Feasibility and acceptability of meticillin‐resistant Staphylococcus aureus biosecurity measures in equine facilities: A cross‐sectional study

Abstract

Background

Biosecurity measures are recommended in stables housing meticillin‐resistant Staphylococcus aureus (MRSA)‐positive horses, but their feasibility and acceptability, as well as their implementation barriers, remain unclear.

Methods

A cross‐sectional study was conducted among clients of a veterinary teaching hospital using an online questionnaire. Information on horse activities, stable characteristics and perceptions (feasibility and acceptability scores) of recommended biosecurity measures for MRSA‐positive horses was collected.

Results

Fifty‐seven horse and/or stable owners completed the questionnaire. Direct contact between horses and shared equipment was reported by 96% and 58% of the respondents, respectively. Hand sanitisers were present in 88% of the stables, but 12% lacked sinks. In a case of MRSA‐positive horse, respondents strongly supported adherence to antibiotic therapy, avoidance of contact between horses or with high‐risk body areas and hand washing. Measures requiring additional infrastructure or resources were perceived as less feasible and acceptable. Limited resources, financial constraints and seasonal factors were identified as barriers to implementation.

Limitations

The study population may not be representative of all horse facilities.

Conclusion

While most measures were feasible and acceptable, challenges remain in implementing measures requiring additional infrastructures and staff.

INTRODUCTION

Staphylococcus aureus is a commensal opportunistic gram‐positive bacterium typically present on the skin and mucous membranes of many animal species. ¹ , ² In horses, it is a significant contributor to bacterial pyoderma and pastern dermatitis, ³ , ⁴ , ⁵ and can also cause various clinical infections, including wound and joint infections or septicaemia. ⁶ , ⁷

In addition to its potential to affect various systems, S. aureus has a strong ability to develop resistance to antibiotics, including meticillin, which complicates the treatment strategies and raises concerns about the transmission of resistance genes. ¹ , ⁸ , ⁹ In healthy horses, this resistance is reflected in nasal carriage risk of meticillin‐resistant S. aureus (MRSA), reported at 0%–4.7% in European and North American studies. ¹⁰ , ¹¹ , ¹² , ¹³ The prevalence of MRSA carriage in horses at hospital admission or during hospitalisation ranged from 2.7% to 16%, as reported in studies from Europe, ¹⁴ , ¹⁵ Canada, ¹⁶ , ¹⁷ the United States, ¹⁸ Australia, ¹⁹ the UK and Israel, ²⁰ , ²¹ supporting hospitalisation as a risk factor for MRSA carriage. ¹⁷ In Canada, approximately 1.8 horses per 1000 admissions acquired MRSA during hospitalisation. ¹⁶ Rates can increase dramatically under outbreak conditions, reaching up to 42% in hospitalised horses in the Netherlands. ¹⁵

Controlling MRSA in horses is relevant for both horse and human health, as equine MRSA carriage or infection may serve as both a reservoir and a potential source of human infection. Indeed, the genotypes of MRSA strains isolated from horses in Canada and elsewhere are suggestive of genetic relatedness with human MRSA strains. ⁷ , ¹⁵ , ²² , ²³ , ²⁴ , ²⁵ In Canada, three equine MRSA strains, including an MRSA‐5 strain, shared similarities with the human MRSA USA500 strain, which is associated with both community‐ and acquired hospital‐associated human infections in North America. ⁷ , ²⁶ , ²⁷ , ²⁸ , ²⁹ In Hungary, Albert et al. reported mecC‐MRSA transmission between a horse and a veterinarian, emphasising the potential for cross‐species transmission of this drug‐resistant pathogen. ³⁰ Genotyping and epidemiological data further strongly suggest that MRSA can be transmitted between horses and human beings in close contact. ²⁵ , ³¹ , ³² , ³³ , ³⁴ MRSA colonisation among equine veterinary personnel reached 10.1%, higher than in the general population, particularly among those exposed to MRSA‐positive farms (prevalence of 20.6%). ³⁵ The transmission pathways proposed for human beings include close contact with horses during professional or personal activities (such as those involving owners, handlers, caregivers and veterinarians) and indirect contact through fomites and contaminated environments. ¹⁶ , ³¹ , ³⁶ , ³⁷

The use of antimicrobial therapy is not recommended for eliminating MRSA colonisation in horses. In the presence of MRSA‐positive horses, specific biosecurity measures are recommended to prevent the transmission of MRSA to other horses in the same environment or to human beings in contact with them. In two horse farms, the combination of active surveillance and strict infection control was associated with a rapid decrease in the prevalence of colonised horses. ³⁸ During an MRSA outbreak at a veterinary teaching hospital (VTH) involving horses and staff, Schwaber et al. reported the successful implementation of isolation protocols and strict infection control measures. ³² Similarly, the introduction of basic hygiene measures and personnel decolonisation were reported to be associated with an important reduction in the number of hospital‐acquired MRSA infections in horses. ³⁹ However, to the authors’ knowledge, the feasibility and acceptability of these biosecurity measures—as perceived by horse and stable owners—have not been evaluated in equine facilities following the discharge of an MRSA‐positive horse from the hospital or after receiving visits from an equine ambulatory service. Such information on the perception of the recommended biosecurity measures is lacking, which hinders efforts to implement strategies that strengthen owner engagement and facilitate compliance with these measures.

The objectives of this study were to: (1) score the perception among horse and stable owners of the feasibility and acceptability of biosecurity measures commonly recommended for MRSA‐positive horses; (2) evaluate the associations between perception scores and stable ownership; and (3) identify barriers that hinder the implementation of these measures in practice. We hypothesised that the feasibility and acceptability perception scores vary according to the proposed measures and depend on the ownership of the stable or the horse.

METHODS

An exploratory cross‐sectional study was conducted from February to May 2022 among all clients, regardless of their prior experience with MRSA‐positive horses, of the VTH of the Faculty of Veterinary Medicine of the Université de Montréal. The study protocol was approved by the health research ethics committee of the Université def Montréal (2022‐1383). This cross‐sectional study was reported following the STROBE guidelines for observational studies. ⁴⁰

Questionnaire design

A grey and scientific literature review was conducted to compile a list of recommended biosecurity measures in the presence of an MRSA‐positive horse. For scientific articles, PubMed (1990‒2022) and Ovid (1990‒2022) databases were searched using the following keywords: ([equidae or horse diseases] and S. aureus) or (prevention measures horses or biosecurity horses and MRSA). English language filters were used. If relevant, the references of the scientific articles retrieved were also screened. The available information was extracted, and a list of unique recommendations based on similar concepts was created.

An online questionnaire was developed in French by the research team and filled by respondents (see Supporting Information S1 for an English version translated by the authors). This questionnaire was created on the Limesurvey platform (Community Edition, version 3.28.52) and pretested by one horse owner for clarity and time for completion. Before answering the questionnaire, as part of the informed consent, a brief written information was provided on MRSA and associated risks in horses. The questionnaire was divided into three sections. The first section included questions about the current horse's activities and stable's characteristics (number of horses, biosecurity measures already in place, infrastructure), and whether respondents had been aware of a horse carrying or infected with MRSA. The second section focused on recommendations for managing stabled horses infected with MRSA or identified as carriers, as well as guidelines for environmental disinfection. The respondents were asked to provide their opinions on a list of both general and specific measures for handling such horses. They were informed that an infected horse was defined as one showing clinical signs of infection, such as skin lesions, coughing or sneezing, which would typically warrant veterinary consultation. In contrast, a colonised horse was defined as one carrying MRSA without exhibiting clinical signs and therefore not necessarily requiring veterinary intervention.

For each recommendation, the owners were asked to rate their current position on a scale from 1 (completely unable or total disagreement) to 10 (completely able or total agreement) regarding its feasibility and acceptability. In this study, feasibility was defined as the availability of the necessary infrastructure, materials, staff, and time to implement the recommendation, whereas acceptability was defined as the willingness to adopt the recommendation under the assumption that all necessary resources were in place. If respondents rated a recommendation as not feasible (score ≤ 5) or not acceptable (score ≤ 5), they were invited to provide the underlying reasons either through free‐text comments and/or by selecting one or more suggested options: lack of time, lack of staff, unavailable infrastructure, cost of materials or incompatibility with horse activity.

Client recruitment and participation

All clients who brought a horse in for a consultation between January 2016 and December 2021 at the hospital and agreed to be contacted for clinical research projects were eligible for the study. These clients could be the owner of the horse and/or the owner of the stable where the horse was boarded. The list of clients fulfilling these criteria was extracted from the hospital practice management software (VetView version 2.1.14.1). Clients were randomly selected and contacted by phone and/or email until a minimum target sample size of 50 clients voluntarily agreed to be enrolled in the study. Given the exploratory nature of the study and absence of preliminary data to perform sample size calculation, the sample size was determined based on available resources and time for recruitment. There was no financial benefit of participating in the study.

Analysis of questionnaire responses

All data management and analyses were performed in SAS 9.4 (SAS Institute). For each recommendation, the correlation between acceptability and feasibility was illustrated using bubble plots and quantified by Spearman's rank correlation coefficient with 95% confidence intervals. Differences in scores between respondents who owned a stable and those who did not were evaluated using the two‐sample median test, which was conducted separately for each acceptability and feasibility recommendation. An alpha value of 0.05 was used for interpretation.

RESULTS

A total of 153 clients of the VTH were invited to participate in the study. Among them, 57 respondents agreed to participate and fully completed the questionnaire, for an overall participation rate of 37%. The average completion time of the questionnaire was 17 minutes (range: 6‒58 minutes).

General information on respondents

The 57 respondents reported themselves as either stable owner only (4/57; 7%), horse owner only (26/57; 46%), or both stable and horse owner (27/57; 47%, Table 1).

TABLE 1.

General characteristics of the 57 participants.

Characteristics	n (%)
Type of respondent
Owner of a stable only	4 (7)
Owner or co‐owner of horse(s) only	26 (46)
Owner of stable and horse(s)	27 (47)
Respondent's primary activities with horses
Competition, lessons and/or training activities only	18 (32)
Retirement, leisure and/or breeding only	17 (30)
Both types of activities	22 (39)
Average number of horses in the main facility housing horses
1‒5	15 (26)
6‒10	8 (14)
11‒20	11 (19)
>20	23 (40)
Possibility of direct contact with other horses at the housing facility
Yes	55 (96)
No	2 (4)
Average number of people who ride, train or take care of the horse regularly (box cleaning and horse grooming) in a year
1	6 (11)
2‒5	40 (70)
6‒10	6 (11)
>10	5 (9)
Sharing of horse equipment (including brushes, bridles, feeders) with other horses
Yes	33 (58)
No	24 (42)
Presence of a facility (box or paddock) on the housing site allowing for isolation of a horse (without nose‐to‐nose contact with other horses)
Yes	33 (58)
No	23 (40)
Unknown	1 (2)
Number of sinks on the horse housing site
None	7 (12)
1‒2	37 (65)
3‒6	13 (23)
Access to soap or hydroalcoholic solution for hand washing after handling an animal
Yes	50 (88)
No	7 (12)
Presence of a disinfection protocol for the equipment and boxes of horses
Yes	12 (21)
No	39 (68)
Unknown	6 (11)
Previous experience of infections with MRSA in the housing site of the horse
Yes	1 (2)
No	51 (89)
Unknown	5 (9)

Abbreviation: MRSA, meticillin‐resistant Staphylococcus aureus.

Forty of them (70%) were engaged in at least one of the following activities: horse competition, lessons or training activities. While 15 respondents (26%) reported housing between one and five horses in the main stable, the majority (34/57; 60%) reported housing 11 or more.

The survey revealed that direct contacts between horses were possible in more than 96% (55/57) of stables, and equipment sharing was reported in most stables (33/57; 58%). The items most commonly shared were water buckets or feeders (n = 27), followed by grooming materials (n = 22), bridles (n = 12), saddles and saddle pads (n = 12), blankets (n = 9) and clippers (n = 7). Most respondents reported sharing multiple types of equipment.

Most stables (50/57; 88%) had at least one sink. Hand sanitisers were also available in 50 of 57 (88%) stables. Disinfection protocols for equipment and stalls were available in at least 12 of 57 (21%) stables.

Most respondents (51/57; 89%) reported no prior encounters with cases of MRSA, while one respondent reported having encountered MRSA previously, and five did not know.

Scoring of recommendations

Twenty recommendations (R1 to R20) were formulated from the information retrieved from 17 selected documents of the literature review. ⁷ , ⁹ , ¹⁵ , ³² , ³⁵ , ³⁸ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ In response to the potential threat of MRSA, respondents expressed strong support for all preventive measures, with a median feasibility score of 7 or more and a median acceptability score of 10 across all recommendations. The Spearman correlations between acceptability and feasibility ranged from 0.28 to 0.85 (all p < 0.05), depending on the recommendations (Figure 1).

FIGURE 1.

Bubble plots illustrating the correlation between acceptability and feasibility for each recommendation. Each bubble size is proportional to the number of respondents, with a colour representing the categorised proportion of stable owners among respondents. The Spearman correlation coefficient (r) with 95% confidence intervals (95% CIs) is also presented.

Medical care of horses

Regarding medical care of MRSA‐positive horses, respondents indicated that adhering to prescribed antibiotic therapy (R1) was both highly feasible (all scores ≥ 9) and acceptable (all scores ≥ 8). Additionally, out of 57 respondents, scores of 8 or more for both acceptability and feasibility were reported by 49 respondents (86%) for avoiding contact or covering infected areas of horses (R2) and by 53 respondents (93%) for wearing gloves when changing horse's bandage (R3).

Handling of horses

Thoroughly washing hands after contact with an MRSA‐positive horse (R4) was considered both feasible and acceptable by 55 of 57 respondents (96%). Similarly, avoiding handling high‐risk areas, such as wounds and the nose (R5), was considered feasible by 54 of 57 respondents (95%), with all finding it acceptable. However, the use of single‐use personal protective equipment when handling horses (R13) was considered feasible by 40 respondents (70%), although it was still highly acceptable by 51 respondents (89%). Avoiding contact between MRSA‐positive horses and vulnerable individuals (R19) was considered both feasible and acceptable by 53 of 57 respondents (93%).

Isolation of horses

A significant portion of respondents considered the isolation of MRSA‐positive horses to prevent transmission by direct or indirect contacts (R6) as feasible (42/57; 74%) and acceptable (50/57; 88%). Keeping horses isolated in a separate stable or stall (R7) was perceived as acceptable by a similar proportion of respondents (45/57; 79%), but fewer considered its application as feasible (37/57; 65%). Isolating an MRSA‐positive horse in a low‐traffic area, with no horses in adjacent stalls (R8), was also viewed as more acceptable by respondents (43/57; 75%) than feasible (32/57; 56%). Similar results were obtained for the isolation of horses in a pasture or individual paddock (R9), with 45 of 57 respondents (79%) scoring this recommendation as acceptable and 34 of 57 respondents (60%) scoring it as feasible. Almost all the respondents (56/57; 98%) reported that limiting the number of people handling MRSA‐positive horses to what is strictly necessary (R17) was both acceptable and feasible, with scores of 8 or more.

Horse activities

More than 91% of the respondents perceived the limitation of horse movements to what is strictly necessary to avoid contamination (R11), as well as the recommendations to ensure that risky areas are covered and close contact with other horses/people is avoided when riding the horse (R18), as both acceptable an feasible.

Equipment and facilities

Over 85% of respondents reported that the following recommendation were both acceptable and feasible: waiting at least 1 week before putting a horse in a paddock that has received an MRSA‐positive horse (R10); indicating on the stall that the horse is contaminated (R12); assigning equipment to the horse with no sharing with other horses (R15); and disinfecting horse stalls and equipment before using them for another horse (R16). Installing a foot bath containing disinfectant at the entrance to the horse's stall (R14) was perceived as both acceptable and feasible by 42 of 57 respondents (75%). Among the 40 stable owners or managers, using smooth, non‐porous materials in the stable to increase cleaning efficiency (R20) was more acceptable (35/40; 88%) than feasible (27/40; 68%).

Associations with stable ownership

For most recommendations, stable ownership was not significantly associated with the median acceptability or feasibility scores. However, in a few cases, stable owners reported significantly higher feasibility scores for compliance with medical care recommendations (R1, R2 and R3; Figure 1 and Table 2).

TABLE 2.

Median values and mean scores of acceptability and feasibility of recommendations for stables with a horse colonised or infected with meticillin‐resistant Staphylococcus aureus (MRSA) according to 26 horse owners and 31 stable owners.

ID	Recommandation	Type	Horse owners only (n = 26)		Stable owners a (n = 31)
			Median value	Mean score c	Median value	Mean score c	p‐value b
1	Comply with the antibiotic treatment as prescribed by the veterinarian. In other words, do not stop treatment earlier than prescribed, even if the horse seems cured before the end of the recommended treatment.	F	10	0.45	10	0.53	0.02
		A	10	0.49	10	0.50	0.82
2	Avoid contact with the infected area of the horse. Cover with a bandage, if indicated.	F	10	0.38	10	0.58	0.01
		A	10	0.46	10	0.52	0.32
3	Wear gloves when changing the horse's bandage and dispose of soiled material directly in the garbage can to avoid contaminating the environment.	F	10	0.43	10	0.54	0.02
		A	10	0.47	10	0.51	0.52
4	Wash hands thoroughly with soap and water and/or a hydroalcoholic solution after any contact with a colonised/infected horse.	F	10	0.44	10	0.53	0.07
		A	10	0.50	10	0.49	0.88
5	Avoid handling high‐risk areas (nose, wounds, etc.) of a colonised/infected horse.	F	10	0.46	10	0.52	0.47
		A	10	0.47	10	0.51	0.50
6	Isolate the horse to prevent transmission by direct contact (nose‐to‐nose, horse‐to‐horse, horse‐to‐human) and indirect contact (contaminated equipment such as water buckets, feeders, blankets, tack, etc.).	F	8	0.45	8	0.52	0.57
		A	10	0.44	10	0.53	0.42
7	Keep the horse in a separate stable or stall, without other horses.	F	7	0.44	8	0.54	0.43
		A	8	0.32	10	0.63	0.01
8	Keep the horse in an area with as little traffic as possible (horse and human) and where there are no horses in adjacent stalls.	F	6.5	0.47	7	0.51	0.81
		A	9.5	0.45	10	0.52	0.55
9	Isolate the horse outdoors in a pasture or individual paddock, with no contact over the fence with other horses.	F	6	0.46	8	0.52	0.68
		A	9	0.42	10	0.55	0.26
10	Wait at least 1 week before putting a horse in a paddock that has received a horse carrying or infected with MRSA.	F	10	0.40	10	0.57	0.06
		A	10	0.46	10	0.52	0.47
11	Limit the horse's movements to what is strictly necessary to avoid contaminating the environment and other horses.	F	10	0.43	10	0.54	0.20
		A	10	0.46	10	0.52	0.49
12	Indicate on the stall that the horse is contaminated.	F	10	0.53	10	0.46	0.28
		A	10	0.52	10	0.47	0.34
13	Handle horses using single‐use personal protective equipment (boot covers, disposable gloves, coats, etc.).	F	9	0.48	10	0.50	0.90
		A	10	0.51	10	0.48	0.79
14	Install a foot bath containing disinfectant at the entrance to the horse's stall.	F	8.5	0.43	10	0.54	0.37
		A	10	0.51	10	0.48	0.71
15	Assign equipment to the horse (feed bucket, water bucket, hay net, tack, blanket), so that it is not shared with other horses.	F	10	0.49	10	0.49	0.99
		A	10	0.53	10	0.46	0.28
16	Disinfect horse stalls and equipment (wash with water and detergent, wait 5 minutes, rinse, dry, then disinfect with bleach, quaternary ammonium or hydrogen peroxide) before using them for another horse.	F	9	0.39	10	0.57	0.10
		A	10	0.49	10	0.49	0.95
17	Limit the number of people handling the horse to what is strictly necessary (essential people such as the rider, groom, etc.).	F	10	0.44	10	0.53	0.19
		A	10	0.48	10	0.50	0.79
18	When riding, ensure that risky areas are covered and that close contact with other horses/people is avoided.	F	10	0.42	10	0.55	0.19
		A	10	0.44	10	0.54	0.20
19	Keep contact between the horse and the most vulnerable people to a minimum (young, elderly, immunocompromised, etc.).	F	10	0.46	10	0.52	0.47
		A	10	0.50	10	0.48	0.70
20	[For stable owners/managers only] Use smooth, non‐porous materials in the stable to increase cleaning efficiency.	‒	‒	‒	7	0.50	‒
		‒	‒	‒	10	0.52	‒

Note: Bold numbers indicate statistically significant differences in mean scores (p < 0.05).

Abbreviations: A, acceptability; F, feasibility.

^a Including respondents owning both horses and stable.

^b Two‐sample median test.

^c The mean score represents the proportion of values in this category with rank greater than the median rank across all data for this variable.

Additionally, higher acceptability scores were observed among stable owners for keeping the horse in a separate stable or stall (R7).

Identification of barriers

The lack of appropriate infrastructure was the most frequently identified barrier reported when respondents scored a recommendation as not acceptable or not feasible (i.e., with scores ≤ 5). This was particularly the case for measures involving the isolation of horses in specific facilities (R6, R7, R8 and R9) or those related to the physical characteristics of the stable (R20; Table 3).

TABLE 3.

Number of respondents reporting reasons for unacceptability or unfeasibility among respondents scoring the recommendation at less than 5 for acceptability or feasibility.

			Reasons for unacceptability or unfeasibility
ID	Recommendation	No. of respondent	Lack of time	Lack of staff	No infra‐structure	Cost of material	Unsuited for horse activity	Others
R1	Comply with the antibiotic treatment as prescribed.	0	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.
R2	Avoid contact or cover infected area of the horse.	5	0	0	2	1	0	2 a , b
R3	Gloves and hygienic disposal when changing the horse bandage.	1	0	0	0	0	0	1b
R4	Wash hands after contact with colonised/infected horse.	2	0	0	1	0	0	1 b
R5	Avoid handling high‐risk areas of colonised/infected horse.	3	0	0	0	0	1	2 c
R6	Isolate the horse to prevent direct and indirect contact.	15	1	1	13	0	2	1 d
R7	Keep the horse in a separate stable or stall, without other horses.	20	0	0	19	1	4	5 d , e
R8	Keep horse in areas with little traffic and no horse in adjacent stalls.	25	0	0	24	0	4	1d
R9	Isolate horse outdoors with no contact with other horses.	23	1	1	20	0	2	1f
R10	Wait before using a paddock exposed to an MRSA‐positive horse.	8	0	0	8	0	1	0
R11	Limit the horse's movements to avoid dissemination.	5	0	0	2	0	2	1d
R12	Clearly indicate horse contamination on the stall.	3	1	0	3	0	0	0
R13	Wearing single‐use protective equipment for handling horses.	18	4	3	7	11	1	0
R14	Foot bath with disinfectant at the horse's stall entrance.	15	2	1	6	6	0	2 e , g
R15	Equipment assigned to the horse and not shared.	4	0	0	1	0	0	1 b
R16	Disinfect the stall and equipment before using them for another horse.	7	4	3	1	1	0	1 b
R17	Limit the number of people handling the horse to a strict minimum.	1	1	0	1	0	0	0
R18	When riding, cover risky area and avoid close contacts.	4	0	0	0	0	1	0
R19	Limit contact between the horse and vulnerable people.	4	0	1	2	0	0	2 h
R20	Use smooth, non‐porous materials in stable to facilitate cleaning.	13	1	1	10	8	0	0

Note: Please refer to Table 2 for the full description of each recommendation.

^a Depends on the infected zone and horse tolerance (e.g., the bandage could be removed by the horse itself).

^b Risk of error (if the person manipulating the horse is unaware or in an emergency, or due to sharing space for equipment).

^c Difficult to manipulate a horse without touching these areas (e.g., nose).

^d Welfare issue related to the need for social interactions between horses, particularly for young horses.

^e Not possible or difficult in wintertime due to cold weather.

^f Horse preference (e.g., horse does not like to go on pasture).

^g The presence of dogs and cats is limiting the use (e.g., foot bath).

^h The owner is old or immunocompromised.

The cost of material was also reported as an important barrier, particularly for the use of single‐use personal protective equipment (R13), non‐porous materials in the stable (R20) and, to a lesser extent, foot baths (R14).

Lack of time and insufficient staffing were rarely reported as barriers for most recommendations, except by some respondents regarding the use of personal protective equipment (R13) and disinfection of horse stalls and equipment (R16).

Only a few respondents considered the recommendations to be poorly adapted to horse activities. Additional barriers were also noted, including those related to the horse itself (tolerance, preferences and welfare), the owner (age and health status), the environment (cold weather and presence of pets) and the handlers (risk of errors and difficulties in measure application).

DISCUSSION

The implementation and compliance with biosecurity measures are influenced by various factors, including feasibility and acceptability. This study assessed the acceptability and feasibility for horse and/or stable owners to follow medical instructions and implement on‐stable biosecurity measures for confirmed or suspected MRSA‐positive horse. Most respondents agreed with the proposed biosecurity measures, with moderate to excellent correlation between feasibility and acceptability, except for hand washing after contact with contaminated horses, suggesting that measures perceived as feasible were also likely to be well accepted.

Recommendations regarding veterinary care (antibiotic therapy, bandaging skin lesions) or horse handling/individual hygiene (e.g., hand washing, limited number of handlers) showed excellent feasibility and acceptability, except for single‐use medical equipment, deemed expensive. Although most respondents supported hand washing, 12% reported no sink access (including two stables with more than 20 horses), while hand sanitisers were available in 88% of the stables. It is unclear whether sinks were readily accessible in a nearby facility. The weak correlation between feasibility and acceptability for this recommendation was unexpected but may reflect variability in access to infrastructure such as sinks. Limited infrastructure may constrain hand hygiene implementation, despite widespread recognition of its importance, potentially affecting infection prevention. Whether hand sanitisers were actively used is unknown, but high regard for hand washing and use of hand sanitisers may stem from a shift in mentality following the COVID‐19 pandemic. Another study concluded that basic hygiene protocols were less implemented, but frequently recommended. ⁵¹ This suggests that even if the acceptability and feasibility are high, it still may not be implemented.

In this survey, some recommendations related to infrastructure, including stable size and human resources, were considered less feasible. The implementation of these recommendations may pose challenges if they require prior improvement of the facilities, such as building a dedicated contagious stall, modifying space usage, or hiring additional staff to ensure proper care for the horses and adherence to environmental maintenance protocols. This contrasts with the study by Germann, in which structural efforts appeared to be more readily implemented, as larger physical efforts seemed to be prioritised over the less demanding daily practices. ⁵¹ Although not explicitly addressed in the survey, these biosecurity recommendations could require significant financial investments, which may lead to financial losses or reduced profits for the stable owners. Nevertheless, they may play a critical role in limiting the spread of bacterial resistance between horses and from horses to people. This is particularly important in the context of gatherings (i.e., situations where horses are brought together within the stable or during events such as competitions or other group activities), but also considering that direct contacts between horses were reported in most stables, and equipment was shared between horses in more than half of the stables. In that regard, recommending the isolation of an MRSA‐positive horse may be less effective if that horse continues to share equipment with non‐contaminated horses.

More than half of the respondents (57%) in this study owned a stable. This percentage is close to the 42% of owners reported in a concurrent biosecurity survey conducted in 271 horse facilities in the neighbouring province of Ontario. ⁵¹ When comparing the responses from the stable owners and horse owners only, there was general agreement on both feasibility and acceptability for most recommendations. The divergence was mainly related to a higher perceived feasibility (rather than acceptability) by stable owners of measures involving medical management of infected horses, such as compliance with antibiotic therapy, avoiding the infected area, wearing gloves, and the specific disposal of contaminated materials. We hypothesise that stable owners had more control over the level of care provided to horses. Despite these differences, these recommendations still received high acceptability and feasibility scores in both groups. The only recommendation that differed in terms of acceptability between the two categories of respondents was isolating the horse. Stable owners considered the isolation of an MRSA‐contaminated horse to be more acceptable, perhaps for the same reasons.

By identifying barriers associated with biosecurity measures perceived as less feasible or acceptable, we can modify these recommendations to make them more practical whenever possible. As reported by Thompson et al., cost and infrastructure, as well as season (given that the administrative region of this study experiences an average daily winter temperature of ‒7.7°C and snow accumulation ⁵² ), were frequently reported as limitations by our respondents. ⁵³ Additional studies in other species have also identified factors such as cost, equipment availability, and infrastructure as key elements influencing perceptions of biosecurity strategies. ⁵⁴ , ⁵⁵ Adapting the isolation protocols to existing infrastructure, modifying disinfection protocols to suit the environment, including temperature considerations, and establishing specific protocols for disinfecting shared equipment are strategies that could improve perceptions and, in turn, enhance compliance. ⁵⁶ , ⁵⁷ Another constraining factor identified by respondents was the nature of the activities, with some specifying that certain activities require horse‐to‐horse contact, while others highlighted that contact between young horses is important for socialisation and preventing separation anxiety.

Our study focus was limited to the acceptability and feasibility dimensions, without a broader assessment of the determinants that could have influenced responses apart from stable ownership. Studies conducted in horse facilities in Canada, Australia and the United States concluded that uptake of various biosecurity measures or willingness to adopt them varies according to the category of horse use, skill level of respondents, facility size and owner personality. ⁵¹ , ⁵³ , ⁵⁸ Germann identified two distinct groups of horse owners: one group, associated with high levels of negative emotions, appeared more reluctant to apply biosecurity measures, while the other group, identified as extraverts, tended to believe more in the efficacy of biosecurity measures, although they were more inclined to debate their implementation. ⁵² In the context of swine, poultry and dairy herds, the perceptions of biosecurity measures were also reported to be influenced by various factors, such as personality traits of respondents and their perspectives. ⁵⁹ , ⁶⁰ , ⁶¹

A New Zealand study showed that uptake of biosecurity measures depended on disease presence on the farm, ⁶² while a Canadian study highlighted perceived disease risk as the main driver. ⁶³ Since stable owners in our study rarely encountered MRSA‐positive horses, their opinions may not be generalisable to other situations. Educational interventions may also play a significant role in shaping perceptions and gradually changing behaviours in a positive way. ⁶⁴ Veterinarians play a key role in raising awareness about the importance of biosecurity measures (verbal information or written protocols). ⁵¹ , ⁵⁸

In addition to implementing biosecurity measures, effective disease prevention and control depend on compliance, defined as the extent to which individuals follow recommended protocols and practices. ⁶⁵ , ⁶⁶ The literature on compliance in veterinary medicine is limited; however, existing reports indicate poor adherence to treatment recommendations for equine asthma and identify factors that may hinder compliance with medical therapy. ⁶⁵ , ⁶⁷ However, the specific factors influencing compliance in veterinary medicine remain unclear, which may be affected by individuals' experiences and perceptions of recommended protocols and practices. ⁵¹ , ⁶⁵ Thus, we may hypothesise that recommendations perceived by horse or stable owners as relevant, but unrealistic in their specific setting (e.g., avoiding direct horse‐to‐horse contact via isolated stalls, etc.), are less likely to be followed. Therefore, biosecurity protocols deemed both highly feasible and acceptable by horse and stable owners, based on their perception, experience, resources and routine management, are expected to have better compliance rates, or greater willingness to implement, compared to those perceived as challenging to implement.

Most horses in this study came from stables housing more than 11 horses and were clients of a VTH, which may not reflect the diversity of horse owners and stable facilities in other regions. This geographic concentration and selection of respondents may limit the generalisability of our results. This population may also be skewed toward wealthier owners and/or higher‐value horses, given their choice to consult with the VTH. Regardless of economic status, owners seeking veterinary care in this context may be more engaged in medical therapies and recommendations, which leads to a more positive perception of these recommendations. According to horse owners, veterinarians are the most trusted source of medical and biosecurity information. ⁵⁸ Therefore, extrapolating our results to horse or stable owners outside the VTH, even locally, may be unreliable.

The literature search for this study was limited to PubMed and Ovid literature databases due to time constraints. The authors acknowledge that these databases do not provide comprehensive coverage of veterinary literature; therefore, some biosecurity recommendations for MRSA‐positive horses may have been overlooked. ⁶⁸ A further limitation of the literature review is that the term ‘biosecurity’ is poorly indexed in databases in the context of horses. Some contacted clients declined to participate in the study, which might lead to selection bias. The reasons for refusal or incomplete surveys were not recorded. As another potential limitation, we asked respondents to score the general feasibility and acceptability of recommendations without consideration of the season of application. Harsh winter weather was reported as a barrier for some recommendations, so responses collected in winter (most questionnaires) likely represent minimal acceptability and feasibility scores.

CONCLUSION

This study indicates that most standard biosecurity recommendations are perceived as feasible and acceptable, although those requiring additional infrastructure, equipment or staff are considered less feasible. Implementing biosecurity measures can be challenging and should be prioritised based on their efficacy, associated costs, time constraints and available human resources. Adapting recommendations for stables with limited resources, as well as enhancing educational initiatives and communication that, among other things, increase awareness of disease risks (e.g., fact sheets on MRSA), could improve their acceptance and implementation.

Enhancing adherence to biosecurity measures can contribute to the health and safety of both horses and human beings within the equestrian community.

AUTHOR CONTRIBUTIONS

Study design: Frédéric Sauvé, Julie Arsenault, Pauline Planes and Marion Allano. Survey conceptualisation and data collection: Pauline Planes. Statistical analyses: Julie Arsenault. Writing the manuscript: Pauline Planes, Frédéric Sauvé and Julie Arsenault. All the authors reviewed the manuscript prior to submission.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

The research protocol was approved by the Health and Sciences Research Ethics Board of the Université de Montréal (certificate number 2022‐1383).

Supporting information

Supporting information

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.