When I graduated in 1998, we knew very little about personal protective equipment. We knew about asepsis and disinfection (making sure that we and our equipment were sterile so as not to infect an animal), but the idea that we might get a disease from an animal was not commonly discussed. We were vaccinated for “Q-Fever” and we had discussions about diseases like Brucellosis and Leptospirosis. Obviously we discussed Hendra Virus, but there had only been a single known outbreak, at Hendra in Brisbane, and at the time the method and mode of transmission was not clear. Work Health and Safety Laws, and our obligations as veterinarians, were not taught to us as graduates, and although our employers did have obligations, these were not obvious to us. We were vets, we needed to fix things, and there was some pride in “diving” into a rotten calving or post mortem, covering ourselves with rotten tissue, pus and blood. The previous generation of veterinarians (our bosses) were even taught NOT to wear gloves for post mortems, so that they could feel the ‘consistency’ of infected or diseased organs.
But in 1999, my first year as a qualified veterinarian, a friend of mine (who has now left veterinary science) went to see a sick horse in Cairns which turned out to have Hendra virus. It was an incredibly stressful experience for him and for the clients involved. That practice has now seen 4 or 5 cases, although they are predominantly a small animal clinic!
Initially, very little changed for us as veterinarians. We were becoming more aware of Hendra and sometimes when we had a really sick horse, we would wonder whether it might be a Hendra case… so we would sometimes perform post mortems with a cursory level of PPE (gloves and boots maybe). But plenty of times when a horse died suddenly, we would perform a basic post mortem and bury or burn the body without a second thought.
Then, a couple of things started to change. After the 2008 outbreak at Redlands (where a colleague died of Hendra virus), Work Health and Safety (WHS) Queensland started to ask questions of veterinarians. By this time, I was a practice owner and I had a visit from WHS Qld asking me about my post mortem kit (still no discussion about full PPE, just gloves, boots and a mask). But within a short period, it became obvious that there were two things that we had to change:
- We were legally responsible for the safety of our clients, and the Qld Government was starting to threaten veterinary practices with very large fines and prosecution in positive Hendra cases. They were now auditing practice policies and enforcing the laws that had existed for some time.
- There were many more cases, and people that I knew well had died.
About this time (2008-2010), we implemented a practice policy regarding use of PPE and specifically with respect to Hendra Virus. There was no vaccine, so we had to rely solely on the efficacy of the PPE.
Hendra virus is not an easy disease to catch, it is a labile virus and doesn’t survive well in the environment. The problem was that there was a high suspicion that the people infected in the Redlands case were infected by a horse that had not been showing clinical signs when they first examined it. And if you do get exposed and get the disease (as a colleague of mine in Rockhampton had), then there is a high chance that you will die. This is a PC4 virus, like Ebola virus in Africa.
PPE is very effective at preventing exposure, so we strongly pushed this with our veterinarians. We also know that Hendra virus can present looking like anything: a mildly unwell horse (off food), maybe colic or a respiratory case, or even a mild lameness. In Redlands, the horse wasn’t sick at all. So this meant that to comply completely, we were going to have to put PPE on multiple times per day. Correctly worn PPE is difficult to put on (yearly training is required to fulfil our legal obligations), greatly increasing time and cost to the client and to veterinarians. Inevitably, we would run the gauntlet, choosing PPE sometimes, but not other times, when really we couldn’t tell which horse was going to turn up positive for Hendra. In addition, many horses HATE personal protective equipment. It rustles and flutters, it changes the silhouette of the veterinarian and owner (WHS laws mean that we would also have to show the owner how to put on PPE correctly and provide PPE for them). Invariably, getting near the horse to do a proper clinical examination was difficult, and sometimes impossible. Having a large blue rustling, flapping object near your rear end, taking a temperature would often trigger the “flight or fight” reflexes of horses. To be honest, sometimes PPE is bloody dangerous – it’s just that it is less dangerous than being exposed to Hendra. AND, because I practice in Northern Australia, it is VERY hot. In the recent Ebola outbreak in Africa, I have read that workers wearing full PPE were only able to work for periods of 45-50 minutes at a time, yet we were regularly doing this multiple times per day and often for longer than this. It was so bad that I even complained to WHS Qld, who immediately told me that I must carry an ice vest in my car…
Recently, several prosecutions by WHS Qld of employed veterinarians have heightened our awareness of PPE and our obligations under the law. We cannot take a risk with any horse that may be a Hendra case, no matter how small the likelihood, and this means pretty much any sick horse (and this is what we do every day, all day). We have to make sure we are spending hours every year training our veterinarians and staff how to triage vaccinated and unvaccinated horses, and how to wear PPE correctly. We have to demonstrate putting on PPE, then make sure that our staff can put PPE on correctly. They need to know how to set up an Entry/Exit zone, how to talk to clients if the veterinarians suspect a Hendra case, how to communicate with the backhoe driver to bury the horse, how to provide PPE for clients and potentially exposed people.
Obviously, vaccination has to play a part in the development of our practice protocols. I still wear PPE now, but the availability of a vaccination has changed our lives as veterinarians. The first question our life partners ask us when we go off to a horse with colic in the middle of the night is: “Is it vaccinated?” They are often worried as much or even more than us. Going to a vaccinated horse with colic is like a holiday now. We wear simpler PPE, we can treat the horse however we want to (we can perform invasive treatments without dressing up in full, hot PPE and scaring the horse). Essentially we can be focused veterinarians again, not worrying about WHS in such an intense way, and are able to treat the horse correctly. Plus, it is far cheaper for the horse owner (less time needed, no extra sets of PPE), and cheaper for us.
I have had 3 particularly horrible experiences using PPE:
- The first occurred in 2009 (pre-vaccination). A horse had died in Gordonvale, and the owner demanded a post mortem. By that time, we knew a post mortem was a risky procedure in any sudden death, but we also had a narrower list of clinical signs regarding Hendra Virus (now we recognise a far greater range of clinical signs that could be Hendra virus). I performed the post mortem in about 35°C heat and 80% humidity, along with a veterinary student from Townsville. The post mortem took about 40 minutes, including sample collection. At the end of this period, I actually started to get blurred vision, and not from the sweat running down the inside of my goggles. I was able to make the shade of a tree and able to sit down and unsuited sitting down (which is completely incorrect from a WHS point of view). I was physically unwell for some time, but after a drink and some rest I was able to get up and return to work. I felt that the extreme nature of short PPE use meant that I would be very selective about when to wear PPE after this. Unfortunately, it was about this time that Qld WHS had started to audit practices and PPE wearing became the norm. However, we did stop performing post mortems in full PPE.
- The second occurred in 2015 when I was called to an unvaccinated horse with colic. There had been a couple of prosecutions initiated in Qld, so in response to this, I had started examining horses on my own without putting the clients at risk (they weren’t suiting up and helping me). This particular horse was initially recumbent and I proceeded over to him to catch and examine him. In response, the horse both tried to kick me (while taking its temperature) and then while trying to treat it with some pain relief, it reared up and struck me. I was unable to take an exclusion test. I then asked the owner to suit up in order to help me. The owner refused and said that if I did an exclusion test, he would not pay for the consultation. I left the property. It was a negative and disheartening experience – neither the client nor I ended up happy, and the animal could also not be treated correctly.
- Another example happened earlier this month when I went to examine an unvaccinated horse. This horse’s stablemate, also unvaccinated, had died suddenly. When I went to catch the horse (again, on my own, without the owner), the horse took fright and galloped off. The owner then came rushing into the paddock before I could ask her not to, and easily caught the horse, helping me greatly but also exposing herself to a potential Hendra case (it later returned a negative exclusion test).
There is a lot of discussion about the use of PPE and it is a necessary “evil”. It is hot, noisy and scary for horses. Vaccination, while not superseding the use of PPE, does greatly reduce the need for full PPE. In our practice, vaccination is by far the cheapest and easiest way to reduce the risk of Hendra virus infection.