Live bird markets can become contaminated with and become a source of transmission for avian influenza viruses including the highly pathogenic H5N1 strain. Many countries affected by the H5N1-virus have limited resources for programs in environmental health, sanitation and disease control in live bird markets. This study proposes five critical control points (CCPs) to reduce the risk of H5N1-virus contamination in markets in low resource settings. The CCPs were developed based on three surveys conducted in Indonesia: a cross-sectional survey in 119 markets, a knowledge, attitudes and practice survey in 3 markets and a microbiological survey in 83 markets. These surveys assessed poultry workflow, market infrastructure, hygiene and regulatory practices and microbiological contamination with the H5N1-virus. The five CCPs identified were (1) reducing risk of receiving infected birds into the market, (2) reducing the risk of virus spread between different bird flocks in holding cages, (3) reducing surface contamination by isolating slaughter processes from other poultry-related processes, (4) minimizing the potential for contamination during evisceration of carcasses and (5) reducing the risk of surface contamination in the sale zone of the market. To be relevant for low resource settings, the CCPs do not necessitate large infrastructure changes. The CCPs are suited for markets that slaughter poultry and have capacity for daily disposal and removal of solid waste from the market. However, it is envisaged that the CCPs can be adapted for the development of risk-based programs in various settings.
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