Mendez, Diana Hélène (2015) Identifying and understanding the factors affecting infection control and Hendra virus risk management in private veterinary practices in Queensland, Australia. PhD thesis, James Cook University.

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Abstract

Background: Infection control (IC) is a universal health care principle. Its main aim is to prevent the transmission of infectious diseases in healthcare settings and the wider community. Failure to implement IC adequately can result in nosocomial diseases; healthcare-associated infections. Despite the evidence-based knowledge, IC gold standards are often not met in medical healthcare, with the added burden of managing nosocomial diseases in patients and healthcare workers. Similar observations have been made in the animal healthcare sector where IC is generally reported to be of a poor standard.

Although IC principles apply equally to both human and animal healthcare, the concept of IC is less well defined in the veterinary field where the terminology referring to IC is often inconsistent. Furthermore, veterinary IC practices have been less scrutinised than those in healthcare settings, and veterinary IC often appears to be benchmarked against standards of its medical counterparts. However, unlike the healthcare sector, the veterinary workforce is, for the most part, based in private practice. Thus the context in which medical and veterinary IC strategies are applied differ significantly in terms of practitioner-patient relationship, communication, and quality of work environment, as well as legal and financial structure of service delivery. It is therefore questionable whether veterinary IC standards can be evaluated against medical standards. Furthermore, despite relevant government departments and veterinary professional peak bodies providing IC guidelines, the implementation of veterinary IC is mostly left to the discretion of individual practices and individual staff; hence, there is a wide variation between IC standards adopted across veterinary practices. This lack of cohesion in IC standards within the veterinary workforce may prevent the overhaul of veterinary IC. Notwithstanding, most reports that concluded veterinary IC was generally suboptimal failed to provide an explanation or make specific recommendations about ways to improve veterinary IC standards.

From biosecurity, public health, and occupational health and safety perspectives, veterinary IC is of particular significance when managing zoonoses, which are infectious diseases transmissible from vertebrate animals to humans. Veterinarians are considered experts in the management of zoonoses and are also at a higher occupational risk of becoming infected with these diseases than other health professionals. Moreover, the majority of emerging infectious diseases are zoonotic in nature, and thus veterinarians are likely to be at an increased risk of exposure to unknown zoonoses in the future; hence the necessity to investigate and improve veterinary IC standards. Improving veterinary IC became an imperative in Australia after the emergence of a new zoonosis, Hendra virus (HeV). When managing zoonoses, veterinarians are not only considered the animal health experts but also have occupational health and safety responsibilities towards their clients, staff and themselves. When HeV first emerged it was assumed that veterinarians would implement the appropriate IC strategies to prevent transmission of HeV from horses to humans. However, the first 13 outbreaks, between 1994 and 2009, led to seven people becoming infected; four of whom subsequently died. Those infected were either veterinary staff or assisting veterinary staff (5/7), or people working in the horse industry (2/7). Knowledge about veterinary IC principles and strategies did not appear to prompt veterinary staff to take the necessary safety precautions. Consequently, the drivers of veterinary IC and HeV management were brought into question. Hence the overarching aims of this thesis were to identify and understand the factors affecting IC and HeV management in the particular context of private veterinary practices in Queensland, Australia.

Methodology: The drivers of veterinary IC behaviours have seldom been studied in-depth. Prior to 2009, the majority of studies that examined veterinary IC, quantified IC choices and outcomes without further insight. Qualitative methodologies are routinely used to study the perceptions about IC and related risks and the reasons the behaviours of healthcare workers. A mixed methods approach was chosen to investigate and understand the factors affecting veterinary IC and the management of zoonoses such as HeV. This thesis comprises four sequential studies.

Study 1 was qualitative and explored the perceived barriers to HeV management and related IC issues in equine veterinary practices in Queensland, Australia. It consisted of a series of semi-structured in-depth interviews with 21 veterinary staff from 14 veterinary practices located within the distribution range of HeV; eastern coast of Australia between Far North and South-East Queensland. The interviews were conducted between December 2009 and September 2010.

Studies 2 and 3 were cross-sectional studies conducted concomitantly between June and September 2011. Both consisted of postal surveys. Study 2 targeted equine veterinarians in Queensland and examined the veterinarians' HeV-related risk perceptions, HeV management practices and the effect the introduction of a HeV vaccine would have on their future management of HeV. Study 3 targeted all private veterinarians in Queensland and examined the veterinarians' zoonotic risk perceptions and IC habits in relation to specific zoonotic risks.

Study 4 was also a cross-sectional study conducted in December 2013. It consisted of an online survey and targeted final year veterinary students from James Cook University in Queensland. The aim of this study was to investigate zoonotic risk perceptions and IC knowledge among final year veterinary students, as well as their experiences of IC implementation in private veterinary practices during their extramural placements.

Results: The results from Study1 showed that some of the issues surrounding the implementation of veterinary IC were specific to the emergence of HeV, while others were associated with a number of factors relating to the veterinary work culture and the service delivery business model of private practices. Veterinarians reported they felt unprepared to manage the unpredictable event that is a slowly emerging zoonosis such as HeV. Their management of HeV was further hindered by the lack of responsiveness and support from relevant government authorities and the communication issues with associated stakeholders, such as local representatives of government departments in charge of biosecurity and health and safety, diagnostic laboratories and horse owners. In some cases, managing a potential outbreak of HeV became untenable for private practices and they ceased providing veterinary services for equine patients due to the added cost and time it required, as well as the associated issues of liability and business reputation.

The findings from Study 1 also highlighted the importance of other factors associated with the implementation of veterinary IC: low prioritization of zoonotic risks compared to other risks, such as risk of physical injury; poor IC work culture; poor professional IC mentorship; and operating a private business. Overall, participants agreed that veterinary IC required improvement but warned that it would take time.

Study 2 confirmed that some veterinarians had moved towards improving their IC and HeV management strategies. When HeV was suspected, those who were most concerned about the HeV-related risks and had had previous experience with HeV management were more likely to use more personal protective equipment. Having attended HeV management training on the other hand did not increase the level of precautions taken by veterinarians who suspected HeV in a horse. The introduction of a HeV vaccine for horses was not perceived as an alternative strategy to maintaining IC and many participants anticipated that they would require the horses they examined in the future to be vaccinated. Findings from Study 2 confirmed results from Study 1, which highlighted the issues associated with communicating about HeV-related risks and risk mitigation strategies with horse owners. These issues included: communication skills of veterinarians; clients' ability to understand veterinarians' messages; mismatch between veterinarians' motivations and clients' expectations; clients' perception of veterinarians' role; and difficulties communicating in a "crisis" situation.

Study 3 confirmed that veterinarians' perceptions of zoonotic risks affected their IC practices but not proportionally, with high levels of risk perception not guaranteeing the implementation of the highest level of IC. Veterinarians who were highly concerned about HeV were more likely to use a mask when examining horses but those who were equally concerned about Australian bat lyssavirus did not seek immunization with the cross-protective rabies vaccine. Moreover, veterinarians who worked in a practice with leadership in IC were more likely to use masks. However, IC leadership did not affect the rates of sharps injuries among veterinarians.

Results from Study 4 showed that final year veterinary students who were about to enter the workforce could assess zoonotic risks appropriately, but ranked the risk of injury higher than the risk of infection with a zoonosis. Notwithstanding, students considered IC measures as very important and had a sound knowledge of IC principles. However, they reported that there were discrepancies between their undergraduate IC training and their IC experiences during extramural placements in private practice. Some students remarked that this led them to follow substandard IC measures in order to receive approval from their professional mentors and conform to a professional identity. The transition of veterinary graduates into the workforce may be a crucial point when IC standards learnt at university are lowered and consequently poor IC work culture among veterinarians is entrenched.

Outcomes: This research has identified the many challenges faced by private veterinarians when implementing IC and managing an emerging zoonosis such as HeV. Veterinarians, associated government departments and professional peak bodies need to be better prepared to mitigate emerging zoonotic risks. Improving veterinary IC will help build the necessary capacity to manage such events as well as infectious risks encountered routinely in veterinary practice. The development and universal dissemination of evidence-based and context specific veterinary IC control gold standards would benefit the veterinary profession. This would require: further investigation into veterinary IC practices within a range of veterinary work environments and scenarios; greater communication, consultation and collaboration between veterinarians, government, professional peak bodies and relevant community groups.

Traditionally, the veterinary work culture has to a great extent helped to ignore the risk of veterinarians becoming infected with a zoonosis and consequently has not prioritised the implementation of IC measures to prevent exposure to zoonotic risks. Therefore, improving veterinary IC will also require a paradigm shift in work culture. Since the perception of zoonotic risks appears to determine risk mitigation strategies, the significance of such risks need to be reiterated and highlighted along with the relevant, most appropriate IC strategies that should be implemented to manage these risks. Leadership in IC also needs to be promoted across all veterinary practices. A clear commitment to uphold high IC standards at the practice level will encourage individuals to use best IC practices and help improve the existing poor veterinary IC culture.

Veterinary IC is one of the major strategies workplace health and safety authorities expect veterinarians to implement at the highest possible standard. Failing to meet this expectation could have legal repercussions for private veterinarians if it leads to staff, clients or themselves becoming infected with a zoonosis. The link between veterinary IC and the legal requirements of occupational health and safety should be emphasised with a focus on "human-safety" for all those interacting in the veterinary work environment.

Although a number of recommendations made in this thesis targeted existing veterinarians, it appeared that the most effective way of improving veterinary IC may be to target veterinary students about to enter the workforce. Academic educators, veterinary mentors and professional peak bodies need to collaborate more closely in order to deliver a high level of IC knowledge and skills in early career veterinarians to provide them with the confidence to maintain the highest possible IC standards throughout their career.

Unless veterinary IC improves, veterinarians are likely to be confronted once more with issues similar to those they experienced during the emergence of HeV. With the rise in zoonotic emerging diseases, biosecurity and public health systems are increasingly recognising the necessity for a One Health approach to human and animal health. Veterinarians are likely to be key players in One Health as they are used to managing infectious diseases affecting multiple species, including humans. As such, the role of veterinarians should be more widely acknowledged and supported, and the veterinary profession should be more closely involved in biosecurity and public health decisions, policies, and the management of zoonoses.

Item ID:	47463
Item Type:	Thesis (PhD)
Keywords:	Australian bat lyssavirus, behavioural change, biosecurity, continuing professional education, emerging infectious disease, emerging zoonoses, health and safety, Hendra virus, horse owners, horses, infection control, laboratory diagnosis, management, One Health, personal protective equipment, Queensland, rabies vaccine, risk communication, vaccines, veterinarians, veterinary students, workplace health and safety, zoonoses
Related URLs:	https://researchonline.jcu.edu.au/20283/ https://researchonline.jcu.edu.au/31706/ https://researchonline.jcu.edu.au/35457/ https://researchonline.jcu.edu.au/31717/ https://researchonline.jcu.edu.au/37477/ https://researchonline.jcu.edu.au/50429/
Additional Information:	For this thesis, Diana Mendez received the Dean's Award for Excellence 2017. Publications arising from this thesis are available from the Related URLs field. The publications are: Chapter 3: Mendez, Diana H., Judd, Jenni, and Speare, Rick (2012) Unexpected result of Hendra virus outbreaks for veterinarians, Queensland, Australia. Emerging Infectious Diseases, 18 (1). pp. 83-85. Chapter 3: Mendez, D., Judd, J., and Speare, R. (2013) Testing for Hendra virus: difficulties experienced by veterinarians in Queensland prior to 2011. Australian Veterinary Journal, 91 (8). pp. 323-327. Chapter 3: Mendez, Diana H., Kelly, Jenny, Buttner, Petra, Nowak, Madeleine, and Speare, Rick (2014) Management of the slowly emerging zoonosis, Hendra virus, by private veterinarians in Queensland, Australia: a qualitative study. BMC Veterinary Research, 10. pp. 1-14. Chapter 4: Mendez, D., Büttner, P., and Speare, R. (2013) Response of Australian veterinarians to the announcement of a Hendra virus vaccine becoming available. Australian Veterinary Journal, 91 (8). pp. 328-331. Chapter 4: Mendez, Diana, Buttner, Petra, and Speare, Rick (2014) Hendra virus in Queensland, Australia, during the winter of 2011: veterinarians on the path to better management strategies. Preventive Veterinary Medicine, 117 (1). pp. 40-51. Chapter 5: Mendez, Diana H., Büttner, Petra, Kelly, Jenny, Nowak, Madeleine, and Speare, Rick (2017) Difficulties experienced by veterinarians when communicating about emerging zoonotic risks with animal owners: the case of Hendra virus. BMC Veterinary Research, 13. pp. 1-12.
Date Deposited:	27 Sep 2017 03:41
FoR Codes:	11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111799 Public Health and Health Services not elsewhere classified @ 60% 07 AGRICULTURAL AND VETERINARY SCIENCES > 0707 Veterinary Sciences > 070799 Veterinary Sciences not elsewhere classified @ 20% 07 AGRICULTURAL AND VETERINARY SCIENCES > 0707 Veterinary Sciences > 070704 Veterinary Epidemiology @ 20%
SEO Codes:	92 HEALTH > 9204 Public Health (excl. Specific Population Health) > 920407 Health Protection and/or Disaster Response @ 60% 92 HEALTH > 9204 Public Health (excl. Specific Population Health) > 920499 Public Health (excl. Specific Population Health) not elsewhere classified @ 40%
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