Over the last few years I have followed the debate that has swirled around the subject of Hendra virus risk management with interest. More recently I have become alarmed, firstly by the prosecution of three equine veterinarians under the Worksafe Act and then by the way in which this action has indirectly lead to the polarisation of the entire equine community. Effectively, the recent prosecutions have put both owners of unvaccinated horses and veterinarians into a ‘no win’ situation that is harming the industry.
In writing, it is not my intention to tell anyone what they should do, rather I hope to provide many readers with ‘some food for thought’ by addressing some of the issues I repeatedly hear raised by horse owners and veterinarians on both sides of the debate, namely vaccination safety, the use of PPE and a veterinarian’s liability in the event of a positive Hendra case.
If we don’t all make more effort to keep an open mind, respect each other’s point of view and then reach some common ground I fear that permanent damage will be done to the wonderful relationship that the equine community and equine veterinarians have both thus far benefited from.
To put my comments into context I would first like readers to consider three key points that I will quote directly from the Queensland Government’s Hendra Virus Infection Prevention Advice: https://www.health.qld.gov.au/ph/documents/cdb/hev-inf-prev-adv.pdf
1. “The Hendra vaccine is the single most effective way of reducing the risk of Hendra virus infection in horses and provides a work health and safety and public health benefit by the vaccine's ability to not only protect horses from infection but also to break the cycle of virus transmission from horses to humans. Widespread uptake of the horse vaccine has the potential to significantly reduce the number and risk of human exposures.” (Page 24)
2. When treating a sick unvaccinated horse, “If HeV cannot be ruled out as a diagnosis, risk controls should be implemented before anyone contacts a sick horse, not after initial examination.” (Page 24)
3. When treating an unvaccinated sick horse “Veterinarians should consider restricting high risk veterinary procedures to those necessary to obtain (exclusion test) samples and /or provide immediate treatment and attend to the horse’s welfare. (antibiotics/pain relief etc.) Veterinarians should AVOID high risk procedures that have potential to result in high level of exposure to the horse’s blood, respiratory fluids, tissues and other body fluids. “ (Pages 26 and 27)
The first issue raised in the Hendra vaccination debate centred on the safety of the Hendra vaccination.
1. From the outset I think it is important to clarify exactly what is meant by ‘safety’. When injecting any foreign material into a horse be it a vitamin, drug or vaccine one can expect a certain number of reactions, however this does not mean any given product is not ‘safe’.
2. All new vaccinations when they are first introduced have a requirement for veterinarians and owners to report all reactions to the Australian Pesticide and Veterinary Medicine Authority (AVPMA) a wholly independent government body. These reports are investigated, analysed and compared with those for similar vaccinations on the market and a decision is made one way or another with regard to safety.
3. Following the administration of over 367,759 doses of the Hendra vaccine, the AVPMA has recently completed a detailed assessment of the Hendra vaccine and found it to be generally safe and effective against the Hendra virus thus granting it full registration. The official government APVMA website has this to say about the ‘safety health and side effects’ of the Hendra vaccine. “The approved label lists potential side effects, including: * swelling and soreness at the site of vaccination * increase in body temperature * lethargy * loss of appetite * muscle stiffness and swelling in the joints (oedema) * skin rashes (urticaria) * colic. These symptoms are generally short-lived and are typical of many vaccines. As with all vaccines, side effect symptoms may vary in severity and on some occasions may require veterinary intervention. Although some side effects may be expected, it is important that people who observe an adverse effect report them to the veterinarian who administered the vaccine, the registration holder, or the APVMA.”
4. Despite the recent full registration of the Hendra vaccine, opinion about its safety remains divided with many owners claiming that their horses have experienced a much higher than normal range of reactions that were in some cases serious.
5. The equine industry as a whole and veterinarians in particular should remember that these owners have a right to be heard and their claims investigated further by an independent body to put the matter to rest for once and for all one way or another.
6. Horse owners also need to remember that they always could and still can report any adverse reactions to the Hendra vaccine to the APVMA for investigation. The AVPMA is a government body independent of both the manufacturer and veterinary community and they are obliged to investigate all reports.
7. There are also a number of initiatives underway at the parliamentary level intended to address the safety issue.
More recently a great deal of emotion has erupted on both sides of the debate about whether or not veterinarian practices are justified in adopting a policy of no longer treating unvaccinated horses.
1. Many horse owners feel that it is a veterinary practice’s moral and ethical responsibility to attend to all horses. This is not the case. For example if a client becomes a bad debtor the practice is not obliged to keep them as a client.
2. If a veterinary practice advises a client that they should vaccinate their horses against Hendra in the interest of their own safety, their horses safety and the safety of any veterinary personal who attend to the horse and the client chooses not to follow this advice, then the veterinary practice is under no obligation to keep them as a client. The practice should respect the client’s right not to vaccinate their horses and in return the client should respect the right of any veterinary practice not to continue treating their unvaccinated horses.
3. Some people say that this initiative is ‘just a money making exercise’. However, veterinary practices are in the business of taking care of horses so why would any one of them suddenly choose to take this course of action, which reduces the number of clients they can service and horses they can treat and is guaranteed to be damaging to their business? And why would so many suddenly choose to do it now, when the vaccine has been available for a number of years?
4. The recent prosecution of three vets under the Worksafe Act has made it clear that Work Place Health and Safety intend to hold the veterinary profession responsible for the personal safety of horse owners and anyone else who comes into contact with a sick horse in a positive Hendra virus case, even when the those same owners have chosen to ignore the professions advice to vaccinate their horses.
5. After talking to many veterinarians it is apparent that the sudden and relatively wide spread decision of many practices not to treat unvaccinated horses anymore comes down to a question of perceived risk. For many practices, the recently increased risk of prosecution under the Worksafe Act is simply one risk too far. Horse owners need to better understand all the potential risks that are involved when treating sick unvaccinated horses (even in full PPE) and then respect the right of any veterinary practice to make its own decisions.
6. I will address the issue of whether or not veterinarians can or should continue to treat all unvaccinated horses indefinitely with the use of full PPE later, suffice to say here and now that whilst PPE reduces the risk of exposure to the virus, it does not eliminate it all together.
7. For horse owners, the chance of their horse being exposed to Hendra virus has and will remain very, very small. For the veterinary profession, who carry out invasive procedures on sick horses every single day, week on week, month after month, year on year, the chance of eventually treating an infected horse and being exposed to all the attendant risks is exponentially higher.
8. As a business, all veterinary practices have a legal obligation to provide a safe working environment for all their staff. The recent prosecutions, carried out under the Worksafe Act have made it very difficult for any employer to guarantee the safety of their employees, even if they are wearing full PPE (see later). Therefore the easiest and most efficient way any veterinary practice owner can protect themselves and their staff from prosecution is to stop treating unvaccinated horses.
The question of whether or not all veterinarians can/should continue treating sick unvaccinated horses with the aid of full PPE is another prominent topic for debate.
This subject encompasses two very different issues which I will deal with separately:
A. The welfare of horses
1. First and foremost it is important to remember that 93 horses have either died or been put down as a result of Hendra virus and wearing full PPE to examine such horses will not save their lives, where a vaccination would have.
2. Even if all other sick unvaccinated horses were attended to by veterinarians wearing full PPE, there still remains a massive welfare issue surrounding these horses. Under the terms of the Queensland Governments Hendra Virus Infection Prevention Advise such horses cannot receive invasive diagnostic services or prompt and appropriate treatment until such time as a Hendra virus exclusion test has been performed.
3. Given that the Queensland Biosecurity Science Laboratory is closed over the week-end, such results can take anything from one four days to complete. As a result many horses are being forced to suffer and their condition deteriorate significantly whilst awaiting a result. The cost of eventual treatment for most owners inevitably increases significantly over time and in the very worst case scenario, horses are dying before appropriate treatment can be implemented.
4. In summary, the only way the welfare of all horses can be protected and veterinarians can ensure that their clients can be promptly and appropriately treated at all times is for owners to keep their horse’s Hendra vaccinations up to date.
B. The safety of veterinarians working in full PPE
1. Workplace Heath and Safety and Biosecurity Queensland have produced a comprehensive array of guidelines requiring the use of full PPE when working with sick unvaccinated horses which are aimed at keeping all personal attending to such horses safe from exposure to Hendra virus.
2. What they have failed to take into account is that in so doing, they have inadvertently made the everyday working environment for all equine veterinarians examining sick unvaccinated horses significantly LESS safe.
3. Veterinarians fall into one of the highest risk categories for income protection insurance of all professions. This is for a very good reason. On a daily basis they deal with considerable:
* Horses are very large strong and flighty animals.
* When sick, injured or in pain they are significantly more difficult to handle.
* Further, when examining sick horses veterinarians are required to perform many procedures that horses don’t like, including the use of needles to take test samples.
* The risk of severe injury to an equine practitioner from a horse’s strike, bite or kick is ever present, of serious concern and the reason for our high insurance premiums.
4. Veterinarians deal with this risk daily by being very observant and ‘in tune’ with their whole environment. They listen for any change in a horse’s respiration, they watch out for the flick of an ear, they detect any shift in weight that might precede a strike or a kick. They have to have eyes in the back of their head and they are sure footed with very, very fast reflexes.
5. In contrast full PPE has been designed specifically to isolate the wearer and thoroughly shield him from his environment. The wearer’s ears are covered by a hood, peripheral vision is obscured by goggles, movement is restricted by a double layer of clothes, sensitivity to touch is reduced by double gloves and the wearer’s balance and speed of reaction is severely hampered by wearing wellington boots.
6. Add to this the fact that an already stressed horse will be further panicked when approached by something virtually unrecognisable as human and the risks increase even further.
7. Whilst the use of full PPE when treating a wide range of sick horses on a daily basis may seem like the answer because it protects vets from the possible but very low risk of exposure to Hendra virus, it must be noted that PPE significantly increases the risk of an equine veterinarian suffering a serious or even fatal accident at work.
8. Many equine vets don’t feel comfortable taking on this additional risk on a daily basis indefinitely, so are therefore now only willing to treat vaccinated horses.
Biosecurity Queensland and Workplace Health and Safety must be accountable for the welfare issues they have created for horses and the additional risks they have imposed upon the equine veterinary profession by introducing these guidelines without also supporting a mandatory vaccination policy. A study should be undertaken to ascertain whether the benefits of enforcing their guidelines out way the serious consequences.
The subject of the veterinary prosecutions is closely linked to the liability veterinarians are now forced to face when they agree to be the ‘vet on call’ at any ‘unvaccinated’ equestrian event.
1. Under the current guidelines, if a veterinarian is on call at an equestrian event and there is a possible case of Hendra virus infection in an unvaccinated horse, the veterinarian automatically becomes responsible for the safety of every other horse and rider at the show (unless the event organisers have agreed in writing to absolve the vet of this responsibility and take it on themselves, which very few do.)
2. Given the frequent interaction between horses, owners and the general public at these events, realistically a situation like this can be virtually impossible to control. Yet if the vet fails to protect the health and safety of everyone at the ‘unvaccinated’ event, he can now be charged with a criminal offence.
3. This liability, and not the desire to force people to vaccinate, is the fundamental reason why so many veterinarians are no longer prepared to be ‘vet on call’ at an unvaccinated show.
4. This state of affairs is having a hugely negative impact on the good relations event organisers and equine veterinarians have historically held and it is resulting in the cancellation of many shows. This issue also needs to be urgently addressed.
The higher cost of the Hendra vaccination has been questioned and Zoetis have been accused of deliberately gouging the equine community. So, while reiterating that I have no links with Zoetis, I would like to make the following observations.
1. Hendra virus has only been diagnosed in a relatively narrow strip along the eastern seaboard of just two sates in the relatively sparsely populated country of Australia. As a result the market for the vaccine is remarkably small.
2. In contrast, because Hendra virus is potentially fatal to humans the costs of developing and then testing the Hendra vaccine have been considerably higher than for most other vaccines on the market.
3. The ability for Zoetis to recover their enhanced research and development costs in such a small market is reduced and this has meant that the vaccine must inevitably cost more.
4. Zoetis is a large multinational company selling multiple different vaccines to hundreds of different counties worldwide. So, far from Zoetis benefitting enormously from the miniscual sales of Hendra vaccinations here, I think Australia has benefitted enormously from a multinational company that has put all their international resources into developing a vaccination that will keep our tiny population of horses, horse owners and vets safe in Australia.
5. Whether a person chooses to use the vaccine or not is up to them, but if they don’t, I believe that they and not veterinarians, should be held responsible for the consequences.
Looking to the future
1. It is important for the equine community in Queensland to consider their long term future when criticising the veterinary profession for not wishing to work in full PPE on a daily basis, risking their lives and fearing prosecution while attending to their sick unvaccinated horses. Three vets have died and three have been prosecuted and that is enough.
2. Just as owners strongly defend their right to choose, so veterinarians also have a choice about where they work and Queensland has already lost many valuable and experienced equine practitioners to other states because the vets have expressed a preference not to risk their lives and livelihoods by working in a Hendra endemic area on unvaccinated horses.
3. Equine veterinary practices in high risk Hendra areas are finding it harder and harder to recruit and retain experienced staff. One of the first questions a new job applicant or recent graduate will ask is, ‘Is your practice in a Hendra endemic area?’ The second question they will ask is’ ‘Does your practice have a Hendra vaccination only policy?’ Given a choice most veterinarians will select the best job they can find in a ‘Vaccination only clinic’ or ‘Hendra free area’.
4. The prosecution of veterinarians under the Worksafe Act for failing to adequately protect horse owners who acted against their vets advice and chose not to vaccinate their horses, has only added to this brain drain. Why would the best veterinarians, with the ‘pick of the jobs’ choose to risk their lives and livelihoods by working in Hendra endemic areas on unvaccinated horses?
5. If the equine industry in Queensland wishes to remain competitive and retain the high quality veterinary services that it has enjoyed thus far, it must give consideration to this brain drain when formulating future policy. Instead of criticising and blaming their veterinarians, please listen to what they are saying and be prepared to work together.
Thank you for your time and consideration.
Carol Smith B.Vet.Med.