William Parker, PhD Duke University Medical Center

1. Dependency of immune function on environmental components: apparent mutualistic aspects of commensalistic and even parasitic relationships William Parker, PhD Duke University Medical Center

2. This presentation accompanies the lecture by William parker given at the 2011 Ecoimmunology meeting in Scotland.

3. Popular Science Worst Jobs in Science 2009 Vermin Handler http://www.popsci.com/scitech/gallery/2009-01/worst-jobs-science-2009

4. Post industrial society serves as a testing ground for the alteration or even loss of various components from the “human biome” (the ecosystem of the human body). In the medical world of post industrial society, we care about the “friendly components” (mutualistic organisms).

5. Three distinct categories of “friendly factors” • Bacteria in dirt. (predominantly mycobacteria) • Mutualistic bacteria (the microbiome) • Mutualistic helminths (known unfortunately as parasites) Rook and Brunet, Gut. 2005 March; 54(3): 317–320. doi: 10.1136/gut.2004.053785.

6. Lessons from the microbiome Gut Bacteria Mutual admiration, or reluctant tolerance? The immune system

7. Accepted paradigm of Science until 2003: Primary Mechanism of Gut Function Immune exclusion of bacteria by Immunoglobulin A (SIgA) in the gut

8. SIgA inhibits 50% to 75% of the binding of common Streptococcus species to human gut cells. Inhibition of Bacterial Adherence by Secretory IgA: A mechanism of Antigen Disposal, by R. C. Williams and R. J. Gibbons Published in Science, 1972

9. Immune Exclusion • An attractive idea • Normal gut bacteria are the most common cause of death in the United States: Something has got to keep these things in check. • SIgA are made against pathogenic bacteria as well as good bacteria. The SIgA must then be antagonistic to bacteria.

11. without SIgA with SIgA (image not magnified)

12. The mucin story No protein SIgA Mucin Mucin + SIgA (image not magnified)

13. Immune Inclusion

14. Predicted biofilms are observed in the proximal large bowel.

16. Normal Infection Recovery Apparent function of the appendix Diarrhea Recovery “Safe House”

17. Heather Smith Michel Laurin For an agonizingly detailed review of the vermiform appendix, see The Anatomical Record, 294:567–579 Rebecca Fisher

18. Three distinct categories of “friendly factors” • Bacteria in dirt. (predominantly mycobacteria) • Mutualistic bacteria (the microbiome) • Mutualistic helminths (known unfortunately as parasites) Rook and Brunet, Gut. 2005 March; 54(3): 317–320. doi: 10.1136/gut.2004.053785.

19. Stimulatesdevelopment Microbiome Helminths ? Supports and Contains Growth Resource commitment Limits colonization Immune suppression Stimulates feedback inhibition Stimulates development Immune system

20. Ubiquitous factors that, by themselves, do not cause pathology Immune hypersensitivity caused by hygiene-associated biome depletion Environmental stimulus (“triggers”, often reduced by hygiene) + 2 1 + 3 Genetic predisposition and/or epigenetic effects Hyper-immune associated diseases, including allergyand autoimmunity Bilbo, Wray, Perkins, and Parker Medical Hypotheses, 2011 doi:10.1016/j.mehy.2011.06.019

21. The adoption of “modern” culture causes epidemics of various conditions that are rare or absent in developing areas of the world. These can be classified into two categories: Biome depletion incompatible with human biology Diet, rest, exercise and other behavior incompatible with human biology coronary artery disease hypertension stroke type 2 diabetes obesity lung cancer automobile-related injury appendicitis asthma allergies (all types) multiple sclerosis lupus type 1 diabetes inflammatory bowel disease The increase in disease rate associated with industrialization depends on disease, and ranges from about 15-fold to more than 100-fold. Numbers from underdeveloped countries are very crude estimates, but have been confirmed by other means. Med Hypotheses (2011), doi:10.1016/j.mehy.2011.06.019

22. Results of biome depletion • Confirmed • asthma • allergies (all types) • some common types of eczema • food allergies • hay fever or rhinitus • multiple sclerosis • lupus • type 1 diabetes • inflammatory bowel disease • Very probable • appendicitis • Graves’ disease • some non-allergic types of eczema • Non-tropical Sprue (Celiac disease or gluten enteropathy) • Very suspicious • heart disease (in part) • chronic fatigue syndrome • autism Med Hypotheses (2011), doi:10.1016/j.mehy.2011.06.019

23. Why did it take so long to figure this out? Modern medicine is so compartmentalized it did not see common factors among different diseases (Rook et al, Springer SeminImmun (2004) 25:237-255) Common factors Emerging, non-infectious diseases of post-industrial society Hyper-reactivity of the immune system involving potent responses to harmless self or foreign antigens Frequent involvement of “triggers” A role of genetics and/or epigenetics

24. Why did it take so long to figure this out? • 2. Modern medicine is so focused on the here and now that • (a) The time lag between factors causing biome depletion and the onset of effects was extremely difficult to see through. • It took about 5 decades for the flush toilet to move from a luxury to a necessity in the US. • The life span of helminths and the effects of epigenetics can delay the onset of pathology for generations.

25. Why did it take so long to figure this out? • 2. Modern medicine is so focused on the here and now that • (b) The obvious role of “triggers” and genetics was (and still is) overwhelmingly attractive. 995 grants and 314 million dollars total research on autism 100 million dollars on cause and prevention of autism Zero dollars on biome depletion and autism *2009 IACC Autism Spectrum Disorder Research Portfolio Analysis Report

26. Why did it take so long to figure this out? • 3. The initial idea involved hygiene, not biome depletion Hygiene causes biome depletion, which underlies epidemics of hyperimmune-associated disease, BUT Hygiene also decreases triggers for both allergy and autoimmune disease.

27. Ubiquitous factors that, by themselves, do not cause pathology Immune hypersensitivity caused by hygiene-associated biome depletion Environmental stimulus (“triggers”, often reduced by hygiene) + 2 1 + 3 Genetic predisposition and/or epigenetic effects Hyper-immune associated diseases, including allergyand autoimmunity Bilbo, Wray, Perkins, and Parker Medical Hypotheses, 2011

28. A brief interlude into the field of biomedical research and clinical studies: Putting out the fire of human disease. Human disease

29. The triple-hit paradigm of immune-associated disorders. Environmental stimulus + → Genetic or epigenetic factors Pathology + Modern medicine tends to deal with hyperimmune-associated disorders using therapeutics that block symptoms. Immune hypersensitivity biome depletion

30. Colonization of laboratory mice with a common roundworm prevents or cures the following: • experimentally induced colitis • experimentally induced allergy • type 1 diabetes

31. Helminths (worms) and MS A prospective study, with 24 patients: 12 accidentally colonized with helminths, and 12 uncolonized(Argentina) After colonization, 3 relapses in the colonized group, 56 relapses in the uncolonized group Annals of Neurology (2007) 61:97-108

32. Helminth (worm) therapy for IBD 29 patients with IBD enrolled, most non-responsive to pharmaceuticals A first attempt: approach not optimized in any way A first attempt: approach not optimized in any way • After 24 weeks of therapy: • 72.4 % completely “cured” • 79.3% improved • No adverse side effects CurrOpinGastroenterol. 2005;21:51-58

33. Immune Modulation Allergy, parasites, and the hygiene hypothesis Science (2002) 296:490-494. Helminthimmunoregulation: The role of parasite secreted proteins in modulating host immunity Molecular & Biochemical Parasitology (2009) 167: 1–11

34. All three components of the “depleted biome” may need to be considered in concert. Microbiome stabilized by fecal transplant. Alexander Khoruts and Janet Jansson, Journal of Clinical Gastroenterology, 44 (8), 562-566 DOI: 10.1097/MCG.0b013e3181dac035 “Friendly” bacteria from dirt activate a group of neurons that produce the brain chemical serotonin. Chris Lowry, Neuroscience (2007), doi: 10.1016/j.neuroscience.2007.01.067

35. Outrageous ambition • Pediatricians routinely prescribe symbiotic helminths for young patients. • General practitioners check the health of symbiotic helminths and of the immune system as a routine part of a physical exam. * • Hyperimmune-associated diseases are only of historical interest. * For examples, a simple blood test to evaluate eosinophil count, or an assessment of helminth antigens in stool

36. The labeling of all helminths as strictly “parasites” was apparently premature. ? or or Helminths cause damage in developing countries for the following reasons, which will not impact the “reintroduction” of helminths in developed countries. Uncontrolled infection Some helminths are not well adapted Malnutrition or lack of water

37. “Evidence from both animal and human studies implicates the immune system in a number of disorders with known or suspected developmental origins, including schizophrenia, anxiety/depression, and cognitive dysfunction.” “We believe that cytokines are important not only for behavioral changes during acute illness, but may also underlie long-term changes in behavior as a consequence of infection early in life.” Staci D. Bilbo, Department of Psychology and Neuroscience, Duke University

38. The end of our brief interlude into the field of biomedical research and clinical studies. Human disease

39. We utilize a comparison between wild-rats and lab rats to model what might be happening to the human immune system in post-industrial society.

40. Some limitations in comparing the immune systems of laboratory and wild rodents (in order of our concern) • More substantial limitations include: • Controlled experiments on wild rodents are very difficult to conduct. • Issues with stress: (reduced by breeding in lab animals, increased by trapping in wild animals) • Issues with exercise: (The lab animals don’t get any.) • Less concerning issues include: • 4. Differences in the genetics of the lab and the wild animals • 5. Difference in the diet of the lab and the wild animals

41. * *Int Arch Allergy ApplImmunol 1979;59:465–8

42. The effects of biome depletion on the immune system

43. ConA-induces up-regulation of CD134 and CD25 on TCR+ cells from lab rats but not wild rats.

44. Unpublished data in this portion of the lecture (4 slides) removed prior to publication on the web.

45. Biome depletion causes wide-spread changes in the immune system Changes found Changes possibly found Changes not found Your immune system (a criminal oversimplification) Not yet studied Immune system diagram from Molecular Systems Biology 2:2006.0022

46. Acknowledgements THE ONES WHO RUN THE LAB Mary Lou Everett Zoie E. Holzknecht Susanne Meza-Keuthen STUDENTS Daniel Palestrant Aaron Wyse Aditya Devalapali Andrew Barbas Andy Tan Aaron Lesher Anitra Thomas COLLABORATORS Randy Bollinger Shu Lin Jeff Platt Duane Davis Sara Miller Paul Orndorff SanetKotze Rebecca Fisher Heather Smith Michel Laurin Sarah Perkins

47. References for gut function 2003: Immunology109, 580-587. 2004: UltrastructuralPathology, 28, 23-27. 2004: Infection & Immunity, 72, 1929-1938. 2004: Clinical and Applied Immunology Reviews, 5, 321-332. 2005: Molecular Immunology, 43, 378-387. 2007: J. Theoretical Biology. 249: 826-831. 2009: Journal of Evolutionary Biology.22: 1984-1999. 2009: Experimental Biology and Medicine. 234:1174–1185 2010:Applied and Environmental Microbiology. doi:10.1128/AEM.00358-10 References for the profoundand widespread effects of biome depletion on the immune system 2006: Scand. J. Immunol. 64:125-136 2006: Immunol. and Cell Bio. 84:374-382 2011: Med Hypotheses doi:10.1016/j.mehy.2011.06.019 References allergy/autoimmune disease 2001: Am. J. Path. 159: 1957-1969 2002: Immunobiology205: 95-107 2005: Ann. Thoracic Surgery75:1037-1038 2010: Surgical Endoscopy24:1066–1074

48. Discussion