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Current status and future challenges in mastitis research

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A couple of years ago, we gathered with 9 individual mastitis experts, to freely discuss issues around mastitis.
One of the results was an overview paper on the current status and future challenges of mastitis research. It was presented at the 50th anniversary Annual Meeting of the NMC (www.nmconline.org). These are the slides of this presentation, given by Joe Hogan and myself.

Published in: Education
  • An instrumental presentation, thanks Dr Henk Hogeveen
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  • Specificity for diagnosis is indeed important. With Ekomilk digital cell counters, a high specificity (few false positives) with good sensitivity is guaranteed at approx. 0.04$/test with an optional mastitis monitoring app per quarter, per cow/udder and for the herd. www.ekomilk.eu . SCC still is one of the most reliable and widely accepted indicators for mastitis (udder health), both for clinical and subclinical cases.
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  • dear collegues ,
    thanks for all researchs that your show in this site NMC, and Linkedin too.
    I thinlk this is the best web site in order to comunícate our comments and suggest.
    for example ,
    we are working here in Chile with a new ,amazing product for use on the skin ( like teat dip).this product is bases to copper salt , the research in going to from U.OF CHILE,INTA, institute. the leader of this research is profesor :Guillermo Figueroa.
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  • Thanx Dr. Henk, brief and very informative presentation.
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Current status and future challenges in mastitis research

  1. 1. Current Status and Future Challenges in Mastitis Research Henk Hogeveen Joe Hogan
  2. 2. This mastitis forum <ul><li>Eric Hillerton </li></ul><ul><li>Henk Hogeveen </li></ul><ul><li>Herman Barkema </li></ul><ul><li>Joe Hogan </li></ul><ul><li>Karin Persson Waller </li></ul><ul><li>Satu Pyorala </li></ul><ul><li>Steve Oliver </li></ul><ul><li>Theo Lam </li></ul><ul><li>Ynte Schukken </li></ul>
  3. 3. Topics <ul><li>Current status </li></ul><ul><ul><li>Pathogens </li></ul></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Immunology </li></ul></ul><ul><ul><li>Therapy </li></ul></ul><ul><ul><li>Environment </li></ul></ul><ul><ul><li>Milking equipment </li></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><li>Socio-economic </li></ul></ul><ul><li>Wrapping up </li></ul>
  4. 4. <ul><li>Etiological agents </li></ul><ul><ul><li>Countries, regions, farms </li></ul></ul><ul><ul><li>Stage of lactation </li></ul></ul><ul><ul><li>Seasons </li></ul></ul><ul><ul><li>Evolve </li></ul></ul>Pathogens
  5. 5. <ul><li>Staphylococci </li></ul><ul><li>Staph aureus </li></ul><ul><ul><li>strain diversity </li></ul></ul><ul><ul><li>related genotypes within herd </li></ul></ul>Pathogens Photo: SVA, Uppsala
  6. 6. <ul><ul><li>CNS - increasing interest in many countries </li></ul></ul><ul><ul><ul><li>Multiple species and strains </li></ul></ul></ul><ul><ul><ul><li>Dfferential diagnostics </li></ul></ul></ul>Pathogens
  7. 7. <ul><li>Streptococci </li></ul><ul><ul><li>Strep agalactiae </li></ul></ul><ul><ul><ul><li>still concern in some countries </li></ul></ul></ul><ul><ul><ul><li>genotypes between human and bovine isolates </li></ul></ul></ul>Pathogens Photo: SVA, Uppsala
  8. 8. <ul><ul><li>Strep dysgalactiae </li></ul></ul><ul><ul><ul><li>(environmental/contagious) </li></ul></ul></ul><ul><ul><ul><li>fresh heifers </li></ul></ul></ul>Pathogens
  9. 9. <ul><ul><li>Strep uberis </li></ul></ul><ul><ul><ul><li>housed and pastured systems </li></ul></ul></ul><ul><ul><ul><li>strain differences </li></ul></ul></ul>Pathogens
  10. 10. <ul><li>Coliforms </li></ul><ul><ul><li>severity = host response </li></ul></ul><ul><ul><li>genetically heterogenous group </li></ul></ul><ul><ul><ul><li>mild to severe </li></ul></ul></ul><ul><ul><ul><li>acute to chronic </li></ul></ul></ul>Pathogens Photo: SVA, Uppsala
  11. 11. <ul><li>Pathogenesis </li></ul><ul><ul><li>bacteria and host </li></ul></ul><ul><li>Epidemiology & Ecology </li></ul><ul><ul><li>genotype and environment </li></ul></ul><ul><li>Emergence of ”new and old” pathogens </li></ul>Future challenges - Pathogens
  12. 12. Topics <ul><li>Current status </li></ul><ul><ul><li>Pathogens </li></ul></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Immunology </li></ul></ul><ul><ul><li>Therapy </li></ul></ul><ul><ul><li>Environment </li></ul></ul><ul><ul><li>Milking equipment </li></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><li>Socio-economic </li></ul></ul><ul><li>Wrapping up </li></ul>
  13. 13. <ul><li>Bacteriological culture </li></ul><ul><li>Somatic cell counts </li></ul><ul><li>Soluble indicators of inflammation </li></ul>Diagnostics
  14. 14. <ul><li>Sample collection </li></ul><ul><li>Sample handling </li></ul><ul><li>Laboratory techniques </li></ul><ul><li>Interpretation </li></ul>Standardization
  15. 15. <ul><li>Precision on antibiotic selection </li></ul><ul><li>Low specificity = false-positives </li></ul>On Farm Diagnostics
  16. 16. <ul><li>Detection of genes </li></ul><ul><li>ID organism </li></ul><ul><li>Identify virulence factors </li></ul><ul><li>Clonal variance </li></ul>PCR
  17. 17. <ul><li>Simple low-cost </li></ul><ul><li>Rapid on farm </li></ul><ul><li>RT Interpretation - Implementation </li></ul>Future Challenges – Diagnostics
  18. 18. Topics <ul><li>Current status </li></ul><ul><ul><li>Pathogens </li></ul></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Immunology </li></ul></ul><ul><ul><li>Therapy </li></ul></ul><ul><ul><li>Environment </li></ul></ul><ul><ul><li>Milking equipment </li></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><li>Socio-economic </li></ul></ul><ul><li>Wrapping up </li></ul>
  19. 19. Host Defense
  20. 20. <ul><ul><li>SOL </li></ul></ul><ul><ul><li>Breed </li></ul></ul><ul><ul><li>Genotype </li></ul></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Milk yield </li></ul></ul><ul><ul><li>Nutrition </li></ul></ul><ul><ul><li>Existing infection </li></ul></ul>Host defense
  21. 21. <ul><li>Teat Canal </li></ul><ul><li>Phagocytic Cells </li></ul><ul><li>Soluble factors </li></ul>Innate Immunity
  22. 22. <ul><li>Macrophages/monocytes </li></ul><ul><li>Lymphocytes </li></ul><ul><li>Antibodies </li></ul>Acquired Immunity
  23. 23. <ul><li>Cytokines </li></ul><ul><ul><li>Recruit </li></ul></ul><ul><ul><li>Class switch </li></ul></ul><ul><ul><li>Activate </li></ul></ul><ul><ul><li>Up regulate/down regulate </li></ul></ul>Bridge Between
  24. 24. <ul><li>Whole cell bacterins </li></ul><ul><li>Subunit vaccines </li></ul><ul><li>Adjuvants </li></ul><ul><li>Route </li></ul>Vaccination
  25. 25. <ul><li>Vaccine </li></ul><ul><li>Virulence factors </li></ul><ul><li>Genotyping </li></ul><ul><li>Environmental factors </li></ul>Future Challenges – Host Defense
  26. 26. Topics <ul><li>Current status </li></ul><ul><ul><li>Pathogens </li></ul></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Immunology </li></ul></ul><ul><ul><li>Therapy </li></ul></ul><ul><ul><li>Environment </li></ul></ul><ul><ul><li>Milking equipment </li></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><li>Socio-economic </li></ul></ul><ul><li>Wrapping up </li></ul>
  27. 27. <ul><li>Eliminate IMI </li></ul><ul><li>Prudent use of antimicrobials </li></ul><ul><li>Welfare of animal </li></ul>Therapy
  28. 28. Treatment should be targeted towards the causing pathogen OIE World Organisation for Animal Health Terrestrial Animal Health Code GUIDELINES FOR THE RESPONSIBLE AND PRUDENT USE OF ANTIMICROBIAL AGENTS IN VETERINARY MEDICINE
  29. 29. Broad-spectrum antibiotics <ul><li>Prudent? </li></ul><ul><li>Efficacious? </li></ul>
  30. 30. <ul><li>The longer, the better? </li></ul><ul><li>Efficacy of longer treatment is available in: </li></ul><ul><ul><li>Staphylococcus aureus </li></ul></ul><ul><ul><li>Streptococcus uberis </li></ul></ul>Duration of Treatment
  31. 31. <ul><li>What is long? </li></ul><ul><li>Very few comparative trials </li></ul><ul><li>> 5 days may seldom be economical </li></ul>Duration of Treatment
  32. 32. <ul><li>Pharmacokinetics </li></ul><ul><li>Route and duration </li></ul><ul><li>Antimicrobial resistance </li></ul><ul><li>Economical benefits </li></ul><ul><li>Alternatives to antibiotics </li></ul>Future challenges - treatment
  33. 33. Topics <ul><li>Current status </li></ul><ul><ul><li>Pathogens </li></ul></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Immunology </li></ul></ul><ul><ul><li>Therapy </li></ul></ul><ul><ul><li>Environment </li></ul></ul><ul><ul><li>Milking equipment </li></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><li>Socio-economic </li></ul></ul><ul><li>Wrapping up </li></ul>
  34. 34. <ul><li>Biological </li></ul><ul><li>Physical </li></ul><ul><li>Chemical </li></ul>Environment
  35. 35. <ul><li>Fecal contamination </li></ul><ul><li>Moisture </li></ul><ul><li>Organic matter </li></ul>Reduce Exposure to Pathogens
  36. 36. Exposure = Density <ul><li>Confinement </li></ul><ul><li>Pasture </li></ul>
  37. 37. Exposure vs Susceptibility
  38. 38. Future Challenges – Environment <ul><li>$ $$$$$ </li></ul><ul><li>Waste/Recycle </li></ul><ul><li>Ecology/Image </li></ul><ul><li>Welfare </li></ul>
  39. 39. Topics <ul><li>Current status </li></ul><ul><ul><li>Pathogens </li></ul></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Immunology </li></ul></ul><ul><ul><li>Therapy </li></ul></ul><ul><ul><li>Environment </li></ul></ul><ul><ul><li>Milking equipment </li></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><li>Socio-economic </li></ul></ul><ul><li>Wrapping up </li></ul>
  40. 41. <ul><li>Acts as a vector to transfer pathogens </li></ul><ul><li>Damages the first line of udder defence </li></ul><ul><ul><li>Teat </li></ul></ul><ul><ul><li>Canal </li></ul></ul>Role of machine milking in udder health
  41. 42. Cyclic and irregular vacuum fluctuations
  42. 43. Claw volume increased to 116 ml -9% Small milk tube bore increased to 11 mm -16% Add smt air bleeds (0.57 mm) -18% Long pulse tube restrictor (3 mm) -19% Change to alternate pulsation -20% COMBINED EFFECT -84% Key changes in machine milking affecting cyclic fluctuations
  43. 44. Knowledge on irregular vacuum fluctuations <ul><li>Blocked air bleeds </li></ul><ul><li>Low reserve </li></ul><ul><li>Excessive losses </li></ul><ul><li>Ineffective regulator </li></ul><ul><li>Liner slip </li></ul><ul><li>Cluster attachment </li></ul><ul><li>Cluster removal </li></ul><ul><li>ALL AFFECT VACUUM STABILITY AND BACTERIAL TRANSFER </li></ul>
  44. 45. Milk flow
  45. 46. Milk flow Bad Good
  46. 47. Completeness of milking Effect on teat color Effect of liner age Liner surface 0 milkings 4000 milkings
  47. 48. h Teat condition and overmilking 2 min 5 min 0 min 0 min 5 min 2 min
  48. 49. Heifers Cows Flow rate (ml/min) 200 400 200 400 Machine-on time (min) 5.5 5.0 7.9 7.4 Yield (kg) 21.1 21.2 31.5 31.6 Teat score 1.3 1.0 1.7 1.1 New infections, % cows 16 15 15 15 From MD Rasmussen Effect of ACR setting
  49. 50. Peri-harvest diagnosis <ul><li>Precision dairy farming </li></ul><ul><li>Milk harvesting technology </li></ul><ul><ul><li>Parlor performance </li></ul></ul><ul><ul><li>In-line/on-line detection of udder inflammation </li></ul></ul><ul><ul><li>Other diseases </li></ul></ul><ul><li>5 robots: 2 prep, 2 attach, 1 post-spray </li></ul><ul><li>http:// www.youtube.com/watch?v =--e_AOeOC4s </li></ul>
  50. 51. In-line/on-line diagnostics <ul><li>Small amount of milk is immediately diverted into diagnostic device: </li></ul><ul><ul><li>Milk meters: milk weight, conductivity, temperature. </li></ul></ul><ul><ul><li>Diagnostic systems: </li></ul></ul><ul><ul><ul><li>Light scattering (fat, protein, lactose, SCC) </li></ul></ul></ul><ul><ul><ul><li>Bio-sensors (LDH, progesteron, BHBA </li></ul></ul></ul><ul><ul><ul><li>Electronic tongue </li></ul></ul></ul><ul><ul><ul><li>Thermal camera </li></ul></ul></ul><ul><ul><ul><li>Light diffusion (color) </li></ul></ul></ul><ul><ul><ul><li>Capilary activity (CMT-like, SCC) </li></ul></ul></ul><ul><ul><ul><li>…… </li></ul></ul></ul>
  51. 52. Future challenges – machine milking <ul><li>Target </li></ul><ul><ul><li>Swift and complete removal of milk </li></ul></ul><ul><ul><li>Remain the integrity of milk and health of teat </li></ul></ul><ul><li>Integrate sensors </li></ul><ul><ul><li>Without disrupting milking process </li></ul></ul><ul><ul><li>Properly evaluated functioning (also economic) </li></ul></ul><ul><ul><li>Associated “new” management </li></ul></ul><ul><li>Further automation </li></ul><ul><li>Managing the teat canal </li></ul><ul><ul><li>Teat closure </li></ul></ul>
  52. 53. Topics <ul><li>Current status </li></ul><ul><ul><li>Pathogens </li></ul></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Immunology </li></ul></ul><ul><ul><li>Therapy </li></ul></ul><ul><ul><li>Environment </li></ul></ul><ul><ul><li>Milking equipment </li></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><li>Socio-economic </li></ul></ul><ul><li>Wrapping up </li></ul>
  53. 54. <ul><ul><li>Dry cow antibiotics </li></ul></ul><ul><ul><li>Post milking teat disinfection </li></ul></ul><ul><ul><li>Milking and milking machine </li></ul></ul><ul><ul><li>Clinical mastitis cases </li></ul></ul><ul><ul><li>Chronically infected cows </li></ul></ul>Basis for numerous on farm udder health programs Have shown to be effective The 5-point plan on contagious mastitis
  54. 55. Sampimon et al., 2009 Dutch prevalence studies
  55. 56. <ul><li>establishment of goals for udder health </li></ul><ul><li>maintenance of clean, comfortable environment </li></ul><ul><li>proper milking procedures </li></ul><ul><li>proper maintenance and use of milking equipment </li></ul><ul><li>good record keeping </li></ul><ul><li>appropriate management of clinical mastitis during lactation </li></ul><ul><li>effective dry cow management </li></ul><ul><li>maintenance of biosecurity for contagious pathogens and culling of chronically infected cows </li></ul><ul><li>regular monitoring of udder health status </li></ul><ul><li>periodic review of mastitis control program </li></ul>The 10 point plan
  56. 57. Contagious mastitis Environmental mastitis Infectious pressure Zadoks, 2002
  57. 58. % score 3 and 4 % score 3 and 4 % new infections BMSCC Hygiene and udder health Schreiner and Ruegg, 2003
  58. 59. Prevent other contact with the milking machine
  59. 60. More than taking measures <ul><li>Evaluation </li></ul><ul><ul><li>Udder health </li></ul></ul><ul><ul><ul><li>BMSCC </li></ul></ul></ul><ul><ul><ul><li>Incidence rate clinical mastitis </li></ul></ul></ul><ul><ul><ul><li>Cows with high SCC </li></ul></ul></ul><ul><ul><ul><li>… .. </li></ul></ul></ul><ul><ul><li>Intermediate factors </li></ul></ul><ul><ul><ul><li>Udder hygiene </li></ul></ul></ul><ul><ul><ul><li>Teat condition </li></ul></ul></ul><ul><ul><ul><li>… . </li></ul></ul></ul><ul><ul><li>Tools are available </li></ul></ul>
  60. 62. Teat scoring strategy
  61. 63. <ul><li>Straightforward management: </li></ul><ul><li>replace after 2500 milkings </li></ul><ul><li>- What are farmers doing? </li></ul>Remember the liners …
  62. 64. Frequency liner replacement Olde Riekerink and Sampimon, 2008
  63. 65. Number of herds 70% Milkings before replacement
  64. 66. Future challenges – Management <ul><li>(Further) develop management measures and tools </li></ul><ul><ul><li>Applicable for a variety of modern dairy farmers </li></ul></ul><ul><ul><li>Straightforward </li></ul></ul><ul><ul><li>Use of technology (precision dairy farming) </li></ul></ul><ul><li>Estimate effect of management measures (“clinical trials”) </li></ul><ul><ul><li>Give advisor arguments to “sell” improved management </li></ul></ul>
  65. 67. Topics <ul><li>Current status </li></ul><ul><ul><li>Pathogens </li></ul></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Immunology </li></ul></ul><ul><ul><li>Therapy </li></ul></ul><ul><ul><li>Environment </li></ul></ul><ul><ul><li>Milking equipment </li></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><li>Socio-economics </li></ul></ul><ul><li>Wrapping up </li></ul>
  66. 68. Literature (€) 1€ = 1.27$US Bar 2008 Halasa 2009 Hagnestam-Nielsen 2009 Huijps 2008 Level Cow Cow Cow-year Cow Milk production losses - 11 78 36 Labour - 11 - 4 Treatment - 14 - 15 Culling - 46 - 22 Death - 0 - 0 Veterinarian - 2 - 1 Milk quality - 0 - 0 Materials - 0 - 0 Diagnostics - 0 - 0 Total 61 84 97 78
  67. 69. Mastitis costs money <ul><li>Estimations: $US 77 – 123 /cow/year </li></ul><ul><li>Variation between farms: </li></ul><ul><ul><li>The Netherlands: $US 99 -195 </li></ul></ul><ul><ul><li>US: $US 45 – 620 </li></ul></ul><ul><li>Farmers attitude: </li></ul><ul><ul><li>Know mastitis = $$$$ </li></ul></ul><ul><ul><li>Underestimate the costs </li></ul></ul>
  68. 70. Specific studies on treatment specifically subclinical mastitis <ul><li>Streptococci: € 12/treatment (Swinkels et al., 2005a) </li></ul><ul><ul><li>Partial budget model R = 0.21 </li></ul></ul><ul><li>Staphylococci: - € 21/treatment (Swinkels et al., 2005b) </li></ul><ul><ul><li>Partial budget model R = 0.32 </li></ul></ul><ul><li>Streptococci: - € 11/treatment (Steeneveld et al., 2007) </li></ul><ul><ul><li>Stochastic model </li></ul></ul><ul><li>Gram positive: € 2,601/100 cows (Van den Borne et al., 2010) </li></ul><ul><ul><li>Stochastic dynamic model </li></ul></ul>
  69. 71. Additional expenditures Reduced losses Net benefit Milk cows with clinical mastitis last 37 16 -21 Milk cows with subclinical mastitis last 104 20 -84 Use of separate cloths during udder preparation 26 9 -17 Wash dirty udders during udder preparation 3 9 6 Prestripping 34 9 -25 Use of milkers’ gloves during milking 1 9 8 Post milking teat disinfection 31 31 -0 Back-flushing clusters after milking a cow with clinical mastitis 1 11 10 Back-flushing clusters after milking a cow with subclinical mastitis 123 15 -108 Replace teat cup liners in time 13 11 -2 Use of a treatment protocol 7 15 8 Application of blanket dry cow therapy 9 36 27 Keep cows standing after milking 2 12 10 Feed additional dry cow minerals 13 13 0 Prevent overcrowding 23 13 -10 Clean boxes 54 15 -39 Clean yards 51 8 -43 Optimize feed ration 24 13 -11
  70. 72. Money is not the only motivator Theory of planned behaviour … ..and there are lots of other frameworks There is an intention-behaviour discrepancy among farmers
  71. 73. Future challenges – socio economics <ul><li>Cost calculations at chain level </li></ul><ul><ul><li>More than accumulation of individual farms </li></ul></ul><ul><ul><li>What are economic consequences of a loss of image </li></ul></ul><ul><li>Cost-effectiveness of management </li></ul><ul><ul><li>Lack of clinical trials </li></ul></ul><ul><ul><li>Effect of measure depends on assumptions (dynamics) </li></ul></ul><ul><li>More insight in motivating farmers </li></ul><ul><ul><li>Bringing the message </li></ul></ul><ul><ul><li>Money </li></ul></ul><ul><ul><li>Other factors </li></ul></ul>
  72. 75. Topics <ul><li>Current status </li></ul><ul><ul><li>Pathogens </li></ul></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Immunology </li></ul></ul><ul><ul><li>Therapy </li></ul></ul><ul><ul><li>Environment </li></ul></ul><ul><ul><li>Milking equipment </li></ul></ul><ul><ul><li>Management </li></ul></ul><ul><ul><li>Socio-economics </li></ul></ul><ul><li>Wrapping up </li></ul>
  73. 76. Reality in developed countries <ul><li>The ‘consumer’ demand: </li></ul><ul><ul><li>A safe healthy product </li></ul></ul><ul><ul><li>Healthy happy cows </li></ul></ul><ul><ul><li>Environmental friendly </li></ul></ul><ul><li>Government (politicians) demands: </li></ul><ul><ul><li>No risk for humans </li></ul></ul><ul><li>Human medicine demands: </li></ul><ul><ul><li>Decrease of antibiotics and hormones in cattle </li></ul></ul><ul><ul><li>Deal with (potential) zoonotic diseases </li></ul></ul><ul><li>Business behavior results in an increase in herd size </li></ul>
  74. 77. Consequences <ul><li>Consumers “in the barn” </li></ul><ul><li>Restrictive use of antibiotics and hormones </li></ul><ul><li>Change in definition of “Quality” </li></ul><ul><li>More organic farms </li></ul><ul><li>Control of zoonotic disease requires </li></ul><ul><li>Changed farming systems </li></ul>
  75. 78. So … <ul><li>Mastitis was and remains: </li></ul><ul><ul><li>A production (economic) disease </li></ul></ul><ul><ul><li>A welfare burden </li></ul></ul><ul><li>Mastitis is becoming: </li></ul><ul><ul><li>An image issue </li></ul></ul><ul><ul><li>A sustainability issue </li></ul></ul><ul><ul><ul><li>(less mastitis -> less culling -> less youngstock raising -> less greenhouse gas emissions etc. </li></ul></ul></ul><ul><li>Of increased importance </li></ul>
  76. 79. Finally <ul><li>We’ve come from far, we’ve done a lot </li></ul><ul><li>There are many challenges ahead of us </li></ul>We acknowledge the Dutch dairy industry for initiating this mastitis forum

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