk

- Red area - for the people with the most risk
because they are in contact with infected birds,
this is also where the birds are housed and culling
takes place.
- Orange area – a staging area for those who are
not in direct contact with the birds. This is
where people and supplies are kept to support
the workers in contact with the birds.
- Yellow area – outer most boundary of the site
where the main gate is, the main
decontamination station – this is a transit area;
have ONLY a decontamination person and the runners in this area.
- Green area – parking and lodging area; people here control traffic and crowds. Only place you
can eat and drink, also location of the toilets.
• A transport corridor with a defined “IN” and “OUT” track, especially important when moving
disposal trucks.
• You want to stay out of the red area as long as possible and stay in the Green area as long as
possible.
• You want to keep those at greatest risk from infecting others by keeping them in the smallest area.
Intermediate decontamination points help you “clean” the workers who have been exposed to the
greatest risk and protect those workers who are not in direct contact with the birds.

MANAGING FLOW

Managing the flow into and out of the site and through the risk areas is critical. We want to get people
safely into and out of the site. One way of doing this is by establishing and enforcing proper gate
control and the use of intermediate decontamination stations within the site at the boundaries of each
risk area.

Functions of the control points and responsibilities include:

• Main Gate: Gate Officer [can be supported by assistants in a major operation]

- To track, register and check the identity of every person, vehicle and piece of equipment that
enters and exits the site.
- To check the PPE of every person entering the site.
- Enforce correct decontamination and removal of PPE of all people leaving the site.
- Enforce destruction of all disposable PPE items.
- Check and approve the cleaning and disinfection of all vehicles and equipment leaving the site.
• Red Area/Orange Area Decontamination Check Point
- Check the reasons for any person entering the Red Area, only people that need to enter are
allowed in. The Red Area leader (usually the vet) controls this point..
- Double check the PPE of any person entering the red area.
- Assist workers in the Red Area in replacing items of PPE under hygienic conditions.
- Instruct vehicle drivers not to exit their vehicles in the red area and assign a ground assistant for
vehicle operations where necessary.
Internal Control Areas

Each area has its own purpose and its own protection protocol. The size of each area depends on the
scale of the operation. For a small incident with few people involved, the Orange and Yellow areas
could be treated as one area as long as bio-security and health protection measures can be maintained.

Green Area

The Green area is set up outside the boundary of the infected premises, by the main entrance. It is a
collecting area for people who need to enter the site. Try to keep people into the Green Area for as
long as possible – you are trying to minimize exposure.

In the Green Area people are:

• Registered, assigned responsibilities and duty locations.

• “Labeled” with an appropriate X on the PPE to mark areas into which they can go.
• Instructed in the rules of the site (short and memorable) could include a handout with symbols.
• Provided with refreshments, rest areas and hygiene facilities.
Yellow Area

The Yellow Area contains the main decontamination control point for people and vehicles exiting the
site, which should be at the main gate. Depending on the size of the site, separate “inwards” and
“outwards” transport corridors should be set up for traveling through the site.

Once inside the Yellow area people should be mostly transporting supplies into the Orange area.

Orange Area

The Orange area is the center for on-site logistics and the forward staging area for equipment and
consumable supplies. Anything that enters the site will have to be cleaned, disinfected or destroyed
before it leaves, so only as much as will be needed in the operation should be brought into the Orange
area, the rest should remain in the green area. The Site Team leader/supervisor/Manager operates from
the Orange area.
Red Area

The Red area should enclose the place where the birds are being kept, the area set up for culling, and
space for birds to be loaded into disposal containers. If birds are to be disposed of on site, then the
Red Area will extend to include the disposal site. Disposal containers should be sealed before leaving
the Red Area to prevent the virus from contaminating more of the site.

Entering and Leaving the Site

Going into the site

The key elements of enforcement at each of the control area stations are:

• Safety Officer briefs people on the safety rules and agrees when rest periods will be taken.
• Ensure that all people have been to the toilet before putting on PPE and entering site.
• Registration of people going in.
• Proper check of the PPE, no jewelry.
• Register equipment and supplies.
• Decontamination of cars/vehicles/trucks going into the site.
Leaving the site

• LEAVING the RED area – Remove the gross contamination

- Full wash and disinfect done by gate keeper
- Take off apron, change respirators if/when appropriate,
- Cleans your boots and gives you shoe covers
- Sign out

IMPORTANT POINT
This decontamination point can also be used to repair or replace worn or damaged PPE for workers in
the RED zone, without having to go through the entire decontamination procedure. The
Decontamination Assistant should help the worker safely remove and replace disposable respirators at
frequent intervals

• LEAVING THE ORANGE area – second check point to remove contamination

- Bucket of disinfectant
- Check for gross contaminate
- Hand washing
• LEAVING the YELLOW – Complete decontamination!
- Taking PPE off in proper order
- Wash hands, face, etc.
- Walk through disinfectant
- Area for washing and disinfecting equipment and vehicles leaving the site

Rest Periods

Under most circumstances rest breaks where food and drink are to be taken should be made in the
Green area. This requires the complete decontamination and removal of PPE and washing of hands and
face, especially before eating, drink or smoking.

Where workers are conducting heavy physical labor, for instance catching or killing poultry, they should
be offered more frequent rest breaks where they can be offered water. It would be extremely
inefficient to remove PPE every 30 minutes just to have a drink, so procedures must be put in place to
allow drinks to be taken.

It is possible to offer water to a worker using the assistant at an internal decontamination points
between risk zones. The procedure is that the worker will not touch anything, the assistant (or buddy)
will carefully remove the face mask, then present a small bottle of water with a straw to the worker.
After drinking the assistant should replace a new face mask on the worker.
This same procedure can be used to simply replace a face mask that has become damp and difficult to
breathe through.
INSERT SITE MANAGEMENT PPT SLIDES HERE
REFERENCES AND RESOURCES

AHA (Animal Health Australia). 2005. Disease strategy: Avian influenza (version 3.1). Australian
Veterinary Emergency Plan (AUSVETPLAN), Edition 3, Primary Industries Ministerial Council, Canberra,
ACT.

CARE. 2005a. Pandemic and avian influenza. Available on the Web at:
www.careusa.org/newsroom/articles/2005/10/20051014_avianflu.pdf.
______. 2005b. How to recognize and prevent avian influenza in poultry and humans. Available on the
Web at: http://www.comminit.com/materials/ma2006/ materials-2801.html.

CDC (Centers for Disease Control). Interim Guidance for Protection of Persons Involved in U.S. Avian
Influenza Outbreak Disease Control and Eradication Activities. Updated January 14. 2006. Web at:
http://www.cdc.gov/flu/avian/professional/protect-guid.htm

ECDC (European Centre for Disease Prevention and Control). 2005. Avian influenza: Chief medical and
veterinary officers discuss guidelines for poultry sector workers. Available on the Web at:
www.ecdc.eu.int/avian_influenza.

Fauci, A. 2005. Q&A on National Public Radio, October 21, 2005. Transcript available on the Web at:
http://www.npr.org/templates/story/story.php?storyId=4969363.

OSHA (Occupational Safety and Health Administration). 2004. Safety and Health Information
Bulletins.Avian influenza: Protecting workers at risk. Available on the Web at www.osha.gov.

WHO (World Health Organization). No date. WHO interim recommendations for the protection of
persons involved in the mass slaughter of animals potentially infected with highly pathogenic avian
influenza viruses.

WHO. 2006a. Avian influenza, including Influenza A (H5N1), in humans: WHO interim infection control
guideline for health care facilities. Available on the Web at:
http://www.who.int/csr/disease/avian_influenza/guildelinestopics/en/index3.html
LIST OF REFERENCES MATERIALS IN MEMORY STICK (USB)

• Public Health and Occupational Safety Participant Manual

• AI Infection Control Guide
• CDC PPE Guidelines for Cullers
• WHO Guidelines for Cullers
INDIVIDUAL REFLECTION WORKSHEET

What 3 points do you want to remember from this session that are important to the work you’re doing
(or anticipate doing for STOP AI)?