Experimental reproduction of necrotic enteritis in chickens: a review

Two different Clostridium perfringens strains produce different levels of necrotic enteritis in broiler chickens

Subclinical necrotic enteritis (NE) is primarily caused by the gram-positive bacterium, Clostridium perfringens (Cp). The trend towards removal of in-feed antimicrobials and subsequent increased emergence of infection in poultry has resulted in a wide interest in better understanding of the mechanism behind this disease. The virulence of NE, to a large extent, depends on the virulence of Cp strains. Thus, this study was to assess how 2 different strains of Cp affect performance and gut characteristics of broiler chickens. Ross 308 male broilers (n = 468) were assigned to a 2 × 3 factorial arrangement of treatments with antibiotics (Salinomycin at 72 ppm and zinc bacitracin at 50 ppm -, or +) and challenge (non-challenge, Cp EHE-NE18, or Cp WER-NE36). Oral administration of Eimeria oocysts (day 9) followed by inoculation with 1 mL 108 CFU Cp strains (day 14 and 15) were used to induce NE. Broiler performance was analyzed at day 10, 24, and 35. On day 16, intestinal lesion score and intestinal pH were evaluated and samples of cecal content were analyzed for bacterial counts and short-chain fatty acid concentrations (SCFA). Birds in both challenged groups showed higher feed conversion ratio (FCR), lower weight gain (P < 0.001), increased lesion scores in the jejunum (P < 0.01), and reduced pH in the ileum and cecum (P < 0.01), compared to the non-challenged birds. They also showed decreased numbers of Bacillus spp. (P < 0.001), and Ruminococcus spp. (P < 0.01) in the cecal content. On day 35, the NE36 challenged birds had a lower weight gain (P < 0.001) and higher FCR (P < 0.001) compared to the NE18 challenged birds. Interestingly, cecal Lactobacillus and lactate were increased by the NE challenge (P < 0.001), and to a greater extent in birds challenged with NE36 compared to the NE18 strain (P < 0.001). This study suggests that Cp strains varying in virulence produce different levels of disease in broiler chickens through modulating the gut environment, intestinal microbiota, and SCFA profile to different extents.

Probiotics mitigating subclinical necrotic enteritis (SNE) as potential alternatives to antibiotics in poultry

Subclinical necrotic enteritis (SNE) caused by Clostridium perfringens (CP), is an important disease in chickens, which causes huge economic losses by damaging the intestinal mucosa, decreasing digestion and absorption of nutrients. Use of antibiotics at a sub-therapeutic level as antimicrobial growth promoters in poultry feed prevents the birds from SNE and improves growth. Due to the ban on the use of antibiotics in 2006 as antimicrobial growth promoters have led to the reemergence of the disease. Worldwide numerous studies have been carried out to investigate the alternatives to antibiotics for the prevention of SNE. Possible alternatives to control SNE include probiotics, prebiotics, bacteriophages, essential oils, organic acids, secondary metabolites and other microbial products. Currently, probiotics are most extensively used in poultry production as an alternative to antibiotics. This review summarizes recent insights and experimental evidence on the use of different microorganisms like Bacillus, Lactic acid bacteria, Bifidobacteria, Enterococcus, yeast, etc. as valuable probiotics for prevention of SNE and potential molecular mechanisms responsible for ameliorating effects of probiotics against SNE.

Developing an experimental necrotic enteritis model in turkeys - the impact of Clostridium perfringens, Eimeria meleagrimitis and host age on frequency of severe intestinal lesions

BACKGROUND

Necrotic enteritis is a significant problem to the poultry industry globally and, in Norway up to 30% of Norwegian turkey grow-outs can be affected. However, despite an awareness that differences exist between necrotic enteritis in chickens and turkeys, little information exists concerning the pathogenesis, immunity, microbiota or experimental reproduction of necrotic enteritis in turkeys. In particular, it is important to determine the appearance of the gross lesions, the age dependency of the disease and the role of netB toxin of Clostridium perfringens. To this end, we report our findings in developing an in vivo experimental model of necrotic enteritis in turkeys.

RESULTS

A four tier (0-3) scoring system with clearly defined degrees of severity of macroscopic intestinal lesions was developed, based on 2312 photographic images of opened intestines from 810 B.U.T. 10 or B.U.T. Premium turkeys examined in nine experiments. Loss of macroscopically recognizable villi in the anterior small intestine was established as the defining lesion qualifying for a score 3 (severe intestinal lesions). The developed scoring system was used to identify important factors in promoting high frequencies of turkeys with severe lesions: a combined Eimeria meleagrimitis and Clostridium perfringens challenge, challenge at five rather than 3 weeks of age, the use of an Eimeria meleagrimitis dose level of at least 5000 oocysts per bird and finally, examination of the intestines of 5-week-old turkeys at 125 to 145 h after Eimeria meleagrimitis inoculation. Numbers of oocysts excreted were not influenced by Clostridium perfringens inoculation or turkey age. Among three different lesion score outcomes tested, frequency of severe lesions proved superior in discriminating between impact of four combinations of Clostridium perfringens inoculation and turkey age at challenge.

CONCLUSIONS

This study provides details for the successful establishment of an in vivo model of necrotic enteritis in turkeys.

Effects of Lactobacillus plantarum on intestinal integrity and immune responses of egg-laying chickens infected with Clostridium perfringens under the free-range or the specific pathogen free environment

Background

Necrotic enteritis, which is caused by Clostridium perfringens, has resulted in more than $2 billion losses in the poultry industry every year. Due to the ban of antibiotics in feed industry, alternatives like environment improvement and probiotics have been found to be effective as well. In our study, we aim to explore the protective effect of Lactobacillus plantarum supplementation on CP infected chickens in two environments.

Results

The results showed that the Clostridium perfringens administration led to visible and histomorphological gut lesions. In the specific pathogen free or free-range system environment, dietary supplementation with LP obvious increased the ratio of intestinal villus height to crypt depth and the expression of MUC2 mRNA in ileum mucosa, then reduced the mRNA expression level of TNF-α gene in the ileum mucosa. LP treatment significantly reduced the contents of total protein, total superoxide dismutase and glutamic oxaloacetic transaminase in serum of the chickens.

Conclusions

The specific pathogen free environment contributed to the recovery of pre-inflammation of the chickens, and free-range system environment contributed to the repair of damage in the later stages of chicken inflammation. Supplementation of LP in FRS environment was more conducive to the recovery of CP infected in chickens.

Effect of Feed Additives as Alternatives to In-feed Antimicrobials on Production Performance and Intestinal Clostridium perfringens Counts in Broiler Chickens

Numerous non-antibiotic feed additives (alternatives to antibiotics, ATAs) have been marketed, but few have been evaluated under uniform testing conditions modelling commercial flocks. We compared 24 ATA treatments and the ionophorous coccidiostat narasin against a diet without any feed additives. Feed conversion ratio and body weight gain were registered from day 0 to 28 in Ross 308 chickens housed on litter floor. The chickens were challenged with Eimeria spp., and cecal Clostridium perfringens (CP) counts were investigated. Active components from all ATA classes had a positive impact on intestinal health or production performance. Whereas narasin had a strong CP-reducing effect in combination with performance-promoting impact, only two ATA treatments achieved significantly beneficial effects on CP counts as well as feed conversion during the time span following Eimeria challenge. Active components present in these two treatments include a Bacillus subtilis probiotic strain, short- and medium-chain fatty acids and Saccharomyces cerevisiae components. Different ATA classes had beneficial impact during distinct rearing phases and on specific performance targets, suggesting that optimizing combinations and use of active components can make ATAs even more useful tools in broiler rearing without the use of in-feed antimicrobials. Further studies of promising ATAs and ATA combinations are required.

The netB-positive Clostridium perfringens in the experimental induction of necrotic enteritis with or without predisposing factors

The netB-positive Clostridium perfringens has been considered as the requisite to consistently induce necrotic enteritis (NE). However, use of a netB-positive strain did not guarantee consistent NE reproduction unless high protein diets or Eimeria, conceived as 2 major predisposing factors, was incorporated. To establish a refined model, the roles of dietary fishmeal inclusion, Eimeria inoculation, and netB-positive C. perfringens challenge in NE induction and the confounding effects of Eimeria infection on NE were examined. The results showed that the use of netB-positive C. perfringens without a predisposing factor failed to induce NE. Fishmeal incorporation promoted the occurrence of NE but did not significantly affect the incidence of the disease in conjunction with challenge of netB-positive C. perfringens. However, the additional participation of Eimeria infection in the same induction procedure produced significantly higher numbers of NE cases and promoted more severe lesions in chickens (P < 0.05). Inoculation of Eimeria resulted in a significant higher incidence of NE compared to the non-Eimeria treated group (P < 0.05). The results demonstrated that both netB-positive C. perfringens and predisposing factors were required for the reproduction of disease. Mild-to-moderate coccidial infection (coccidial lesion score ≤ 2) was noted in NE cases in this model but severe coccidial infection did not correlate with the occurrence of NE, indicating mild coccidial infection may be beneficial for the development of NE. If multiple species infection of Eimeria precedes the challenge of C. perfringens, days 19 to 21 (1 to 3 D after the last clostridial challenge) was the time period favorable for observations of NE lesions. The time after this period may be subject to bias of severity, incidence, or mortality of NE owing to the profound coccidial lesions in the intestinal region. This study demonstrated that the co-infection with netB-positive C. perfringens and Eimeria species under fishmeal incorporation produced a desirable NE model, being of value in studying the effectiveness of novel feed additives and alternative mitigation strategies to prevent NE.

Eimeria maxima-induced transcriptional changes in the cecal mucosa of broiler chickens

Background

Apicomplexan protozoans of the genus Eimeria cause coccidiosis, one of the most economically relevant parasitic diseases in chickens. The lack of a complete understanding of molecular mechanisms in the host-parasite interaction limits the development of effective control measures. In the present study, RNA sequencing (RNA-Seq) was applied to investigate the host mRNA profiles of the cecal mucosa collected at day 5 post-infection with Eimeria maxima (EM).

Results

Total RNA from cecal samples of the uninfected naïve control and the EM groups was used to make libraries, generating 354,924,372 and 356,229,250 usable reads, respectively, which were assembled into a total of 386,088 high-quality unigenes (transcripts) in Trinity software. RNA-Seq analysis of cecal samples in the two groups revealed 332 upregulated and 363 downregulated genes with significant differences (P ≤ 0.05), including several significant immune-related gene families, such as the major histocompatibility complex (MHC) class I alpha chain, granzyme A and immunoglobulin subtype genes among upregulated differentially expressed genes. In addition, a total of 60 clusters of differentiation (CD) molecular genes and 570 novel genes were found. The completeness of the assembled transcriptome was further assessed using the Kyoto Encyclopedia of Genes and Genomes (KEGG) database, Gene ontology (GO), eggNOG and CAZy for gene annotation. The broad gene categories represented by the highly differentiated host genes suggested enrichment in immune responses, and downregulation in the metabolic pathway, MARK signaling pathway, vascular smooth muscle contraction, and proteins processing in endoplasmic reticulum after EM infection.

Conclusions

Eimeria maxima induced statistically significant differences in the cecal mucosal gene expression of infected chickens. These findings provide new insights into the host-parasite interaction and enhance our understanding of the molecular mechanism of avian coccidiosis.

Electronic supplementary material

The online version of this article (10.1186/s13071-019-3534-4) contains supplementary material, which is available to authorized users.

Analysis of gut microbiota and the effect of lauric acid against necrotic enteritis in Clostridium perfringens and Eimeria side-by-side challenge model

Gut microbiota has been demonstrated to be involved in intestinal nutrition, defense, and immunity, as well as participating in disease progression. This study was to investigate gut microbiota changes in chickens challenged with netB-positive Clostridium perfringens strain (CP1) and/or the predisposing Eimeria species (Eimeria) and fed diets with fishmeal supplementation. In addition, the effects of lauric acid, a medium-chain fatty acid (MCFA), on necrotic enteritis (NE) reduction and modulation of microbiota were evaluated. The results demonstrated that microbial communities in the jejunum were distinct from those in the cecum, and the microbial community change was more significant in jejunum. Challenge of CP1 in conjunction with Eimeria significantly reduced species diversity in jejunal microbiota, but cecal microbiota remained stable. In the jejunum, CP1 challenge increased the abundance of the genera of Clostridium sensu stricto 1, Escherichia Shigella, and Weissella, but significantly decreased the population of Lactobacillus. Eimeria infection on its own was unable to promote NE, demonstrating decrements of Clostridium sensu stricto 1 and Lactobacillus. Co-infection with CP1 and Eimeria reproduced the majority of NE lesions with significant increment of Clostridium sensu stricto 1 and reduction in Lactobacillus. The advance of changes on these two taxa increased the severity of NE lesions. Further analyses of metagenomeSeq, STAMP, and LEfSe consistently showed significant overgrowth of Clostridium sensu stricto 1 was associated with NE. The supplementation of lauric acid did not reduce NE incidence and severity but decreased the relative abundance of Escherichia Shigella. In conclusion, significant overgrowth of C. perfringens as well as other Clostridium species in Clostridium sensu stricto 1 with the decrement of Lactobacillus in the jejunum is the featured microbiota correlated with NE. Controlling proliferation of Clostridium sensu stricto 1 and manipulation of Lactobacillus in the jejunum should be the strategy to prevent NE.

Impact of a Bacillus Direct-Fed Microbial on Growth Performance, Intestinal Barrier Integrity, Necrotic Enteritis Lesions, and Ileal Microbiota in Broiler Chickens Using a Laboratory Challenge Model

Decreases in the use of antibiotics and anticoccidials in the poultry industry have risen the appearance of necrotic enteritis (NE). The purpose of this study was to evaluate the effect of a Bacillus direct-fed microbial (DFM) on growth performance, intestinal integrity, NE lesions and ileal microbiota using a previously established NE-challenged model. At day-of-hatch, chicks were randomly assigned to three different groups: Negative control (NC), Positive control (PC) challenged with Salmonella Typhimurium (day 1), Eimeria maxima (EM, day 13) and Clostridium perfringens (CP, day 18-19), and Bacillus-DFM group (DFM) challenged as the PC. Body weight (BW) and body weight gain (BWG) were measured weekly. Total feed intake (FI) and feed conversion ratio (FCR) were evaluated at day 21. Liver samples were collected to assess bacterial translocation and blood samples were used to measure superoxide dismutase (SOD) and fluorescein isothiocyanate-dextran (FITC-d). Intestinal contents were obtained for determination of total IgA and microbiota analysis. NE lesion scores (LS) were performed at day 21. Chickens consuming the DFM significantly improved BW and had a numerically more efficient FCR compared to PC at day 21. Additionally, there were no significant differences in FCR between the DFM group and NC. Furthermore, the DFM group showed significant reductions in LS, IgA and FITC-d levels compared to the PC. However, there were no significant differences in SOD between the groups. The microbiota analysis indicated that the phylum Proteobacteria was significantly reduced in the DFM group in comparison to PC. At the genus level, Clostridium, Turicibacter, Enterococcus, and Streptococcus were reduced, whereas, Lactobacillus and Bacillus were increased in the DFM group as compared to PC (p < 0.05). Likewise, the DFM significantly reduced CP as compared to PC. In contrary, no significant differences were observed in bacterial composition between NC vs. DFM. In addition, beta diversity showed significant differences in the microbial community structure between NC vs. PC, and PC vs. DFM. These results suggest that the dietary inclusion of a selected DFM could mitigate the complex negative impacts caused by NE possibly through mechanism(s) that might involve modulation of the gut microbiota.

Characterization of intestinal immune response to Clostridium perfringens infection in broiler chickens

Necrotic enteritis toxin B (NetB)-producing Clostridium perfringens (CP) type A is the etiological agent of necrotic enteritis (NE) – an economically significant disease in broiler chickens. Understanding the immune response to CP infection in broiler chickens is becoming important to develop effective vaccines against NE. An experiment was conducted to determine the expression levels of selected cytokine genes in the intestine and cecal tonsil of CP-challenged broiler chickens. In a floor-pen housing, broiler chickens were randomly assigned to the following treatment groups: 1) bacitracin methylene disalicylate (BMD)-free control diet with no CP challenge (CX), 2) BMD-supplemented diet with no CP challenge (CM), 3) BMD-free control diet with CP challenge (PCX), or 4) BMD-supplemented diet with CP challenge (PCM). The establishment of CP infection was confirmed, with the treatment groups exposed to CP having a 1.5 to 2-fold higher CP levels (P < 0.05) compared to the non-exposed groups. On day 1 and 7 post-challenge, jejunal segments and cecal tonsils were collected from experimental chickens for quantitative real-time RT-PCR analysis to determine the expression levels of interleukin (IL)-1β, interferon-γ (IFN-γ), IL-2, IL-13, IL-17, IL-10, and transforming growth factor (TGF)-β genes. Levels of antibodies to CP recombinant proteins were also determined in the plasma of experimental chickens. Results indicated that on day 7 post-challenge, IL-1β (proinflammatory cytokine), IL-13 (Th2 cytokine), and IL-17 (Th17 cytokine) were upregulated (P < 0.05) in CP-challenged PCX and PCM treatments, compared to the unchallenged (control) CX and CM treatments. A reverse trend was observed for TGF-β (anti-inflammatory cytokine), while no change was observed in IFN-γ (Th1 cytokine). Levels of plasma antibodies (IgY) to CP recombinant proteins were higher in CP-challenged treatments (PCX and PCM; P < 0.05), compared to their corresponding controls (CX and CM). It was concluded that CP infection induced inflammatory response in the intestine of broiler chickens, and the mechanisms of inflammation are probably mediated via Th2 and Th17 cells.

Histological parameters to evaluate intestinal health on broilers challenged with Eimeria and Clostridium perfringens with or without enramycin as growth promoter

The maintenance of integrity of the gastrointestinal tract is an important aspect for animal productivity, since it is able to absorb nutrients more efficiently and serves as a barrier against microorganisms. To control agents detrimental to intestinal integrity, growth-promoting antibiotics (AGP) are used, which reduce the number of toxin-producing microorganisms in the intestinal lumen, acting as anti-inflammatory agents. There is a demand for restriction of use of AGP in animal feed, but there are few studies showing what parameters we should observe to search for alternative additives. The aim of this study was to establish histological parameters that explain the effect of enramycin as growth promoter on intestinal health in broilers challenged with Eimeria and Clostridium perfringens. The zootechnical performance and the histology by I See Inside (ISI) methodology were evaluated on liver and ileum samples. Chickens challenged without AGP have the worst BWG, FCR, and histological ISI score (ISI score 9) in the ileum compared to non-challenged (ISI score 5). The use of enramycin on challenged group significantly minimized the ISI score in the ileum at 21 and 28 d (ISI score 7.4 and 8.0, respectively) compared with the challenged group not fed with enramycin (ISI score 9.2 and 9.9, respectively), associated with reduced lamina propria thickness and inflammatory cell infiltration. We suggest these 2 histological parameters as a standard to compare products for gut health.

Bacillus licheniformis normalize the ileum microbiota of chickens infected with necrotic enteritis

Necrotic enteritis (NE) is a severe intestinal disease, which can change gut microbiota and result in a high cost for the poultry industry worldwide. However, little is known regarding how the gut microbiota of NE chicken ileum are changed by Bacillus licheniformis. This study was conducted to investigate how ileum microbiota structure was changed by B. licheniformis in broiler chickens challenged with Clostridium perfringens-induced NE through Illumina MiSeq sequencing. The broilers were randomly separated into four groups: the negative control group (NC), the positive control group (PC), the fishmeal and coccidia group (FC), and the PC group supplied with feed containing B. licheniformis (BL). Compared to the PC and FC, alpha diversity, beta diversity, and the bacterial taxa of the ileum microbiota were more similar in BL and NC. Some genera, which were related to the NE control, became insignificant in BL with NC, such as Lactobacillus, Lactococcus, Bacteroides, Ruminococcus and Helicobacter. The PICRUSt analysis revealed that a tumour suppressor gene, p53, which was negatively correlated with Helicobacter, was enriched in the BL group. Our findings showed that the ileum microbiota disorder caused by NE in chickens was normalized by dietary B. licheniformis supplementation.

Genetics and genomics of susceptibility and immune response to necrotic enteritis in chicken: a review

Global poultry production is facing many challenges and is currently under pressure due to the presence of several diseases like Necrotic Enteritis (NE). It is estimated that NE-caused global economic losses has increased from 2 billion to 6 billion US$ in 2015 because it is not easy to diagnose and control disease at the earlier stage of occurrence. Additionally, ban on the in-feed antibiotics and some other genetic and non-genetic predisposing factors affect the occurrence of the disease. Though the incidence of the disease can be reduced by minimizing the predisposing factors and through immunization of birds but there is no single remedy to control the disease. Therefore, we suggest that there is need to find out the genetic variants that could help to select the birds resistant to NE. The current review details the pertinent features about the genetic and genomics of susceptibility and immune response of birds to Necrotic Enteritis. We report here the list of candidate gene reported for their involvement with the susceptibility and/or resistance to the disease. However, most of these genes are involved in immune-related functions. For better understanding of the role of Clostridium perfringens and its toxins in the pathogenesis of disease there is need to unveil the association between any specific genetic variation and clinical status of NE. However, the presence of substantial genetic variations among different breeds/strains of chicken shows that it is possible to develop broiler strain with genetic resistant against NE. It would help in the cost-effective and sustainable production of safe broiler meat.

Complete genome sequences of Clostridium perfringens Del1 strain isolated from chickens affected by necrotic enteritis

BACKGROUND

Clostridium perfringens is ubiquitous in nature. It is a normal inhabitant in the intestinal tract of animals and humans. As the primary etiological agent of gas gangrene, necrosis and bacteremia, C. perfringens causes food poisoning, necrotic enteritis (NE), and even death. Epidemiology research has indicated that the increasing incidence of NE in poultry is associated with the withdrawal of in-feed antibiotic growth promoters in poultry production in response to government regulations. The recent omics studies have indicated that bacterial virulence is typically linked to highly efficient conjugative transfer of toxins, or plasmids carrying antibiotic-resistance traits. Currently, there is limited information on understanding of host-pathogen interaction in NE caused by virulent strains of C. perfringens. Elucidating such pathogenesis has practical impacts on fighting infectious diseases through adopting strategies of prophylactic or therapeutic interventions. In this report, we sequenced and analyzed the genome of C. perfringens Del1 strain using the hybrid of PacBio and Illumina sequencing technologies.

RESULTS

Sequence analysis indicated that Del1 strain comprised a single circular chromosome with a complete 3,559,163 bp and 4 plasmids: pDel1_1 (82,596 bp), pDel1_2 (69,827 bp), pDel1_3 (49,582 bp), and pDel1_4 (49,728 bp). The genome had 3361 predicted coding DNA sequences, harbored numerous genes for pathogenesis and virulence factors, including 6 for antibiotic and antimicrobial resistance, and 3 phage-encoded genes. Phylogenetic analysis revealed that Del1 strain had similar genome and plasmid sequences to the CP4 strain.

CONCLUSION

Complete chromosomal and plasmid sequences of Del1 strain are presented in this report. Since Del1 was isolated from a field disease outbreak, this strain is a good source to identify virulent genes that cause many damaging effects of Clostridial infections in chicken gut. Genome sequencing of the chicken pathogenic isolates from commercial farms provides valuable insights into the molecular pathogenesis of C. perfringens as a gastrointestinal pathogen in food animals. The detailed information on gene sequencing of this important field strain will benefit the development of novel vaccines specific for C. perfringens-induced NE in chickens.

Experimental induction of necrotic enteritis in chickens by a netB-positive Japanese isolate of Clostridium perfringens

Necrotic enteritis (NE) is one of the most important bacterial diseases in terms of economic losses. Clostridium perfringens necrotic enteritis toxin B, NetB, was recently proposed as a new key virulent factor for the development of NE. The goal of this work was to develop a necrotic enteritis model in chickens by using a Japanese isolate of C. perfringens. The Japanese isolate has been found to contain netB gene, which had the same nucleotide and deduced amino acid sequences as those of prototype gene characterized in Australian strain EHE-NE18, and also expressed in vitro a 33-kDa protein identified as NetB toxin by nano-scale liquid chromatographic tandem mass spectrometry. In the challenge experiment, broiler chickens fed a commercial chicken starter diet for 14 days post-hatch were changed to a high protein feed mixed 50:50 with fishmeal for 6 days. At day 21 of age, feed was withheld for 24 hr, and each chicken was orally challenged twice daily with 2 ml each of C. perfringens culture (10⁹ to 10¹⁰ CFU) on 5 consecutive days. The gross necrotic lesions were observed in 90 and 12.5% of challenged and control chickens, respectively. To our knowledge, this is the first study that demonstrated that a netB-positive Japanese isolate of C. perfringens is able to induce the clinical signs and lesions characteristic of NE in the experimental model, which may be useful for evaluating the pathogenicity of field isolates, the efficacy of a vaccine or a specific drug against NE.