Junior Trainees Group (JTG) of the British Association of Oral and Maxillofacial Surgeons (BAOMS) conference 2018: overview of the conference and analysis of delegates' feedback.

The Junior Trainees Group (JTG) of the British Association of Oral and Maxillofacial Surgeons (BAOMS) and the JTG Annual Conference aim to support pre-registrar trainees interested in OMFS. The theme of the 2018 conference, "Research and Innovation" was disseminated through a diversity of expert speakers and interactive workshops. This paper provides an overview of the conference and analysis of the delegates' feedback to show how it represented their interests and influenced their decisions to pursue OMFS. Online questionnaires assessed demographics and the impact of the conference on numerous aspects of the decisions made about careers by delegates at different levels of training. A Kruskal Wallis test with post-hoc pairwise comparisons was done to assess the significance of differences between groups. A total of 135 delegates completed the questionnaires (13% dual-qualified; 13% second-degree medics; 18% second-degree dentists; 6% singly-qualified medics; 41% singly-qualified dentists; 5% first-degree medics; and 4% first-degree dentists), and 141 submitted abstracts of which 32 poster and 12 oral presentations were accepted. A total of 79/135 (59%) were members of the BAOMS. Word-of-mouth was the commonest way by which delegates became aware of the conference. As the stage of training advanced, they agreed more that it represented their training level and influenced them to pursue research and attend the BAOMS 2018 conference. The JTG conference is the only national meeting for pre-registrar trainees, and this year there were record numbers of delegates and abstracts. As the JTG grows, we continue to assist juniors to pursue their involvement in OMFS units and to participate in research and collaborative projects. Our goals are to expand as a national platform to represent junior trainees who are interested in OMFS, and to support them as they progress towards registrar training.

Cost-based optimization of the stopping threshold for local disease surveillance during progressive eradication of tuberculosis from New Zealand wildlife.

Bovine tuberculosis (TB) is managed in New Zealand largely via population reduction of the major wildlife disease reservoir of Mycobacterium bovis, the introduced brushtail possum Trichosurus vulpecula. New Zealand aims to eradicate M. bovis infection from its livestock and wildlife within 40 years, as the culmination of progressive regional eradication programmes. Declarations of regional eradication are decided after extensive possum population control and post-control surveillance; hence, we developed a modelling framework, based on eco-epidemiological simulation data, to provide cost-evaluated options for deciding when to make these declarations. A decision-support framework evaluated potential costs of wildlife surveillance (and recontrol, if required) with respect to the calculated probability of successful eradication of M. bovis from wildlife. This enabled expected costs to be predicted in terms of stopping thresholds, allowing selection of optimal stopping rules based on minimizing costs. We identified factors that could influence optimal stopping values applied during regional eradication. Where vector/disease surveillance was inexpensive (for example, using low-cost detection devices or sentinel wildlife hosts) optimization involved setting a higher rather than lower stopping value, as it would be cheaper to minimize the risk of making a false declaration of eradication than to remedy any such failure. In addition, any cost of recontrol would largely depend on the time to rediscovery of residual M. bovis infection in wildlife, which would in turn be linked to the level of ongoing passive surveillance (with more rapid detection of re-emergent infection among wildlife in farmland situations than in remote forested regions). These two scenarios would favour different optimal stopping rules, as would the consideration of stakeholder confidence and socio-political issues, which are discussed. The framework presented here provides guidance to assess the economics underlying eradication of bovine TB from New Zealand farming; this eliminates reliance upon a pre-determined and uniform stopping rule for ceasing active management.

Livestock as sentinels for an infectious disease in a sympatric or adjacent-living wildlife reservoir host.

A central question to address in managing wildlife diseases is how much effort and resources are required to reduce infection prevalence to below a requisite threshold? This requires surveillance for infection in at least one species involved in the infection cycle, a process that is often expensive and time-consuming but one which could be enhanced using additional sources of readily-obtainable surveillance data. We demonstrate how surveillance data from ruminant livestock monitored for bovine tuberculosis (bTB) in New Zealand can be employed in spatially-explicit modelling to help predict the probability of freedom from Mycobacterium bovis infection in a sympatric wildlife reservoir species, the brushtail possum (Trichosurus vulpecula). We apply the model to a case study and compare resulting probabilities of freedom when utilizing (1) livestock data only, (2) wildlife data only, and (3) combined livestock-plus-wildlife surveillance data. Results indicated that the greatest probability of M. bovis eradication was achieved using wildlife monitoring data supplemented with livestock surveillance data. This combined approach lessened the time required for a confident (95% probability) declaration of regional eradication. However, the combined model was sensitive to the precision of the input parameters, and we describe ways to account for this. In a broad sense, this modelling approach is flexible in that any spatial arrangement of wildlife habitat and farms can be analysed, provided infection is readily detectable in both the wild and domestic animal(s) of interest. It is applicable to monitoring any communicable wildlife disease that affects regularly-tested livestock. The potential benefits to wildlife disease management include reduced surveillance costs and more rapid achievement of targeted reductions in disease prevalence.

An audit of CT chest surveillance following oral cancer treatment.

Computed tomography (CT) of the chest is an integral part of the staging of patients with oral cancer. It identifies metastases, synchronous pulmonary primaries, and detects small nodules of indeterminate character that require a follow-up scan. We aimed to find out how many patients with small nodules had had subsequent scans, and the outcome of those who did. Between 2010 and 2013, 413 patients with oral squamous cell carcinoma (SCC) were treated with curative intent or were actively monitored at the Merseyside and Cheshire Regional Surgical Head and Neck Unit. A total of 324 (78%) had CT at diagnosis. The scans of 246 were clear, metastases were detected in 4, and 51 showed abnormalities. Forty-nine of the patients with abnormalities were recommended for further interval scans but only 20 (41%) actually had them. Further pathological findings were found in 11 (increase in the size of the nodule n=2; metastatic disease n=5; and primary pulmonary tumour n=4). A substantial number of patients did not have the recommended follow-up scans and potentially serious disease was found in some who did. As a result of this audit we have changed the process regarding the booking of CT surveillance scans, and we now check periodically that they have been done. The audit will be repeated to include other sites in the head and neck.

A CCL24-dependent pathway augments eosinophilic airway inflammation in house dust mite-challenged Cd163(-/-) mice.

CD163 is a macrophage scavenger receptor with anti-inflammatory and pro-inflammatory functions. Here, we report that alveolar macrophages (AMΦs) from asthmatic subjects had reduced cell-surface expression of CD163, which suggested that CD163 might modulate the pathogenesis of asthma. Consistent with this, house dust mite (HDM)-challenged Cd163(-/-) mice displayed increases in airway eosinophils and mucous cell metaplasia (MCM). The increased airway eosinophils and MCM in HDM-challenged Cd163(-/-) mice were mediated by augmented CCL24 production and could be reversed by administration of a neutralizing anti-CCL24 antibody. A proteomic analysis identified the calcium-dependent binding of CD163 to Dermatophagoides pteronyssinus peptidase 1 (Der p1). Der p1-challenged Cd163(-/-) mice had the same phenotype as HDM-challenged Cd163(-/-) mice with increases in airway eosinophils, MCM and CCL24 production, while Der p1 induced CCL24 secretion by bone marrow-derived macrophages (BMMΦs) from Cd163(-/-) mice, but not BMMΦs from wild-type (WT) mice. Finally, airway eosinophils and bronchoalveolar lavage fluid CCL24 levels were increased in Der p1-challenged WT mice that received adoptively transferred AMΦ's from Cd163(-/-) mice. Thus, we have identified CD163 as a macrophage receptor that binds Der p1. Furthermore, we have shown that HDM-challenged Cd163(-/-) mice have increased eosinophilic airway inflammation and MCM that are mediated by a CCL24-dependent mechanism.

Development of the New Zealand strategy for local eradication of tuberculosis from wildlife and livestock.

We describe the progressive development of New Zealand's national strategy for control of tuberculosis (TB) in its agricultural sector over the last four decades. The strategy is globally unique, reflecting the need for effective and co-ordinated management of TB in a wildlife maintenance host, the brushtail possum (Trichosurus vulpecula), in addition to controlling infection in cattle and farmed deer herds. Since the early 1990s, the strategy has been developed by the Animal Health Board (AHB), formed to empower the farming industry to take the leadership role in funding of TB control, policy development and administration. The AHB became the first non-government organisation to develop and gain acceptance by the funders (farming industry and government) of a National Pest Management Strategy (NPMS) under the Biosecurity Act 1993. A key outcome of the NPMS for TB control was the development and inclusion of very challenging objectives that provided direction for management, research and possum control. This paper describes the process whereby the NPMS was revised twice, following achievement of each successive set of strategy objectives within budget. Success was based on firstly, reorganisation of the AHB and its operational systems to achieve increased efficiency; secondly, improved efficiency through contracting possum and disease control, and thirdly research delivering effective and practical applications, while also providing a scientific basis for setting directions for future control strategies. The last revision of the NPMS was implemented in 2011, and included objectives to eradicate Mycobacterium bovis-infected wildlife populations over 2.5 million hectares by 2026. This ambitious objective was adopted only after extensive forecast modelling enabled stakeholders to identify and select the most cost-effective long-term solution for the management of M. bovis-infected possum populations. The accomplishment of New Zealand's TB control programme, in meeting successive sets of demanding NPMS objectives, has seen a 95% decrease in the number of infected cattle and deer herds since they peaked at 1,694 in 1994, and the eradication of TB from infected possum populations from 830,000 hectares. Provided the current level of funding continues, New Zealand is positioned to achieve national eradication of TB well in advance of the 40-50-year timeline forecast 3 years ago.

Toward eradication: the effect of Mycobacterium bovis infection in wildlife on the evolution and future direction of bovine tuberculosis management in New Zealand.

New Zealand's bovine tuberculosis (TB) control programme has greatly reduced the burden of tuberculosis on the farming industry, from 11% of mature cattle found with TB at slaughter in 1905 to <0.003% in 2012/13. New Zealand implemented TB control measures in cattle from the mid-twentieth century, and later in farmed deer. Control was based on established methods of tuberculin testing of herds, slaughter of suspect cases, and livestock movement control. Unexplained regional control failures and serious disease outbreaks were eventually linked to wildlife-vectored infection from the introduced Australian brushtail possum (Trichosurus vulpecula), which also triggered a wildlife disease complex involving a range of introduced species. This paper reviews the progressive elucidation of the epidemiology of Mycobacterium bovis in New Zealand's wildlife and farmed livestock, and the parallel development of research-led, multi-faceted TB control strategies required to protect New Zealand's livestock industries from damaging infection levels. The adoption of coordinated national pest management strategies, with increasingly ambitious objectives agreed between government and industry funders, has driven a costly but very successful management regime targeted at controlling TB in the possum maintenance host. This success has led to initiation of a strategy designed to eradicate TB from New Zealand's livestock and wildlife, which is considered a realistic long-term prospect.

Epidemiology and control of Mycobacterium bovis infection in brushtail possums (Trichosurus vulpecula), the primary wildlife host of bovine tuberculosis in New Zealand.

The introduced Australian brushtail possum (Trichosurus vulpecula) is a maintenance host for bovine tuberculosis (TB) in New Zealand and plays a central role in the TB problem in this country. The TB-possum problem emerged in the late 1960s, and intensive lethal control of possums is now used to reduce densities to low levels over 8 million ha of the country. This review summarises what is currently known about the pathogenesis and epidemiology of TB in possums, and how the disease responds to possum control. TB in possums is a highly lethal disease, with most possums likely to die within 6 months of becoming infected. The mechanisms of transmission between possums remain unclear, but appear to require some form of close contact or proximity. At large geographic scales, TB prevalence in possum populations is usually low (1-5%), but local prevalence can sometimes reach 60%. Intensive, systematic and uniform population control has been highly effective in breaking the TB cycle in possum populations, and where that control has been sustained for many years the prevalence of TB is now zero or near zero. Although some uncertainties remain, local eradication of TB from possums appears to be straightforward, given that TB managers now have the ability to reduce possum numbers to near zero levels and to maintain them at those levels for extended periods where required. We conclude that, although far from complete, the current understanding of TB-possum epidemiology, and the current management strategies and tactics, are sufficient to achieve local, regional, and even national disease eradication from possums in New Zealand.

The epidemiology of Mycobacterium bovis in wild deer and feral pigs and their roles in the establishment and spread of bovine tuberculosis in New Zealand wildlife.

In New Zealand, wild deer and feral pigs are assumed to be spillover hosts for Mycobacterium bovis, and so are not targeted in efforts aimed at locally eradicating bovine tuberculosis (TB) from possums (Trichosurus vulpecula), the main wildlife host. Here we review the epidemiology of TB in deer and pigs, and assess whether New Zealand's TB management programme could be undermined if these species sometimes achieve maintenance host status. In New Zealand, TB prevalences of up to 47% have been recorded in wild deer sympatric with tuberculous possums. Patterns of lesion distribution, age-specific prevalences and behavioural observations suggest that deer become infected mainly through exposure to dead or moribund possums. TB can progress rapidly in some deer (<10%), but generalised disease is uncommon in wild deer; conversely some infected animals can survive for many years. Deer-to-deer transmission of M. bovis is rare, but transmission from tuberculous deer carcasses to scavengers, including possums, is likely. That creates a small spillback risk that could persist for a decade after transmission of new infection to wild deer has been halted. Tuberculosis prevalence in New Zealand feral pigs can reach 100%. Infections in lymph nodes of the head and alimentary tract predominate, indicating that TB is mostly acquired through scavenging tuberculous carrion, particularly possums. Infection is usually well contained, and transmission between pigs is rare. Large reductions in local possum density result in gradual declines (over 10 years) in TB prevalence among sympatric wild deer, and faster declines in feral pigs. Elimination of TB from possums (and livestock) therefore results in eventual disappearance of TB from feral pigs and wild deer. However, the risk of spillback infection from deer to possums substantially extends the time needed to locally eradicate TB from all wildlife (compared to that which would be required to eradicate disease from possums alone), while dispersal or translocation of pigs (e.g. by hunters) creates a risk of long-distance spread of disease. The high rate at which pigs acquire M. bovis infection from dead possums makes them useful as sentinels for detecting TB in wildlife. It is unlikely that wild deer and feral pigs act as maintenance hosts anywhere in New Zealand, because unrestricted year-round hunting keeps densities low, with far less aggregation than on New Zealand farms. We conclude that active management of wild deer or feral pigs is not required for local TB eradication in New Zealand.

Feral ferrets (Mustela furo) as hosts and sentinels of tuberculosis in New Zealand.

The control and eventual eradication of bovine tuberculosis (TB) poses major challenges in New Zealand, given the variety of wildlife species susceptible to TB, many of which are capable of onwards transmission of Mycobacterium bovis infection. Here we discuss the role of feral ferrets (Mustela furo), focussing on potential transmission or risk pathways that have implications for management of TB. Firstly inter-specific transmission to ferrets. Ferrets scavenge potentially infected wildlife, including other ferrets, thus prevalence of TB can be amplified through ferrets feeding on tuberculous carcasses, particularly brushtail possums (Trichosurus vulpecula). Secondly intra-specific transmission between ferrets. The rate of ferret-ferret transmission depends on population density, and in some places ferret densities exceed the estimated threshold for disease persistence. TB can therefore potentially be maintained independently of other sources of infection. Thirdly transmission from ferrets to other wildlife. These include the main wildlife maintenance host, brushtail possums, that will occasionally scavenge potentially tuberculous ferret carcasses. Fourthly transmission from ferrets to livestock. This is considered to occur occasionally, but the actual rate of transmission has never been measured. Fifthly geographical spread. M. bovis-infected ferrets can travel large distances and cause new outbreaks of TB at locations previously free of TB, which may have caused an expansion of TB-endemic areas. Ferrets play a complex role in the TB cycle in New Zealand; they are capable of contracting, amplifying and transmitting M. bovis infection, sometimes resulting in ferret populations with a high prevalence of TB. However, ferret population densities are usually too low to sustain infection independently, and transmission to other wildlife or livestock appears a rarer event than with possums. Nevertheless, management of ferrets remains a key part of the National Pest Management Strategy for TB. Control is prudent where M. bovis-infected ferret populations exist in high numbers, to reduce the onward transmission risk of any self-sustained infection to livestock. When ferret numbers are well below the theoretical disease maintenance threshold, ferret control is still sometimes warranted because of the animals' ability to acquire infection when young and, through dispersal, transport it outside TB-endemic areas. Ferrets can also be used as disease sentinels for TB, especially in areas where alternative sentinel species are rare or expensive to survey, and when sampling of possums is not cost-effective.

Development of integrated surveillance systems for the management of tuberculosis in New Zealand wildlife.

Disease surveillance for the management of bovine tuberculosis (TB) in New Zealand has focussed, to a large extent, on the development of tools specific for monitoring Mycobacterium bovis infection in wildlife. Diagnostic techniques have been modified progressively over 30 years of surveillance of TB in wildlife, from initial characterisation of gross TB lesions in a variety of wildlife, through development of sensitive culture techniques to identify viable mycobacteria, to molecular identification of individual M. bovis strains. Of key importance in disease surveillance has been the elucidation of the roles that different wildlife species play in the transmission of infection, specifically defining brushtail possums (Trichosurus vulpecula) as true maintenance hosts compared to those that are predominantly spillover hosts, but which may serve as useful sentinel species to indicate TB persistence. Epidemiological modelling has played a major role in TB surveillance, initially providing the theoretical support for large-scale possum population control and setting targets at which control effort should be deployed to ensure disease eradication. As TB prevalence in livestock and wildlife declined throughout the 2000s, more varied field tools were developed to gather surveillance data from the diminishing possum populations, and to provide information on changing TB prevalence. Accordingly, ever more precise (but disparate) surveillance information began to be integrated into multi-faceted decision-assist models to support TB management decisions, particularly to provide informed parameters at which control effort could be halted, culminating in the Proof of Freedom modelling framework that now allows an area to be declared TB-free within chosen confidence limits. As New Zealand moves from large-scale TB control to regional eradication of disease in the coming years, further integrative models will need to be developed to support management decisions, based on combined field data of possum and TB prevalence, sentinel information, risk assessment in relation to financial benefits, and changing political and environmental needs.

Assessing the Effectiveness of Tuberculosis Management in Brushtail Possums (Trichosurus vulpecula), through Indirect Surveillance of Mycobacterium bovis Infection Using Released Sentinel Pigs.

In New Zealand, wild pigs acquire Mycobacterium bovis infection by scavenging tuberculous carrion, primarily carcasses of the main disease maintenance host, the brushtail possum (Trichosurus vulpecula). We investigated the utility of captive-reared, purpose-released pigs as sentinels for tuberculosis (TB) following lethal possum control and subsequent population recovery. Within 2-3 years of possum control by intensive poisoning, TB prevalence and the incidence rate of M. bovis infection in released sentinel pigs were lower than in an adjacent area where possums had not been poisoned. Unexpectedly, TB did not decline to near zero levels among pigs in the poisoned area, a fact which reflected an unanticipated rapid increase in the apparent abundance of possums. Monitoring infection levels among resident wild pigs confirmed that TB prevalence, while reduced due to possum control, persisted in the poisoned area at >20% among pigs born 2-3 years after poisoning, while remaining >60% among resident wild pigs in the nonpoisoned area. When fitted with radio-tracking devices, purpose-released pigs provided precise spatial TB surveillance information and facilitated effective killing of wild pigs when employed as "Judas" animals to help locate residents. Sentinel pigs offer value for monitoring disease trends in New Zealand, as TB levels in possums decline nationally due to large-scale possum control.

Comparison of ranging behaviour in a multi-species complex of free-ranging hosts of bovine tuberculosis in relation to their use as disease sentinels.

Sentinel species are increasingly used by disease managers to detect and monitor the prevalence of zoonotic diseases in wildlife populations. Characterizing home-range movements of sentinel hosts is thus important for developing improved disease surveillance methods, especially in systems where multiple host species co-exist. We studied ranging activity of major hosts of bovine tuberculosis (TB) in an upland habitat of New Zealand: we compared home-range coverage by ferrets (Mustela furo), wild deer (Cervus elaphus), feral pigs (Sus scrofa), brushtail possums (Trichosurus vulpecula) and free-ranging farmed cattle (Bos taurus). We also report in detail the proportional utilization of a seasonal (4-monthly) range area for the latter four species. Possums covered the smallest home range (<30 ha), ferrets covered ~100 ha, pigs ~4 km(2), deer and cattle both >30 km2. For any given weekly period, cattle, deer and pigs were shown to utilize 37­45% of their estimated 4-month range, while possums utilized 62% during any weekly period and 85% during any monthly period of their estimated 4-month range. We suggest that present means for estimating TB detection kernels, based on long-term range size estimates for possums and sentinel species, probably overstate the true local surveillance coverage per individual.

A novel approach to assess the probability of disease eradication from a wild-animal reservoir host.

Surveying and declaring disease freedom in wildlife is difficult because information on population size and spatial distribution is often inadequate. We describe and demonstrate a novel spatial model of wildlife disease-surveillance data for predicting the probability of freedom of bovine tuberculosis (caused by Mycobacterium bovis) in New Zealand, in which the introduced brushtail possum (Trichosurus vulpecula) is the primary wildlife reservoir. Using parameters governing home-range size, probability of capture, probability of infection and spatial relative risks of infection we employed survey data on reservoir hosts and spillover sentinels to make inference on the probability of eradication. Our analysis revealed high sensitivity of model predictions to parameter values, which demonstrated important differences in the information contained in survey data of host-reservoir and spillover-sentinel species. The modelling can increase cost efficiency by reducing the likelihood of prematurely declaring success due to insufficient control, and avoiding unnecessary costs due to excessive control and monitoring.

Percutaneous interdigital injection of Mycobacterium bovis as a model for tuberculous lesion development in wild brushtail possums (Trichosurus vulpecula).

Brushtail possums (Trichosurus vulpecula) are the major wildlife reservoir of Mycobacterium bovis, the causative agent of bovine tuberculosis (BTB), in New Zealand. Primary diagnosis of BTB in wild possums is by palpation to detect peripheral lymphadenomegaly followed by necropsy examination, which frequently identifies gross tuberculous lesions in the peripheral lymph nodes and lungs. Experimental infection studies were conducted with wild possums in an attempt to emulate field BTB, focussing on percutaneous administration of virulent M. bovis in the paws. In a preliminary study, viable M. bovis bacilli were recovered from lymph nodes draining fore- or hindlimbs 12 days after percutaneous injection. Subsequently, 21 wild possums were injected interdigitally with 500 colony forming units (cfu) of M. bovis, radio-collared and released; 17/18 possums recaptured 8 weeks later had an established M. bovis lymphatic infection, with 16 having culture-positive gross lesions in the superficial and/or deep axillary lymph nodes. A dual-site infection model was established, involving simultaneous interdigital injection of 100 cfu of M. bovis into front and rear paws of 19 wild possums; this identified that the average degree of lymphadenitis involved 30-fold enlargement of the draining lymph node by 7-8 weeks post injection (wpi). A time-course study demonstrated establishment of M. bovis infection in peripheral lymph nodes of 9/11 possums at 3-5 wpi of doses ranging from 60 to 190 cfu, but with no development of gross lesions; by 7 weeks, 8/8 animals injected similarly had both an established infection and gross lesions of peripheral lymph nodes. The incidence and progression of peripheral lesion development, together with indications of sequential infection of the lungs, liver and mesenteric lymph nodes(MLNs), indicates that a low-dose percutaneous M. bovis infection model is likely to emulate natural disease in possums.

Importance and mitigation of the risk of spillback transmission of Mycobacterium bovis infection for eradication of bovine tuberculosis from wildlife in New Zealand.

Introduced brushtail possums (Trichosurus vulpecula) are wildlife maintenance hosts for Mycobacterium bovis in New Zealand, often living sympatrically with other potential hosts, including wild red deer (Cervus elaphus scoticus). Population control of possums has been predicted to eradicate tuberculosis (TB) from New Zealand wildlife ; however, there is concern that long-lived M. bovis-infected deer could represent a ' spillback' risk for TB re-establishment (particularly when possum populations recover after cessation of intensive control). We constructed a time-, age- and sex-structured, deer/TB population generic model and simulated the outcomes of deer control on this potential spillback risk. Maintaining intensive possum control on a 5-year cycle, the predicted spillback risk period after TB eradication from possums is ~7 years, while the probability of TB re-establishing in possums over that period is ~6%. Additional targeted control of deer would reduce the risk period and probability of spillback; however, even with high population reductions (up to 80%) only modest decreases in risk and risk period would be achieved. We conclude that possum control alone remains the best strategy for achieving TB eradication from New Zealand habitats in which possums and wild deer are the main M. bovis hosts.

Reduced spillover transmission of Mycobacterium bovis to feral pigs (Sus scofa) following population control of brushtail possums (Trichosurus vulpecula).

In New Zealand, bovine tuberculosis (bTB) is present in domestic cattle and deer herds primarily as the result of on-going disease transmission from the primary wildlife host, the brushtail possum (Trichosurus vulpecula). However, bTB is also present in other introduced free-ranging mammalian species. Between 1996 and 2007, we conducted a series of studies to determine whether poison control of possum populations would have any effect on the prevalence of Mycobacterium bovis infection in sympatric feral pigs (Sus scrofa). We compared trends in the prevalence of bTB infection in feral pigs in six study areas: possum numbers were reduced in three areas, but not in the other three, effectively providing a thrice-replicated before-after-control-intervention design. Before possum control, the overall prevalence of culture-confirmed M. bovis infection in feral pigs was 16.7-94.4%, depending on area. Infection prevalence varied little between genders but did vary with age, increasing during the first 2-3 years of life but then declining in older pigs. In the areas in which possum control was applied, M. bovis prevalence in feral pigs fell to near zero within 2-3 years, provided control was applied successfully at the whole-landscape scale. In contrast, prevalence changed much less or not at all in the areas with no possum control. We conclude that feral pigs in New Zealand acquire M. bovis infection mainly by inter-species transmission from possums, but then rarely pass the disease on to other pigs and are end hosts. This is in contrast to the purported role of pigs as bTB maintenance hosts in other countries, and we suggest the difference in host status may reflect differences in the relative importance of the oral route of infection in different environments. Despite harbouring M. bovis infection for a number of years, pigs in New Zealand do not sustain bTB independently, but are good sentinels for disease prevalence in possum populations.

Mycobacterium avium subsp. paratuberculosis infection in wildlife on three deer farms with a history of Johne's disease.

AIM: To determine the prevalence of Mycobacterium avium subsp. paratuberculosis (Map) infection in wildlife, in pastoral landscapes with a recent history of clinical Johne's disease in livestock. METHODS: A total of 449 wild mammals and birds from three farms in the South Island of New Zealand with recent histories of clinical Johne's disease in their deer herds were trapped and examined for gross pathological changes in the gastrointestinal tract. Additionally, individual mesenteric lymph nodes from 380 mammals, and segments of gastrointestinal tract from 32 birds were excised, homogenised and cultured for viable Map bacilli. The prevalence of Map infection was then calculated for the various species. Faecal samples from those mammals which had culture-positive tissues were further cultured for the presence of Map. RESULTS: Gross pathological changes were identified in the gastrointestinal tract of four brushtail possums, one cat, six ferrets, 12 hares, six hedgehogs, three rabbits, one stoat, and one paradise shelduck. Infection with Map in the gastrointestinal tract was confirmed in only three of these cases, one each of brushtail possums, hares and hedgehogs. In contrast, Map infection in the absence of gross pathological changes was frequently recorded in enteric tract tissues of mammals and birds. Among mammals, Map infection was recorded in 18/73 (25%) brushtail possums, 4/23 (17%) cats, 15/42 (36%) hedgehogs and 29/113 (26%) rabbits. Among birds, intestinal tract tissue Map infection was recorded in 3/17 (18%) paradise shelducks. Among 64 of the 74 mammals which had Map culture-positive tissues, 38% (n=5) of hedgehogs and 11% (n=3) of rabbits also had culture-positive faecal samples. CONCLUSIONS: This study is the first to identify that Map infection can be prevalent in wildlife in New Zealand. There was a high prevalence of Map infection among both scavenging and grazing wild animals. Both mammals and birds are capable of harbouring viable Map organisms in their gastrointestinal tract; further, viable Map was excreted into the environment via faeces by hedgehogs and rabbits. CLINICAL RELEVANCE: Previous studies overseas have postulated a role of wildlife as reservoirs of Map infection and possible vectors of Johne's disease to livestock. Here, brushtail possums, hedgehogs and rabbits and in particular were identified as potential wildlife hosts for Map infection in New Zealand. This suggests that several wildlife species could contribute to the persistence of Map infection within a wildlife/livestock complex, and potentially, perhaps more importantly, to the spread of infection between farms.

Holding relationships in primary care: a qualitative exploration of doctors' and patients' perceptions.

BACKGROUND: Ongoing doctor-patient relationships are integral to the patient-centred ideals of UK general practice, particularly for patients with chronic conditions or complex health problems. 'Holding', a doctor-patient relationship defined as establishing and maintaining a trusting, constant, reliable relationship that is concerned with ongoing support without expectation of cure, has previously been suggested as a management strategy for such patients. AIM: To explore urban GPs' and patients' experiences of the management of chronic illness, with a particular focus on holding relationships. DESIGN AND SETTING: A qualitative study in urban and suburban areas of north west England. METHOD: Participating GPs recruited registered patients with chronic illness with whom they felt they had established a holding relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis. RESULTS: GP responders considered holding to be a small but routine part of their work. Benefits described included providing support to patients but also containing demands on secondary care. Patient responders, all with complex ongoing needs, described the relationship with their GP as a reassuring, positive, and securing partnership. Both GP and patient responders emphasised the importance of pre-existing knowledge of past life-story, and valued holding as a potential tool for changing health-related behaviour. Difficulties with holding work included fears of dependency, and problems of access. CONCLUSION: Holding relationships are a routine part of general practice, valued by both GPs and patients. Naming and valuing holding work may legitimise this activity in the management of people with chronic and complex health problems.