On a recent Monday morning, workers embarked on their week at a large poultry farm in Franklin County, Washington. Home to over 800,000 chickens, by the end of the day, avian flu was detected among some of these chickens. By the end of the week, four workers fell ill with the disease, which had only infected a few others in the U.S. After two more days of testing by the Benton Franklin Health District, another 10 workers at the farm tested positive. This outbreak, initially detected on October 14, marked the first human cases of avian flu in the Pacific Northwest this year. The first human case in Oregon was confirmed on November 15, adding to the evidence of the flu spreading to farmworker populations across the Western U.S. However, efforts to test and monitor the disease among workers are sporadic and inconsistent, leaving the responsibility on the laborers themselves, many of whom are undocumented and can't afford to take time off if they test positive.

Urgency to Limit Spread

The virus is spreading rapidly among cows and chickens, raising concerns among epidemiologists that it could merge with the regular flu and cause a pandemic. Regular testing helps health officials better understand how the virus is transmitted and how to protect workers. Without it, dozens of positive workers could go undetected, handling symptoms on their own. "The gold standard for public health is to be able to respond, do surveillance and understand what's happening," said Amy Liebman, chief program officer of workers, environment and climate for Migrant Clinicians Network. "If we don't know these things are happening, it's very hard to respond."

Testing Disparities

In Idaho, which has the most cases among livestock in the region, only seven human tests have been conducted, and officials aren't gathering information about workers on farms with animal outbreaks. In contrast, Washington has tested 77 people, all associated with the Franklin County farm, and Oregon has tested 33, both gathering information about exposed workers. Washington and Oregon are two of six states where humans have tested positive for avian flu, but infectious disease researchers suspect there are many more unreported cases due to lack of testing.

Impact on Farmworkers

Farmworker advocates and public health experts say there is a vast undercount of human avian flu cases. Past protocols in transmissible illness outbreaks include contact tracing, but Idaho public health districts aren't doing it yet. In Idaho, it's up to individual employers to encourage workers to be tested. Rick Naerebout of the Idaho Dairymen's Association said there are reservations among workers due to their legal status. Liebman said undocumented migrants don't need to provide their immigration status for flu shots or healthcare. In the Franklin County outbreak, health district staff spoke with farm owners and tested workers at clinics.

Surveillance and Testing

Liebman said surveillance is crucial for understanding how people are exposed to the illness. Public health staff should regularly contact local private healthcare providers and workers. Clinicians cite Colorado as a state that effectively responds to outbreaks by testing workers. But Liebman said even asymptomatic exposed workers should be tested. Dillon said Idaho workers are given protective equipment and that's sufficient. Jonathan Modie of the Oregon Health Authority said they reserve testing for symptomatic or high-risk exposed people. Lang said the Washington Department of Health is clarifying CDC guidelines before implementing more testing.

Human Cases and Mortality

So far, human cases of avian flu have been mild, with mild respiratory symptoms and conjunctivitis. But in 2003, there was a high fatality rate. Amber Betts said early signs of avian flu in poultry include lethargy and confusion, and in dairy operations, a significant drop in milk production. Once a farm has a positive test, it has to stop operations and sanitize. There are no payments to farm owners if workers contract avian flu and take time off. All recorded human cases except one came from farmworkers who worked with infected animals.

Worker Health and Safety

Liebman thinks the public health response to avian flu should learn from the COVID-19 pandemic. Workers can't afford to have a positive test and may hide symptoms to continue working. Community health workers who speak Spanish and understand workers' hesitancy are important. "You have to understand the risk a worker takes to work here is significant, and their priority is to stay employed," she said.