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1.
Commun Biol ; 4(1): 508, 2021 04 29.
Article in English | MEDLINE | ID: mdl-33927339

ABSTRACT

Immune evasion of pathogens can modify the course of infection and impact viral persistence and pathology. Here, using different strains of the lymphocytic choriomeningitis virus (LCMV) model system, we show that slower propagation results in limited type I interferon (IFN-I) production and viral persistence. Specifically, cells infected with LCMV-Docile exhibited reduced viral replication when compared to LCMV-WE and as a consequence, infection with LCMV-Docile resulted in reduced activation of bone marrow derived dendritic cells (BMDCs) and IFN-I production in vitro in comparison with LCMV-WE. In vivo, we observed a reduction of IFN-I, T cell exhaustion and viral persistence following infection of LCMV-Docile but not LCMV-WE. Mechanistically, block of intracellular protein transport uncovered reduced propagation of LCMV-Docile when compared to LCMV-WE. This reduced propagation was critical in blunting the activation of the innate and adaptive immune system. When mice were simultaneously infected with LCMV-Docile and LCMV-WE, immune function was restored and IFN-I production, T cell effector functions as well as viral loads were similar to that of mice infected with LCMV-WE alone. Taken together, this study suggests that reduced viral propagation can result in immune evasion and viral persistence.


Subject(s)
Arenaviridae Infections/virology , Dendritic Cells/virology , Lymphocytic choriomeningitis virus/immunology , Receptor, Interferon alpha-beta/physiology , T-Lymphocytes/virology , Virus Replication , Animals , Arenaviridae Infections/immunology , Arenaviridae Infections/metabolism , Dendritic Cells/immunology , Dendritic Cells/metabolism , Mice , Mice, Inbred C57BL , Mice, Knockout , T-Lymphocytes/immunology , T-Lymphocytes/metabolism
3.
Gut ; 69(1): 133-145, 2020 01.
Article in English | MEDLINE | ID: mdl-31409605

ABSTRACT

OBJECTIVE: The Fragile X mental retardation (FMR) syndrome is a frequently inherited intellectual disability caused by decreased or absent expression of the FMR protein (FMRP). Lack of FMRP is associated with neuronal degradation and cognitive dysfunction but its role outside the central nervous system is insufficiently studied. Here, we identify a role of FMRP in liver disease. DESIGN: Mice lacking Fmr1 gene expression were used to study the role of FMRP during tumour necrosis factor (TNF)-induced liver damage in disease model systems. Liver damage and mechanistic studies were performed using real-time PCR, Western Blot, staining of tissue sections and clinical chemistry. RESULTS: Fmr1null mice exhibited increased liver damage during virus-mediated hepatitis following infection with the lymphocytic choriomeningitis virus. Exposure to TNF resulted in severe liver damage due to increased hepatocyte cell death. Consistently, we found increased caspase-8 and caspase-3 activation following TNF stimulation. Furthermore, we demonstrate FMRP to be critically important for regulating key molecules in TNF receptor 1 (TNFR1)-dependent apoptosis and necroptosis including CYLD, c-FLIPS and JNK, which contribute to prolonged RIPK1 expression. Accordingly, the RIPK1 inhibitor Necrostatin-1s could reduce liver cell death and alleviate liver damage in Fmr1null mice following TNF exposure. Consistently, FMRP-deficient mice developed increased pathology during acute cholestasis following bile duct ligation, which coincided with increased hepatic expression of RIPK1, RIPK3 and phosphorylation of MLKL. CONCLUSIONS: We show that FMRP plays a central role in the inhibition of TNF-mediated cell death during infection and liver disease.


Subject(s)
Fragile X Mental Retardation Protein/physiology , Hepatitis, Viral, Animal/immunology , Tumor Necrosis Factor-alpha/immunology , Animals , Arenaviridae Infections/immunology , Arenaviridae Infections/pathology , CD8-Positive T-Lymphocytes/immunology , Cell Death/drug effects , Cell Death/immunology , Cell Death/physiology , Cells, Cultured , Cholestasis/immunology , Cholestasis/metabolism , Cholestasis/pathology , Fragile X Mental Retardation Protein/metabolism , Hepatitis, Viral, Animal/pathology , Hepatitis, Viral, Animal/prevention & control , Hepatocytes/pathology , Imidazoles/pharmacology , Imidazoles/therapeutic use , Indoles/pharmacology , Indoles/therapeutic use , Lymphocytic choriomeningitis virus , Male , Mice, Inbred C57BL , Mice, Knockout , Receptor-Interacting Protein Serine-Threonine Kinases/antagonists & inhibitors , Receptor-Interacting Protein Serine-Threonine Kinases/physiology
4.
Sci Signal ; 12(605)2019 10 29.
Article in English | MEDLINE | ID: mdl-31662486

ABSTRACT

Chronic liver disease can induce prolonged activation of hepatic stellate cells, which may result in liver fibrosis. Inactive rhomboid protein 2 (iRhom2) is required for the maturation of A disintegrin and metalloprotease 17 (ADAM17, also called TACE), which is responsible for the cleavage of membrane-bound tumor necrosis factor-α (TNF-α) and its receptors (TNFRs). Here, using the murine bile duct ligation (BDL) model, we showed that the abundance of iRhom2 and activation of ADAM17 increased during liver fibrosis. Consistent with this, concentrations of ADAM17 substrates were increased in plasma samples from mice after BDL and in patients suffering from liver cirrhosis. We observed increased liver fibrosis, accelerated disease progression, and an increase in activated stellate cells after BDL in mice lacking iRhom2 (Rhbdf2-/- ) compared to that in controls. In vitro primary mouse hepatic stellate cells exhibited iRhom2-dependent shedding of the ADAM17 substrates TNFR1 and TNFR2. In vivo TNFR shedding after BDL also depended on iRhom2. Treatment of Rhbdf2-/- mice with the TNF-α inhibitor etanercept reduced the presence of activated stellate cells and alleviated liver fibrosis after BDL. Together, these data suggest that iRhom2-mediated inhibition of TNFR signaling protects against liver fibrosis.


Subject(s)
Carrier Proteins/genetics , Cholestasis/genetics , Liver Cirrhosis/genetics , Signal Transduction/genetics , ADAM17 Protein/genetics , ADAM17 Protein/metabolism , Animals , Anti-Inflammatory Agents, Non-Steroidal/pharmacology , Bile Ducts/surgery , Carrier Proteins/metabolism , Cells, Cultured , Cholestasis/metabolism , Etanercept/pharmacology , Gene Expression Regulation , Hepatic Stellate Cells/drug effects , Hepatic Stellate Cells/metabolism , Humans , Ligation , Liver Cirrhosis/metabolism , Liver Cirrhosis/prevention & control , Male , Mice, Inbred C57BL , Mice, Knockout , Receptors, Tumor Necrosis Factor, Type I/genetics , Receptors, Tumor Necrosis Factor, Type I/metabolism , Receptors, Tumor Necrosis Factor, Type II/genetics , Receptors, Tumor Necrosis Factor, Type II/metabolism , Signal Transduction/drug effects
5.
JCI Insight ; 4(17)2019 09 05.
Article in English | MEDLINE | ID: mdl-31484831

ABSTRACT

`NK cell-mediated regulation of antigen-specific T cells can contribute to and exacerbate chronic viral infection, but the protective mechanisms against NK cell-mediated attack on T cell immunity are poorly understood. Here, we show that progranulin (PGRN) can reduce NK cell cytotoxicity through reduction of NK cell expansion, granzyme B transcription, and NK cell-mediated lysis of target cells. Following infection with the lymphocytic choriomeningitis virus (LCMV), PGRN levels increased - a phenomenon dependent on the presence of macrophages and type I IFN signaling. Absence of PGRN in mice (Grn-/-) resulted in enhanced NK cell activity, increased NK cell-mediated killing of antiviral T cells, reduced antiviral T cell immunity, and increased viral burden, culminating in increased liver immunopathology. Depletion of NK cells restored antiviral immunity and alleviated pathology during infection in Grn-/- mice. In turn, PGRN treatment improved antiviral T cell immunity. Taken together, we identified PGRN as a critical factor capable of reducing NK cell-mediated attack of antiviral T cells.


Subject(s)
Antiviral Agents/pharmacology , Cytotoxicity, Immunologic/immunology , Killer Cells, Natural/immunology , Progranulins/metabolism , T-Lymphocytes/immunology , Animals , CD8-Positive T-Lymphocytes , Cyclin T , Cyclin-Dependent Kinase 9/metabolism , Cytotoxicity, Immunologic/drug effects , Disease Models, Animal , HEK293 Cells , Humans , Killer Cells, Natural/drug effects , Killer Cells, Natural/metabolism , Liver/immunology , Liver/pathology , Lymphocyte Activation/drug effects , Lymphocytic Choriomeningitis/immunology , Lymphocytic choriomeningitis virus , Macrophages/metabolism , Mice , Mice, Inbred C57BL , Mice, Knockout , Progranulins/genetics , Progranulins/pharmacology , T-Lymphocytes/drug effects , T-Lymphocytes/metabolism , Virus Diseases
7.
Sci Rep ; 8(1): 12179, 2018 08 15.
Article in English | MEDLINE | ID: mdl-30111770

ABSTRACT

Immune responses are critical for defense against pathogens. However, prolonged viral infection can result in defective T cell immunity, leading to chronic viral infection. We studied immune activation in response to arenavirus infection during cholestasis using bile duct ligation (BDL). We monitored T cell responses, virus load and liver pathology markers after infection with lymphocytic choriomeningitis virus (LCMV). BDL mice failed to induce protective anti-viral immunity against LCMV and consequently exhibited chronic viral infection. BDL mice exhibited reduced anti-viral T cell immunity as well as reduced type 1 interferon production early after LCMV infection. Consistently, the presence of serum from BDL mice reduced the responsiveness of dendritic cell (DC) and T cell cultures when compared to Sham controls. Following fractionation and mass spectrometry analyses of sera, we identified several serum factors to be upregulated following BDL including bilirubin, bile acids, 78 kDa Glucose regulated protein (GRP78) and liver enzymes. Bilirubin and GRP78 were capable of inhibiting DC and T cell activation. In this work, we demonstrate that liver damage mediated by cholestasis results in defective immune induction following arenavirus infection.


Subject(s)
Arenaviridae Infections/immunology , Cholestasis/immunology , Liver Diseases/immunology , Liver/immunology , Animals , Arenaviridae Infections/pathology , Arenavirus/immunology , Bile Ducts/immunology , Bile Ducts/pathology , CD4-Positive T-Lymphocytes/immunology , Cholestasis/pathology , Dendritic Cells/immunology , Endoplasmic Reticulum Chaperone BiP , Interferon Type I/immunology , Liver/pathology , Liver Diseases/pathology , Lymphocyte Activation/immunology , Lymphocytic Choriomeningitis/immunology , Lymphocytic choriomeningitis virus/immunology , Mice , Mice, Inbred C57BL , Signal Transduction
8.
Hepatology ; 68(6): 2348-2361, 2018 12.
Article in English | MEDLINE | ID: mdl-29742809

ABSTRACT

The liver has an extraordinary capacity to regenerate through activation of key molecular pathways. However, central regulators controlling liver regeneration remain insufficiently studied. Here, we show that B cell-deficient animals failed to induce sufficient liver regeneration after partial hepatectomy (PHx). Consistently, adoptive transfer of B cells could rescue defective liver regeneration. B cell-mediated lymphotoxin beta production promoted recovery from PHx. Absence of B cells coincided with loss of splenic cluster of differentiation 169-positive (CD169+ ) macrophages. Moreover, depletion of CD169+ cells resulted in defective liver regeneration and decreased survival, which was associated with reduced hepatocyte proliferation. Mechanistically, CD169+ cells contributed to liver regeneration by inducing hepatic interleukin-6 (IL-6) production and signal transducer and activator of transcription 3 activation. Accordingly, treatment of CD169+ cell-depleted animals with IL-6/IL-6 receptor rescued liver regeneration and severe pathology following PHx. Conclusion: We identified CD169+ cells to be a central trigger for liver regeneration, by inducing key signaling pathways important for liver regeneration.


Subject(s)
B-Lymphocytes/physiology , Liver Regeneration/immunology , Animals , Hepatectomy , Interleukin-6/metabolism , Male , Mice , Sialic Acid Binding Ig-like Lectin 1/metabolism
9.
J Virol ; 92(3)2018 02 01.
Article in English | MEDLINE | ID: mdl-29142134

ABSTRACT

Innate immune activation is essential to mount an effective antiviral response and to prime adaptive immunity. Although a crucial role of CD169+ cells during vesicular stomatitis virus (VSV) infections is increasingly recognized, factors regulating CD169+ cells during viral infections remain unclear. Here, we show that tumor necrosis factor is produced by CD11b+ Ly6C+ Ly6G+ cells following infection with VSV. The absence of TNF or TNF receptor 1 (TNFR1) resulted in reduced numbers of CD169+ cells and in reduced type I interferon (IFN-I) production during VSV infection, with a severe disease outcome. Specifically, TNF triggered RelA translocation into the nuclei of CD169+ cells; this translocation was inhibited when the paracaspase MALT-1 was absent. Consequently, MALT1 deficiency resulted in reduced VSV replication, defective innate immune activation, and development of severe disease. These findings indicate that TNF mediates the maintenance of CD169+ cells and innate and adaptive immune activation during VSV infection.IMPORTANCE Over the last decade, strategically placed CD169+ metallophilic macrophages in the marginal zone of the murine spleen and lymph nodes (LN) have been shown to play a very important role in host defense against viral pathogens. CD169+ macrophages have been shown to activate innate and adaptive immunity via "enforced virus replication," a controlled amplification of virus particles. However, the factors regulating the CD169+ macrophages remain to be studied. In this paper, we show that after vesicular stomatitis virus infection, phagocytes produce tumor necrosis factor (TNF), which signals via TNFR1, and promote enforced virus replication in CD169+ macrophages. Consequently, lack of TNF or TNFR1 resulted in defective immune activation and VSV clearance.


Subject(s)
Interferon Type I/immunology , Macrophages/immunology , Tumor Necrosis Factor-alpha/immunology , Vesicular Stomatitis/immunology , Adaptive Immunity , Animals , Immunity, Innate , Macrophages/virology , Mice , Mice, Inbred C57BL , Mucosa-Associated Lymphoid Tissue Lymphoma Translocation 1 Protein/genetics , Receptors, Tumor Necrosis Factor, Type I/immunology , Sialic Acid Binding Ig-like Lectin 1 , Transcription Factor RelA/metabolism , Vesiculovirus/physiology , Virus Replication
10.
Sci Rep ; 7(1): 7938, 2017 08 11.
Article in English | MEDLINE | ID: mdl-28801579

ABSTRACT

The devastating consequences of hepatic failure include hepatic encephalopathy, a severe, life threatening impairment of neuronal function. Hepatic encephalopathy is caused by impaired hepatic clearance of NH4+. Cellular NH4+ uptake is accomplished mainly by the Na+,K+,2Cl- cotransporter. Here we show that hepatic clearance of NH4+ is impaired in TNFα deficient as well as TNFR1&TNFR2 double knockout mice, which both develop hyperammonemia. Despite impaired hepatic clearance of NH4+, TNFα deficient mice and TNFR1 deficient mice were protected against acute ammonia intoxication. While 54% of the wild-type mice and 60% of TNFR2 deficient mice survived an NH4+ load, virtually all TNFα deficient mice and TNFR1 deficient mice survived the treatment. Conversely, TNFα treatment of wild type mice sensitized the animals to the toxic effects of an NH4+ load. The protection of TNFα-deficient mice against an NH4+ load was paralleled by decreased cerebral expression of NKCC1. According to the present observations, inhibition of TNFα formation and/or NKCC1 may be strategies to favorably influence the clinical course of hepatic encephalopathy.


Subject(s)
Hyperammonemia/genetics , Receptors, Tumor Necrosis Factor, Type II/genetics , Receptors, Tumor Necrosis Factor, Type I/genetics , Solute Carrier Family 12, Member 2/metabolism , Tumor Necrosis Factor-alpha/deficiency , Ammonia/toxicity , Animals , Brain/metabolism , Hyperammonemia/metabolism , Liver/chemistry , Mice , Mice, Knockout , Solute Carrier Family 12, Member 2/genetics , Tumor Necrosis Factor-alpha/genetics , Up-Regulation
11.
Cell Physiol Biochem ; 39(2): 668-76, 2016.
Article in English | MEDLINE | ID: mdl-27442519

ABSTRACT

BACKGROUND/AIMS: Similar to apoptosis of nucleated cells, red blood cells (RBC) can undergo suicidal cell death - called eryptosis. It is characterized by cell shrinkage and phosphatidylserine translocation. Eryptosis is triggered by an increase of intracellular calcium concentration due to activation of nonselective cation channels. The cation channels and consequently eryptosis are inhibited by erythropoietin. Eryptotic RBC are engulfed by macrophages and thus rapidly cleared from circulating blood. In this study, we explored whether storage of RBC influences the rate of eryptosis. METHODS: Flow cytometry was employed to quantify phosphatidylserine exposing erythrocytes from annexin V binding and cytosolic Ca2+ activity from Fluo-3 fluorescence. Clearance of stored murine RBC was tested by injection of carboxyfluorescein succinimidyl ester (CFSE)-labelled erythrocytes. RESULTS: Storage for 42 days significantly increased the percentage of phosphatidylserine exposing and haemolytic erythrocytes, an effect blunted by removal of extracellular calcium. Phosphatidylserine exposure could be inhibited by addition of erythropoietin. Upon transfusion, the clearance of murine CFSE-labelled RBC from circulating blood was significantly higher following storage for 10 days when compared to 2 days of storage. CONCLUSION: Storage of RBC triggers eryptosis by Ca2+ and erythropoietin sensitive mechanisms.


Subject(s)
Apoptosis/physiology , Blood Preservation/methods , Eryptosis/physiology , Erythrocytes/metabolism , Animals , Apoptosis/drug effects , Biological Transport/drug effects , Calcium/metabolism , Cell Death/drug effects , Cell Death/physiology , Eryptosis/drug effects , Erythrocytes/chemistry , Erythrocytes/cytology , Erythropoietin/pharmacology , Flow Cytometry/methods , Fluoresceins/chemistry , Humans , Intracellular Space/metabolism , Mice, Inbred C57BL , Phosphatidylserines/metabolism , Succinimides/chemistry , Time Factors
12.
Nat Immunol ; 17(5): 593-603, 2016 May.
Article in English | MEDLINE | ID: mdl-26950238

ABSTRACT

Persistent viral infections are characterized by the simultaneous presence of chronic inflammation and T cell dysfunction. In prototypic models of chronicity--infection with human immunodeficiency virus (HIV) or lymphocytic choriomeningitis virus (LCMV)--we used transcriptome-based modeling to reveal that CD4(+) T cells were co-exposed not only to multiple inhibitory signals but also to tumor-necrosis factor (TNF). Blockade of TNF during chronic infection with LCMV abrogated the inhibitory gene-expression signature in CD4(+) T cells, including reduced expression of the inhibitory receptor PD-1, and reconstituted virus-specific immunity, which led to control of infection. Preventing signaling via the TNF receptor selectively in T cells sufficed to induce these effects. Targeted immunological interventions to disrupt the TNF-mediated link between chronic inflammation and T cell dysfunction might therefore lead to therapies to overcome persistent viral infection.


Subject(s)
CD4-Positive T-Lymphocytes/immunology , HIV Infections/immunology , HIV/immunology , Lymphocytic Choriomeningitis/immunology , Lymphocytic choriomeningitis virus/immunology , Tumor Necrosis Factor-alpha/immunology , Adolescent , Adult , Aged , Animals , CD4-Positive T-Lymphocytes/metabolism , CD4-Positive T-Lymphocytes/virology , Flow Cytometry , HEK293 Cells , HIV/physiology , HIV Infections/genetics , HIV Infections/virology , Host-Pathogen Interactions/immunology , Humans , Immunoblotting , Lymphocytic Choriomeningitis/genetics , Lymphocytic Choriomeningitis/virology , Lymphocytic choriomeningitis virus/physiology , Mice, Inbred C57BL , Mice, Knockout , Mice, Transgenic , Middle Aged , Oligonucleotide Array Sequence Analysis , Programmed Cell Death 1 Receptor/genetics , Programmed Cell Death 1 Receptor/immunology , Programmed Cell Death 1 Receptor/metabolism , Receptors, Tumor Necrosis Factor/genetics , Receptors, Tumor Necrosis Factor/immunology , Receptors, Tumor Necrosis Factor/metabolism , Reverse Transcriptase Polymerase Chain Reaction , Transcriptome/drug effects , Transcriptome/genetics , Transcriptome/immunology , Tumor Necrosis Factor-alpha/metabolism , Tumor Necrosis Factor-alpha/pharmacology , Young Adult
13.
J Virol Methods ; 222: 28-33, 2015 Sep 15.
Article in English | MEDLINE | ID: mdl-25997377

ABSTRACT

In view of the emerging avian influenza (AI) viruses, it is important to study the susceptibility of AI viruses to inactivating agents for preparation of antigens and inactivated vaccines. The available information on susceptibility of both the high and low pathogenic AI viruses to different inactivating agents is inadequate and ambiguous. It has been shown that different subtypes of influenza viruses require different physical and chemical conditions for inactivation of infectivity. The present study was undertaken to evaluate the use of beta-propiolactone (BPL), formalin and ether for inactivation and its impact on antigenicity of AI viruses. A total of nine high and low pathogenic AI viruses belonging to four influenza A subtypes were included in the study. The H5N1 viruses were from the clades 2.2, 2.3.2.1 and 2.3.4. The H9N2 virus included in the study was of the G1 genotype, while the H11N1 and H4N6 viruses were from the Eurasian lineage. The viruses were treated with BPL, formalin and with ether. The confirmation of virus inactivation was performed by two serial passages of inactivated viruses in embryonated chicken eggs. The infectivity of all tested AI viruses was eliminated using 0.1% BPL and 0.1% formalin. Ether eliminated infectivity of all tested low pathogenic AI viruses; however, ether with 0.2% or 0.5% Tween-20 was required for inactivation of the highly pathogenic AI H5N1 viruses. Treatment with BPL, ether and formalin retained virus hemagglutination (HA) titers. Interestingly ether treatment resulted in significant rise in HA titers (P<0.05) of all tested AI viruses. This data demonstrated the utility of BPL, formalin and ether for the inactivation of infectivity of AI viruses used in the study for the preparation of inactivated virus antigens for research and diagnosis of AI.


Subject(s)
Disinfectants/pharmacology , Disinfection/methods , Influenza A virus/drug effects , Influenza A virus/physiology , Influenza in Birds/virology , Microbial Viability/drug effects , Virus Inactivation , Animals , Antigens/isolation & purification , Chick Embryo , Chickens , Ether/pharmacology , Formaldehyde/pharmacology , Hemagglutination Inhibition Tests , Hemagglutinin Glycoproteins, Influenza Virus/immunology , Influenza A virus/growth & development , Influenza A virus/isolation & purification , Propiolactone/pharmacology
14.
Avian Dis ; 56(1): 257-60, 2012 Mar.
Article in English | MEDLINE | ID: mdl-22545557

ABSTRACT

An avian influenza (AI) surveillance was undertaken in Maharashtra state, India during the period 2010-2011. There are no reports of AI surveillance in emus from India. A total of 202 blood samples and 467 tracheal and cloacal swabs were collected from eight emu farms. A hemagglutination inhibition (HI) assay was performed for detection of antibodies against AI H5N1, H7N1, H9N2, and avian paramyxovirus type 1 (APMV-1) viruses. A microneutralization (MN) assay was performed to confirm the presence of neutralizing antibodies against AI H9N2 and to compare with HI assays. A total of 28.2% and 28.7% of samples were positive for antibodies against AI H9N2 by HI and MN assays, respectively, using > or = 1:40 as a cut-off titer; 15.3% samples were positive for APMV-1 by HI assay using a > or = 1:10 cut-off titer. Seropositivity of AI H9N2 was nil in the grower (<1 yr) age group and highest (78%) in the breeder (2-3 yr) age group, whereas seropositivity against APMV-1 was observed in all age groups. Performance of both HI and MN assays was similar, suggesting the utility of using the MN assay along with HI assay for surveillance studies. This is the first report of the seroprevalence of AI H9N2 and APMV-1 in emus in India.


Subject(s)
Dromaiidae , Hemagglutination Inhibition Tests/methods , Influenza A virus/isolation & purification , Influenza in Birds/virology , Neutralization Tests/methods , Newcastle Disease/virology , Newcastle disease virus/isolation & purification , Agriculture , Animals , Antibodies, Viral/blood , Hemagglutination Inhibition Tests/veterinary , India/epidemiology , Influenza A virus/classification , Influenza in Birds/epidemiology , Neutralization Tests/veterinary , Newcastle Disease/epidemiology , Newcastle disease virus/classification , Seroepidemiologic Studies
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