Owner awareness, knowledge and understanding of equine infectious diseases in Choluteca, Honduras.

Kirsten Anderson Introduction Working equids play a vital role in the livelihoods of the people of Honduras. 62.5% of the country’s population lives below the poverty line and around 4 million people living in remote communities depend on horses, donkeys and mules for transportation of people, food, water and firewood, and agricultural work (World Bank, 2013; World Horse Welfare, 2015). These animals are crucial in helping to alleviate poverty, promote mobility and ensure food security in one of the world’s poorest countries.

Horse owner preparing cart filled with water containers in San Lorenzo

Infectious disease poses a major threat to equine health, welfare and performance worldwide. This burden is most severe in developing countries due to a lack of education and access to affordable and available treatment and advice (Stringer, 2014). In addition to their impact on working equids, these diseases have both direct and indirect effects on human health and wellbeing. The associated reduction in equine productivity caused by infectious disease can have a devastating economic impact on horse owners and the people they supply goods and services to.!Additionally, many important equine diseases are infectious to humans. It is estimated that zoonoses account for over 60% of infectious diseases affecting humans, resulting in a significant risk of debilitating or fatal disease to people working with and living near horses (Morse, 1995).

Owner knowledge and education are important factors in disease control and prevention. World Horse Welfare’s disease education programme aims to inform owners about how to identify and reduce the risk of important infectious diseases in their horses. The objective of this study was to assess and compare the level of awareness, local knowledge and management practices of horse owners within and outwith the programme in the study area of Choluteca, Honduras. Hopefully, the results will assess the efficacy of the programme and enable the development of effective disease surveillance and control guidelines, ultimately improving the welfare and livelihoods of working equids and their owners. !

Horse owners rely heavily on their animals in Honduras

Method Study area and population The study was conducted at 16 community visits in the Choluteca department of Honduras. Ten of those - El Fantasioso, El Palenque, Los Humos du Suyapa, La Fortunita, El Carrizo, San Jose de la Landa, Las Piletas, Barrio Santo Lucia, Los Colorados and El Palomar - were from within World Horse Welfare’s community programme. Six - San Lorenzo, Colonia Williams, Tierra Hueca, Majares, La Pitas and Guasaule - were new to the charity’s programme. Study design and data collection A semi-structured open-ended questionnaire was developed to assess awareness, perceptions and knowledge of infectious diseases of equids in Choluteca, Honduras. This technique was used to gather information on diseases owners thought their horse was at risk of, the clinical signs of each disease in the horse, transmission routes, zoonotic potential and any preventative measures or treatments that had been undertaken. Another focus of the questionnaire was to gather sociodemographic information about the participants in order to better describe the population of horse owners and their needs in the area.

Conducting an interview with a horse owner

Results Sociodemographic characteristics of participants In total, 130 horse owners participated in the questionnaire; 84 of these were from within World Horse Welfare’s existing community programme and 46 were from new communities with no previous involvement with the charity. 23% (n=84) of the participants from the existing communities were female and 77% (n=84) were male. From the new communities, 9% (n=46) were female and 91% (n=46) were male. In the existing communities, 70% of participants were educated to primary school level, 6% to high school and 24% (n=84) had received no formal education. This is compared to 67% of owners in the new communities educated at primary school, with 16% and 17% (n=46) at high school and without education, respectively, shown in Figure 1. The main source of income for owners in both sets of communities was predominantly agriculture (37/35%), as well as selling wood (24/28%) and water (0/13%). Average income is $200/month and $172/month for the existing and new communities respectively, with both groups working an average of 6.75 hours/day. 86% of participants from the existing communities also owned other animals; mainly cows, chickens and pigs, as well as dogs and cats, which were commonly kept near or with horses. 100% of owners from the new communities owned other livestock.

Fig. 1. Level of education of horse owners in the communities

Information about horses and their work The main uses for working equids in the region are shown in Figure 2. Important roles were carrying firewood (67% in the existing communities compared to 43% in the new group), working with cattle (13/15%), carrying water (6/15%) and transport (6/9%). Other uses included carrying construction materials and crops. Horses travel a daily distance ranging from 0.5-30km, with a mean of 5.2km in the existing communities and 7.5km in the new group. Animals were generally purchased or gifted from a local source within the community; just 8% were from outwith a radius of 4km. 69% of owners from the existing communities stated that their animal was regularly in contact with other horses, while 91% of new owners agreed with this statement. Fig. 2. Distribution of horses across their different roles in the community

Diseases reported by respondents In total, participants identified ten infectious diseases affecting equids, shown in Fig.3. Venezuelan Equine Encephalitis (VEE), Vesicular Stomatitis (VS), rabies, tetanus and Streptococcus equi (strangles) were the most commonly mentioned. Two infectious diseases that do not affect horses in actuality (Chikungunya and blackleg) were also reported, as participants believed equids were susceptible to the causative pathogens, but have not been included in the analysis.

Fig. 3. Community awareness of equine infectious diseases

VEE Venezuelan equine encephalitis is a potentially fatal zoonotic viral disease transmitted by mosquito vectors. Clinical signs in the horse range from mild (depression, anorexia) to severe neurological symptoms including incoordination, excitability and seizures. Of the horse owners that were aware of VEE in the existing communities (n=58), 12% stated that depression was the major clinical symptom, 9% incoordination, 5% inappetance with weight loss and 2% collapse. 5% thought that a cough was the major clinical symptom and 3.5% associated VEE with colic. 63% did not know how to recognise VEE in their horse. When asked about the transmission route of VEE, only 5% correctly identified mosquitoes as the vector. 15.5% suggested that their horse might be infected by the airborne route and 8% by direct contact with an infected horse. Others thought that infection could be spread through water and via shared syringes and 51% did not know how their horse could contract VEE. 35% correctly identified VEE as a zoonotic disease. In the new communities (n=11), 36% correctly associated VEE with incoordination, 27% with hyperexcitability and 16% with collapse, but 64% could not name any clinical symptoms. No participant could correctly identify how the disease was transmitted to horses and no one identified it as a zoonosis. Vesicular stomatitis This viral disease causes sloughing lesions at the coronary band that cause severe lameness, as well as blister-like lesions around the mouth. It is thought that the virus is most commonly passed between horses by contact with vesicular fluid or saliva, for example in shared food or on fomites, but biting flies can also play a role in transmission. In Central America, it is commonly believed that the lesions are caused by the bite of a spider. VS can cause mild flu-like symptoms and, rarely, encephalitis in humans (Reis, 2009). Of those that were aware of vesicular stomatitis (n=57), 77% named lameness as the main clinical symptom of the disease. Other symptoms included depression and ocular discharge and 3.5% mentioned oral lesions. 60% stated that the disease is transmitted by a spider, but 18.5% thought that water was the main source of infection. Specific preventative care involved good husbandry, vitamins, observing the horse and cleaning the feet with boiled or salted water. 7% also stated that they had

applied hot gasoline or paraffin oil to the feet when they began to notice lesions and 5% used a topical antibiotic cream. 10% correctly identified that VS is a zoonosis. In the new communities (n=19), all owners described lameness as the main symptom. Depression and inappetance were also recognised as clinical signs and 10.5% associated oral lesions with the disease. 95% of participants believed that a spider caused the disease. There was an increased use (32%) of non-veterinary treatments, including application of a solution made from a local plant (Diablo jerva), herbicides and human urine to the hoof lesions. 27% identified the zoonotic potential of VS. Rabies Rabies is an acute fatal zoonotic disease that is most commonly transmitted by a bite or saliva from an infected animal. There are two forms of the disease; the “dumb” form appears as depression, weakness, ataxia and paralysis and is the most common manifestation of rabies in the horse. More rarely, horses may become hyperexcitable and aggressive when exhibiting the “furious” form. In the existing communities, owners who were aware of rabies (n=48) stated that clinical signs included behavioural changes (22% hyperexcitability, 18% biting and aggression), depression (6%) and weight loss (2%). 56% did not know how rabies would manifest itself in their horse. When asked about the transmission route of rabies, 29% correctly reported that rabies could be transmitted by a bite or from the saliva of an infected animal. However, other suggestions included via mosquito, food and airborne transmission, and 36% did not know how their horse could contract rabies. 46% correctly identified rabies as a zoonosis. In the new communities (n=6), 25% thought that the main symptoms were ocular discharge and biting. 50% did not know what rabies would look like in their horse and no one could correctly describe how it was transmitted. Only 17% knew that rabies could infect humans. Tetanus Tetanus is caused by exotoxins produced by the spores of the Clostridium tetani bacteria and infection is usually initiated when these enter an open wound contaminated by soil. The most commonly recognised symptom is generalised muscle stiffness, but can also

include abnormal posture and muscle spasms. Tetanus is transmissible to humans. Owners from the existing communities (n=44) most frequently stated that depression (7%) was the main clinical sign they associated with tetanus, and 9% associated the disease with wounds – interestingly identifying a coincidental transmission route rather than a symptom. Only one participant (2%) mentioned the typical muscular stiffness seen in the disease. A large proportion of the group (68%) did not know how tetanus manifested in the horse. 14% of participants correctly identified that tetanus could infect horses through wounds, but others thought that animals could be infected by drinking water or via the airborne route. 47% did not know the transmission route of tetanus. Just 29% knew that tetanus was transmissible to humans. Participants from the new communities (n=7) also believed that depression was the main symptom of tetanus (71%), although no one recognised the classical manifestation of tetany. 57% correctly named the involvement of wounds in the transmission route and 42% were aware that tetanus was zoonotic. Streptococcus Strangles is an upper respiratory infection caused by the bacteria Streptococcus equi. Clinical signs include a purulent nasal discharge, depression, fever, coughing and abscessation of lymph nodes. It is highly contagious and can be transmitted by direct contact, via contaminated fomites and by aerosol. There are no documented cases of transmission to humans. Of the owners from existing communities who were aware of Streptococcus infection (n=35), 60% associated the disease with nasal and ocular discharge, 51% with depression and 20% with respiratory distress and coughing. Inappetance and weight loss were also highlighted as important symptoms. The top three correct suggested routes of transmission were drinking contaminated water (29%), aerosol (9%) and sharing food (6%). 26% thought the infection was airborne and 24% did not know how the disease was transmitted. 60% thought strangles posed a risk to humans. Of those in the new communities who were aware of the disease (n=34), 64% associated the disease with nasal discharge, 44% with depression and 15% with respiratory distress. 3% recognised swollen lymph nodes in the disease. 46% could correctly identify transmission routes (sharing contaminated water and food, aerosol), but 24% believed it was airborne

and 12% thought the disease was transmitted by the bite of an insect. 52% believed strangles was zoonotic. Habronemiasis Habronema spp. are stomach roundworms which can cause weight loss and impaction with heavy burdens. Cutaneous habronemiasis is caused when the larval stages emerge from flies and burrow into the skin, causing irritation and a granulomatous reaction. There is no evidence this parasite can infect humans. In the existing communities (n=4), 50% stated that inflamed cutaneous lesions were the major clinical sign of Habronemiasis; the remaining 50% did not know how to recognise the disease. 75% correctly stated that the disease was caused by a parasite but could not explain the life cycle or how it might be transmitted to the horse, however 50% also associated the disease with muddy areas. 75% mistakenly believed that the disease was zoonotic. In the new communities (n=10), 90% associated the disease with sores and cutaneous lesions. 10% also identified weight loss as a clinical sign. 70% stated that the causal agent was a parasite, and 20% correctly identified the role of flies in disease transmission. Similarly, 30% mentioned mud as being important in transmission. 40% thought that the disease was zoonotic. Equine influenza EIV is a highly contagious virus that causes coughing, nasal discharge and depression. Transmission occurs by inhalation of virus secretions. Two owners from the existing communities were aware of equine influenza. 50% correctly described common clinical signs as coughing and nasal discharge but 0% could correctly identify the transmission route of the disease. Awareness in the new communities was 0%. Anthrax This infectious disease is caused by spores formed by the bacterium Bacillus anthracis. Animals become infected after ingestion or inhalation of spores found in the environment and develop rapid onset fever, colic, bloody diarrhoea and septicaemia. Carcases will frequently exhibit bloody orifices. The spores can be transmitted to humans causing severe illness and death.

Only one horse owner from the existing communities was aware of anthrax. When asked about the clinical symptoms of the disease, only skin lesions were described, but the participant correctly identified that the infectious agent was found in the environment and could be picked up from the ground. However, he did not know that anthrax could infect humans. Awareness in the new communities was 0%. Equine papillomavirus EPV is a virus that causes warts on the skin. It is transmissible by direct contact and indirectly via contaminated fomites and flies. One participant from the existing communities was aware of EPV after seeing it in his own horse. Skin nodules around the muzzle were described as the main clinical sign but it was not known how the horse might have contracted the disease. The owner correctly stated that the disease was not zoonotic. Awareness in the new communities was 0%. Treponematosis Treponema carateum is a spirochaetal bacterium that causes hyperkeratotic and depigmented skin lesions. It also causes disease in humans. Awareness of Treponema infection was 0% in the existing communities. In the new communities (n=9), owners associated the disease with skin lesions and nodules (78%), itching (56%) and hair loss (11%). 33% thought that the disease was transmitted by direct contact with an infected horse, and others thought that fomites or parasites could transmit the infection. 33% did not know how the disease could be transmitted to horses. 66% stated that the disease was zoonotic.

Sources of information Owners had largely gained their information about infectious disease from personal experience, family and neighbours or friends (Fig. 4). In the communities within World Horse Welfare’s programme, the charity was overwhelmingly the main source of information for owners. Other sources included local vets and media, especially TV and radio. Fig. 4. Sources of information about infectious disease for horse owners

Importance of diseases Participants were asked to rank diseases in order of perceived importance, giving reasons for their placement. The amalgamated results for both groups are displayed in Tables 1 and 2. Rank Disease Reasons 1 Vesicular Stomatitis Prevalence

Mortality rate 2 VEE Mortality rate

Severity of symptoms 3 Streptococcus Severity of symptoms

Welfare concern 4 Rabies Mortality rate

Severity of symptoms 5 Tetanus Mortality rate

Prevalence

Table 1. Existing communities: diseases ranked in order of importance

Rank Disease Reasons 1 Vesicular Stomatitis Severity of symptoms

Prevalence Unable to use horse

2 Streptococcus Severity of symptoms Prevalence

3 Habronemiasis Severity of symptoms Time to recovery

4 VEE Mortality rate Severity of symptoms

5 Tetanus Mortality rate Little known about disease

Table 2. New communities: diseases ranked in order of importance

Management practices When asked about what measures they had taken to prevent disease in their animals, 58% of owners from the existing communities (n=84) stated that their horse had received vaccinations compared to 9% in the new communities (n=39). The breakdown of these vaccines is shown in Figure 5. Other practices included observing the horse, veterinary and non-veterinary treatments, maintaining environmental hygiene and good animal husbandry and seeking professional advice from World Horse Welfare and vets (Fig. 6). When asked if they would have liked to be able to do anything differently, 30% and 64% of the existing and new groups respectively expressed a wish for informed advice about disease prevention in horses. Owners also wanted access to the right veterinary treatment for their horses, to provide better husbandry and observe their animals for signs of ill health. The main barriers preventing owners from taking these actions were cited as a lack of money (56% in the existing communities compared to 65% in the new group), time (6/11%), knowledge and available information (8/11%) and provision of a local vet (5/11%).

Fig. 5. Vaccination coverage of working horses in the communities

Fig. 6. Preventative measures and management practices implemented by

horse owners in the communities

Discussion Owner awareness and understanding of infectious diseases has an important role in equine disease control and prevention. A lack of knowledge leads to a delay in detection, improper treatment and increased risk of transmission. Local knowledge in both groups is limited to a restricted number of infectious diseases and neglects several important pathogens, for example piroplasmosis, Equine Infectious Anaemia and Trypanosomiasis. Awareness of VEE, rabies and tetanus was significantly higher in the existing communities compared to the new group. This is likely to be due to the impact of World Horse Welfare’s disease programme, which focuses on teaching owners about these three diseases. Similar awareness between the groups for vesicular stomatitis is likely to be due to its apparent prevalence throughout the country, as well as the role of word of mouth in knowledge of this disease. Where awareness of Streptococcus and Treponematosis were higher in the new communities, this may be due to a higher number of cases seen in these areas. It would be interesting to establish the true regional prevalence of these diseases in order to further explore this relationship and assess disease risk. Significant knowledge gaps were identified in both groups where owners were unable to describe clinical signs and transmission routes of all diseases. A high percentage of owners did not know how to recognise specific diseases in their animals and there was often confusion surrounding potential transmission routes. Rabies and tetanus were particularly poorly understood in the new communities, meaning that the majority of owners interviewed were unaware of how to prevent these diseases in their animals. Educating communities about what symptoms to look for in their horse, and when to seek advice or suitable treatment can contribute to sustainable reduction in disease. Participants across both groups consistently underestimated the zoonotic potential of VEE, rabies and tetanus – all of which can cause potentially life-threatening disease in humans. This lack of awareness is likely to expose owners to an increased risk of contracting disease, as they are unlikely to take appropriate precautions during outbreaks. This poses a serious public health risk to the population and it is important that this issue is tackled in order to encourage owners to protect themselves and their families as well as their horses, using vaccination, hygienic practices and thoughtful preventative care.

Vesicular stomatitis was rated as the most important disease by both groups, due to its prevalence and the impact of its severe symptoms on the horse’s welfare and productivity. Streptococcal infection was also frequently highlighted as a major problem. This prioritisation is important to take into account in order to understand the needs and requirements of horse owners and support their best interests by discussing important issues with them. Current preventative measures implemented by owners are variable, but both groups show willingness to be proactive in disease prevention. It is clear that a lack of available information in the new communities is hindering disease control, so by educating owners World Horse Welfare has the power to enable them to implement best practice. SENASA, the Honduran government’s agricultural health service, provides equine vaccines for VEE, rabies and tetanus, but coverage is extremely variable and communities outwith WHW’s programme seem to have been especially neglected by the scheme. It is also unclear how regular vaccination is; some owners explained that their horse had received one vaccination without a follow-up course. Low vaccination levels in endemic areas will increase the risk of severe disease in animals and humans, so a more stringent programme is recommended in order to reduce this. Owners frequently confused other injectable treatments (from vitamin supplementation to antibiotics) with vaccination. It is important that any treatment administered to an animal is explained to the owner so that they are empowered with the knowledge and responsibility for their own horse’s health. Facilitating and supporting communication between vet and owner can improve community understanding of equine diseases and their prevention. While horses generally travel a short radial distance from their community, the majority of owners in both groups also stated that their horses are regularly in contact with others, either while working or turned loose in a field at rest. This indicates that there is significant potential for mixing and increased transmission of infectious diseases. The importance of isolating infected horses and environmental hygiene should be emphasised to owners in order to reduce this risk. Education and thorough training can be used effectively to increase horse owner knowledge, and to raise awareness by facilitating communication and collaboration between owners, CBEAs, veterinary and medical professionals and government. This approach can be used to guide the development of an inclusive and efficient One Health approach to infectious disease control.

Limitations of the study As the rate of illiteracy in Honduras is so high, the questionnaire was read to participants by a Spanish-speaking translator in order for owners to understand the questions as thoroughly as possible. Although highly competent, the translator was not medically trained so a full brief was provided to the team in order to reduce confusion. The study relied on owners reporting diseases that they were aware of their horse being at risk of. One difficulty was that several of the diseases discussed by participants do not have direct or straightforward translations into English, and are recognised by local names instead. To clarify the results, a local vet was consulted to confirm the diseases mentioned. Conclusion This study has identified a patchy awareness and limited understanding of equine infectious diseases amongst horse owners in Choluteca, Honduras. Disease awareness was generally higher in the communities from within World Horse Welfare’s programme, although owners from the new communities could provide more accurate descriptions of symptoms and zoonotic risk of some diseases. Specific knowledge gaps identified can be exploited to design effective interventions and develop World Horse Welfare’s disease education programme. Although it is unrealistic to expect horse owners to be well informed on a plethora of infectious diseases with complex transmission routes and life cycles, a working knowledge of general symptoms and risk factors would be hugely beneficial to managing disease sustainably through preventative care, diagnosis and treatment. Although infectious disease control presents many challenges, the information gathered from this survey has demonstrated the value of communication and education in supporting owners to prevent disease in their horses. This holistic approach engages stakeholders and incorporates communities in active decision-making regarding animal health, with fundamental implications for sustainable reduction of disease and improved welfare of working horses and their owners. Acknowledgements This project was funded by World Horse Welfare, for which I am extremely grateful for the opportunity to carry out this exciting research. I would like to thank Alana Chapman for her support and encouragement throughout the project, and the team in Choluteca – especially Mario and Daniela Robles and Jonathan Rodriguez – for their help and generosity

during my time in Honduras. I am also grateful to Sarah Cleaveland and John Braid for lending me their thoughts and advice on the research. References Morse, S. S. (1995) Factor in the emergence of infectious diseases. Emerg. Infect. Dis. 1. 7-15 Stringer, A. (2014) Infectious diseases of working equids. Vet Clin North Am Equine Pract. 30(3):695-718. World Bank (2015) http://data.worldbank.org/country/honduras World Horse Welfare (2015) http://www.worldhorsewelfare.org/honduras