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FEI report on 2021 EHV-1 outbreak reveals human error, lack of rule compliance and systemic failures

Wednesday, 02 March 2022

FEI: “Clearly there has to be accountability for actions or non-actions that enabled the rapid spread of the disease to a large number of horses”

The FEI has concluded that while it is not possible to pinpoint a single reason or a single responsible person for last year’s deadly outbreak of the neurological form of EHV-1 in mainland Europe, their investigation into the outbreak has revealed that it was caused by several risk factors being present within a limited space and time, a lack of compliance with the FEI Veterinary Regulations, a lack of preparedness, in combination with poor decision making and lack of cooperation with the FEI Headquarters once the outbreak had been confirmed. 

Earlier this week, the FEI published the first of their three reports on last year’s EHV-1 outbreak that started in Valencia, Spain – and which resulted in the deaths of 18 horses in mainland Europe, confirmed related cases in ten countries, as well as a six-week shutdown of all international events in mainland Europe from 1 March to 11 April aimed at minimising the spread of the virus. 

The FEI promised a comprehensive and fully transparent investigation into every aspect of the outbreak and to make the full findings public. The investigation has shown that there were systemic failures in a number of areas and the published report details these.

In the report, the FEI states that the disease itself was not the problem, but rather the management of it, and that human error allowed the virus to spread much more rapidly than it would have done if the mandated biosecurity protocols had been followed correctly and immediately. 

The report also details key risk factors for an EHV-1 outbreak, such as the size of the horse population spent onsite at a tour, the use of tent stables with shared and sometimes poorly ventilated airspace, predisposing factors such as long travels and lack of biosecure management, as well as how preventive measures such as pre-arrival examination and daily temperature monitoring could have helped minimise or prevent an outbreak.

The virus 

In early March 2021, the Valencia strain of the virus was identified as a A2254/N752 genotype which commonly circulates in Europe. 

The FEI report details that:

“A2254/N752 genotype is more common than the G2254/D752 genotype and is less often associated with neurological disease than the G2254/D752, which is more frequently associated with hyper-virulent disease expression, meaning that the disease is extremely contagious. 

Gene sequencing of the Valencia strain by Ghent University found that it was not a novel virus but was similar to strains previously found in Europe.”

CES Valencia: Too little, too late

While there were FEI biosecurity rules in place already at the time of the outbreak, it is pointed out in the report that the implementation of these rules, compliance by the organising committee and FEI officials, some athletes and their entourage, as well as enforcement of the rules by FEI officials, was insufficient at the venue in CES Valencia. As a result, the outbreak had already started to spread prior to the FEI Veterinary Department being officially informed on 20 February 2021. 

The report details several factors that contributed to the outbreak in Valencia, and its disastrous consequences: 

Lack of examination on arrival: According to information received by the FEI, examination on arrival was not correctly conducted at CES Valencia. 

Lack of temperature monitoring: Although there is no record, the report states it is unlikely that all athletes or their entourage were monitoring their horses’ daily body temperatures in Valencia. 

Number of horses sharing the same airspace and effects of construction: According to the report, the outbreak started in tented stables that had more than 400 boxes. The walls were closed, resulting in reduced ventilation/air circulation. The large number of horses sharing the same airspace increased the risk of viral transmission. With the large number of infected horses, the escalating virus load in the shared airspace meant that the outbreak became increasingly difficult to manage. The rapid spread in one aisle of the large stabling tent was according to the report noteworthy as the height of the roof was lower over that aisle. This smaller airspace may have caused an increased concentration of virus particles compared to other parts of the stable tent. 

Lack of biosecurity contingency plan: Despite numerous requests, the FEI never received the required biosecurity contingency plan from the organisers with protocols describing how to separate horses with clinical signs of infectious disease from the other horses. 

Inadequate number of isolation boxes: The FEI was informed that there was an inadequate number of isolation boxes. 

Notification of the outbreak in Valencia came much too late to the FEI and to the Spanish veterinary authorities: As part of its investigation, the FEI was made aware that there were several febrile horses on the venue in Valencia as early as 14 February 2021, almost a week before any information was passed on to the FEI Veterinary Department on 20 February. As reported by FEI Veterinary Team Leader Dr Federico Nieto León there were already four horses on venue with fever on 17 February, which the FEI was unaware of until receipt of the team leader’s report in March, with an additional two febrile horses on 19 February 2021. 

Additionally, the report details that that there was a photograph circulating among the French riders onsite of a neurological EHV-1 case in France in a horse that had left Valencia on 14 February 2021. However, there was no communication on this to the regional authorities, to the FEI or to others at the venue. 

In the report, it is pointed out that despite the fact that there were six horses on the venue with fever on 19 February 2021, and the knowledge of the neurological case in France, no action was taken to isolate any of the onsite sick horses nor to immediately inform the FEI as required under article 1078 of the FEI Veterinary Regulations.

As detailed in the FEI Veterinary Manager’s report, he was informed of the outbreak by the veterinary delegate by telephone in the afternoon of 20 February 2021, after the competitions were over for the day. By then, 11 horses had fever and later that day the number had increased to 20. The FEI Veterinary Manager advised the veterinary delegate to isolate the sick horses, to stop all movement of horses on the venue, to immediately inform the competent authority and to cancel the rest of the event. 

The event in Valencia continued despite FEI’s orders to cancel: After immediately informing the FEI Veterinary Director, the FEI Veterinary Manager followed with an e-mail to the veterinary delegate, ground jury and organising committee with further advice to cancel the event.

The following morning, on Sunday 21 February, the number of febrile horses had increased to around 35, but competitions continued despite an urgent phone call from the FEI Veterinary Director and a follow-up e-mail to the ground jury telling them to cancel the rest of the event immediately. Competition only stopped after the FEI Veterinary Director sent an additional e-mail to the ground jury, organising committee and veterinary delegate warning that the FEI could take disciplinary action unless the event was cancelled immediately. Following subsequent representation from some athletes requesting that the Grand Prix be restarted, the veterinary delegate e-mailed the FEI Veterinary Director seeking permission for the remaining 15 horses to be allowed to jump. This request was rejected by the FEI, with the FEI Veterinary Director warning that the situation was very serious, that any movement of horses on the venue would risk further spread of the virus, and reiterating that any further competition would be a violation of FEI rules. 

On that same evening, the number of febrile horses had increased to 40. 

Horses left the CES Valencia venue in an uncontrolled fashion and without the necessary health papers – increasing the risk of spreading the virus further: It is detailed in the report that “A workable biosecurity plan with clear separation of sick and healthy horses could have meant that athletes had confidence in the protocols in place and did not feel there was an urgent need to take their horses away from the venue as quickly as possible, therefore allowing for a controlled departure of horses.”

Lack of veterinary resources: According to the report, there were only two veterinarians available between 20 and 26 February 2021 to treat the many sick horses. 

Delay in the management plan for the outbreak: On 24 February 2021, the Spanish veterinary authorities provided CES Valencia with a formal plan for the management of the outbreak, including testing of horses and separation of horses into sub-groups. However, for a number of reasons laid out in the report, the plan proved difficult to implement and was therefore delayed. 

Furthermore, the FEI investigation found that there was a serious gap in jurisdiction between the event being cancelled on 21 February 2021 and the Spanish veterinary authorities taking over jurisdiction the following day. In the report, the FEI writes: “In hindsight, the FEI should have requested permission from the Spanish authorities to allow additional veterinarians onsite more rapidly. The FEI did not send help earlier because FEI HQ was not immediately informed how critical the situation was until alerted by an owner whose horse was seriously ill.”

Sunshine Tour: The virus travels from Valencia to Vejer de la Frontera

The FEI report also details how the virus found its way to the Sunshine Tour in Vejer de la Frontera, Spain. According to the report, it is likely that at least one of the horses that left Valencia for the Sunshine Tour between 7 and 13 February 2021 carried the virus strain and transmitted it to one or more horses at the Sunshine Tour. Horses that had arrived from CES Valencia were considered in-contact horses by the FEI Veterinary Department, and were isolated on 22 February in accordance with FEI Veterinary Regulations, but prior to isolation these horses had already been competing and stabled for one to two weeks at the Sunshine Tour. 

On 26 February 2021, a horse was moved from the showground to the isolation stables at Vejer de la Frontera after developing a fever. The report details that it is believed that viral transmission occurred on venue between this horse and one of the horses that had been in Valencia. 

On 4 March, the team leader of the three additional FEI Veterinary Delegates at the venue informed the FEI Veterinary Department that the horse that had been moved to the isolation stables had developed neurological signs of EHV-1 although it reportedly had tested negative to the virus. That same day, a team veterinarian contacted the FEI Jumping Director by e-mail to advise that he had seen cases of suspected EHV-1 with neurological symptoms on the venue. 

In the afternoon of 5 March, the FEI was informed by the team leader of the three additional FEI Veterinary Delegates that a second horse at the venue had been put into isolation after developing mild neurological signs and a slightly elevated temperature. As the FEI had also received evidence late that afternoon from the official laboratory in Madrid that the negative test on the first horse showing neurological signs was inconclusive, a meeting with the organisers and onsite FEI officials was arranged. After a follow-up emergency internal meeting, the FEI informed the organisers that the event was cancelled with immediate effect. 

That same day, the FEI was informed that the additional veterinary delegates appointed by the FEI had been blamed for having caused the cancellation. In a phone call with a representative of the organising committee, two of the additional veterinary delegates had been requested by the organising committee to leave the venue. The next day, the additional veterinary delegate that had not been directly requested by the organising committee to leave the previous day, went to the venue to continue with health controls of departing horses. This individual was forced off the venue by a representative of the organising committee. 

The report also details some of the factors that contributed to the spread of the virus at the Sunshine Tour: 

Lack of examination on arrival: According to information received by the FEI, examination on arrival was not correctly conducted. 

Lack of temperature monitoring: Although there is no record, it is unlikely that all athletes or their entourage were monitoring their horses’ daily body temperatures at the tour. 

Basic hygiene protocols were not followed: The reports from the FEI Additional Veterinary Delegates described how the isolation stables were managed and gave examples of how basic hygiene protocols were not followed. As an example, personal protective equipment was not used, which gives a possible explanation on how the infection may have transferred indirectly within the isolation stable. The details in the veterinary reports are supported by information from the riders that had sick horses in the isolation stable. 

Lack of biosecurity contingency plan: Despite requests for the organising committee's biosecurity contingency plan, this was not supplied to the FEI Veterinary Department. 

Mediterranean Equestrian Tour: No sign of viral transmission onsite

On the Mediterranean Equestrian Tour in Oliva Nova, the report notes: “The biosecurity measures on venue at Oliva, the close cooperation with the Organising Committee and its veterinary team, and the rigorous testing protocols put in place, meant that there was no sign of viral transmission onsite.”

Accountability for actions or non-actions 

In the report, the FEI concludes that there has to be accountability for actions or non-actions that enabled the rapid spread of the disease to a large number of horses. Based on the report, the FEI will be establishing individual accountabilities prior to any further potential actions. 

It’s emphasized by the FEI that while the rules in place at the time were appropriate, the work with the report has made it clear that the FEI’s oversight of these rules and ensuring their enforcement by the relevant parties was not optimal. 

Furthermore, the FEI makes it clear that as the international governing body it has to take its share of the blame. “The FEI did not ensure that OCs, Officials, Athletes and their entourage were prepared to confront such a situation. The FEI did not have a structure in place to ensure enforcement. We, as a community, were not ready,” the report states.

The FEI points out that it now has reinforced its rules and improved education of organising committees, officials and athletes, as well as strengthened its jurisdiction to take immediate action if rules around biosecurity are not being enforced and horse health is at risk. Enforcement is now controlled through use of the mandatory FEI HorseApp for examination on arrival, monitoring during the event, and checkout of horses prior to departure. The FEI will also be conducting a minimum of one pre-event regulatory visit to specifically identified high-risk events, such as tours where there are a large number of horses (more than 400) spending multiple weeks at one venue. The pre-event inspection will ensure that the required measures under the rules around biosecurity are in place. The FEI will also appoint and pay for a foreign veterinary delegate to attend high-risk events, and any others deemed necessary. Where required, an FEI Headquarters representative will additionally visit venues to oversee compliance. 

Click here to read the first part of the FEI’s report. 

Click here for the annexes to the report.

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