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Hygiene hypothesis

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In medicine, the hygiene hypothesis states that a lack of early childhood exposure to infectious agents, symbiotic microorganisms (e.g. gut flora or probiotics), and parasites increases susceptibility to allergic diseases by modulating immune system development.[1]

History

First proposed by David P. Strachan in an article published in the British Medical Journal (now the BMJ), in 1989,[2] the hygiene hypothesis was developed to explain the observation that hay fever and eczema, both allergic diseases, were less common in children from larger families, which were presumably exposed to more infectious agents through their siblings, than in children from families with only one child. The hygiene hypothesis has been extensively investigated by immunologists and epidemiologists and has become an important theoretical framework for the study of allergic disorders. It is used to explain the increase in allergic diseases that has been seen since industrialization, and the higher incidence of allergic diseases in more developed countries. The hygiene hypothesis has now expanded to include exposure to symbiotic bacteria and parasites as important modulators of immune system development, along with infectious agents.

Mechanism of action

Allergic diseases are caused by inappropriate immunological responses to harmless antigens driven by a TH2-mediated immune response. Many bacteria and viruses elicit a TH1-mediated immune response, which down-regulates TH2 responses. The first proposed mechanism of action of the hygiene hypothesis stated that insufficient stimulation of the TH1 arm of the immune system lead to an overactive TH2 arm, which in turn led to allergic disease.[3]

The first proposed mechanistic explanation for the hygiene hypothesis cannot explain the rise in incidence (similar to the rise of allergic diseases) of several TH1-mediated autoimmune diseases, including inflammatory bowel disease (IBD), multiple sclerosis (MS), and type I diabetes. The major proposed alternative mechanistic explanation is that the developing immune system must receive stimuli (from infectious agents, symbiotic bacteria, or parasites) in order to adequately develop regulatory T cells, or it will be more susceptible to autoimmune diseases and allergic diseases, because of insufficiently repressed TH1 and TH2 responses, respectively.[4]

Breadth of the hypothesis

The hygiene hypothesis has expanded from eczema and hay fever to include exposure to several varieties of microorganisms and parasites, with which humans coexisted throughout much of our evolutionary history, as necessary for balanced and regulated immune system development.[5] In recent times, the development of hygienic practices and effective medical care, like vaccines, have diminished or eliminated exposure to these microorganisms and parasites during development. Examples of organisms that may be important for proper development of T regulatory cells include lactobacilli, various mycobacteria, and certain helminths.[6]

Evidence for the hypothesis

The hygiene hypothesis is supported by epidemiological data. Studies have shown that various immunological and autoimmune diseases are much less common in the developing world than the industrialized world and that immigrants to the industrialized world from the developing world increasingly develop immunological disorders in relation to the length of time since arrival in the industrialized world.[7]

Studies in mice have shown that exposure of young mice to viruses can result in a decreased incidence of diabetes. [8]

In Cell : Homeostatic Expansion of T Cells during Immune Insufficiency Generates Autoimmunity they showed that when lymphocytes are replaced, but there are too few memory cells (because of lack of infections) the chance for autoreactive T-cells grows, causing autoimmune diseases like MS.[9] One conclusion is that a clean environment, with lack of infections (like early life infections) increases the chance of an autoimmune disorder.

TH2 immune disorders such as asthma and other allergic diseases are probably related to the hygiene hypothesis. A baby has many TH2 cells, which stimulates producing antibodies. When an infectious fewer early life diseases, too many TH2 cells are present, leading to a greater chance of TH2 immune disorder. In developed countries where childhood diseases are eliminated, the asthma rate for youth is approximately 10%. In the 19th century, asthma was a very rare disease.

Longitudinal studies in the third world demonstrate an increase in immunological disorders as a country grows more affluent and, presumably, cleaner[10]. The use of antibiotics in the first year of life has been linked to asthma and other allergic diseases.[11] The use of antibacterial cleaning products has also been associated with higher incidence of asthma, as has birth by Caesarean section rather than vaginal birth.[12],[13] However, the studies investigating these links showed only tenuous correlations between the factors described and the conditions they are hypothesised to cause. [citation needed].

Several pieces of experimental evidence also support the hygiene hypothesis. Work performed in the laboratory of Professor Anne Cooke at the University of Cambridge showed that mice of the NOD strain (which spontaneously develop type 1 diabetes mellitus) had a significantly reduced incidence of this disease when infected with the helminth parasite Schistosoma mansoni.

Therapies arising out of the hygiene hypothesis

The use of infectious organisms, specifically helminths, to treat the types of disease described by the hygiene hypothesis is being studied in the UK, USA and Australia.

Because of the promise shown by this research two versions of what is now commonly referred to as Helminthic therapy, using Trichuris suis or Necator americanus ova, have become available.

Helminthic therapy is the treatment of autoimmune diseases and immune disorders by means of deliberate infestation with a helminth or with the ova of a helminth. Helminthic therapy is currently being studied as a promising treatment for several (non-viral) auto-immune diseases including Crohn's disease,[14][15][16][17] multiple sclerosis,[18] asthma,[19][20] and ulcerative colitis.[21] Autoimmune liver disease has also been demonstrated to be modulated by active helminth infections.[22]

In addition to the treatment of immune disorders the anti-inflammatory effects of helminth infection are prompting interest and research into diseases that involve inflammation but that are not currently considered to include autoimmunity or immune dysregulation as a causative factor. Heart disease and arteriosclerosis both have similar epidemiological profiles as autoimmune diseases and both involve inflammation. Nor can their increase be solely attributed to environmental factors. Recent research has focused on the eradication of helminths to explain this discrepancy.[23]

As a result of the hygiene hypothesis helminthic therapy emerged from the extensive research into why the incidence of immunological disorders and autoimmune diseases is relatively low in less developed countries, while there has been a significant and sustained increase in immunological disorders and autoimmune diseases in the industrialized countries.[20][24][25][26]. If helminthic therapy and other therapies using other types of infectious organisms, such as protozoa[27], to treat disease are proven successful and safe the hygiene hypothesis has potentially large implications for the practice of medicine in the future.

Alternative hypotheses

For immunological conditions related to Strachan's original version of the hygiene hypothesis, such as atopy and asthma, the pool chlorine hypothesis was proposed by Albert Bernard and his colleagues as an alternative hypothesis based on epidemiological evidence in 2003.

See also

References

  1. ^ Strachan DP (2000). "Family size, infection and atopy: the first decade of the "hygiene hypothesis"". Thorax. 55 Suppl 1: S2–10. doi:10.1136/thorax.55.suppl_1.S2. PMC 1765943. PMID 10943631. {{cite journal}}: Unknown parameter |month= ignored (help)
  2. ^ Strachan DP (1989). "Hay fever, hygiene, and household size". BMJ. 299 (6710): 1259–60. PMC 1838109. PMID 2513902. {{cite journal}}: Unknown parameter |month= ignored (help)
  3. ^ Folkerts G, Walzl G, Openshaw PJ (2000). "Do common childhood infections 'teach' the immune system not to be allergic?". Immunol Today. 21 (3): 118–20. doi:10.1016/S0167-5699(00)01582-6. PMID 10777250. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  4. ^ Bufford JD, Gern JE (2005). "The hygiene hypothesis revisited". Immunol Allergy Clin North Am. 25 (2): 247–62, v–vi. doi:10.1016/j.iac.2005.03.005. PMID 15878454. {{cite journal}}: Unknown parameter |month= ignored (help)
  5. ^ Gold DR,Wright R (2005). "Population disparities in asthma". Annu Rev Public Health. 26: 89–113. doi:10.1146/annurev.publhealth.26.021304.144528. PMID 15760282.
  6. ^ Rook GA,Brunet LR (2005). "Old friends for breakfast". Clin Exp Allergy. 35 (7): 841–2. doi:10.1111/j.1365-2222.2005.02112.x. PMID 16008666.
  7. ^ Gibson PG, Henry RL, Shah S, Powell H, Wang H (2003). "Migration to a western country increases asthma symptoms but not eosinophilic airway inflammation". Pediatr. Pulmonol. 36 (3): 209–15. doi:10.1002/ppul.10323. PMID 12910582. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  8. ^ Oldstone MB (1988). "Prevention of type I diabetes in nonobese diabetic mice by virus infection". Science. 239 (4839): 500–2. PMID 3277269. {{cite journal}}: Unknown parameter |month= ignored (help)
  9. ^ King C, Ilic A, Koelsch K, Sarvetnick N (2004). "Homeostatic expansion of T cells during immune insufficiency generates autoimmunity". Cell. 117 (2): 265–77. PMID 15084263. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  10. ^ Addo-Yobo EO, Woodcock A, Allotey A, Baffoe-Bonnie B, Strachan D, Custovic A (2007). "Exercise-induced bronchospasm and atopy in Ghana: two surveys ten years apart". PLoS Med. 4 (2): e70. doi:10.1371/journal.pmed.0040070. PMC 1808098. PMID 17326711. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
  11. ^ Marra F, Lynd L, Coombes M; et al. (2006). "Does antibiotic exposure during infancy lead to development of asthma?: a systematic review and metaanalysis". Chest. 129 (3): 610–8. doi:10.1378/chest.129.3.610. PMID 16537858. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  12. ^ Thavagnanam S, Fleming J, Bromley A, Shields MD, Cardwell, CR (2007). "A meta-analysis of the association between Caesarean section and childhood asthma". Clin. And Exper. Allergy. online ahead of print: 629. doi:10.1111/j.1365-2222.2007.02780.x.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  13. ^ Zock JP, Plana E, Jarvis D; et al. (2007). "The use of household cleaning sprays and adult asthma: an international longitudinal study". Am J Respir Crit Care Med. 176 (8): 735–41. doi:10.1164/rccm.200612-1793OC. PMID 17585104. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  14. ^ Hunter MM, McKay DM (2004). "Review article: helminths as therapeutic agents for inflammatory bowel disease". Aliment. Pharmacol. Ther. 19 (2): 167–77. doi:10.1111/j.0269-2813.2004.01803.x. PMID 14723608.
  15. ^ Croese J, O'neil J, Masson J, Cooke S, Melrose W, Pritchard D, Speare R. (2006). "A proof of concept study establishing Necator americanus in Crohn's patients and reservoir donors". Gut. 55: 136–137. doi:10.1136/gut.2005.079129. PMID 16344586.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  16. ^ Summers RW, Elliott DE, Urban JF, Thompson R, Weinstock JV (2005). "Trichuris suis therapy in Crohn's disease". Gut. 54 (1): 87–90. doi:10.1136/gut.2004.041749. PMID 15591509.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  17. ^ Summers RW, Elliott DE, Qadir K, Urban JF, Thompson R, Weinstock JV (2003). "Trichuris suis seems to be safe and possibly effective in the treatment of inflammatory bowel disease". Am. J. Gastroenterol. 98 (9): 2034–41. doi:10.1111/j.1572-0241.2003.07660.x. PMID 14499784.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  18. ^ Correale J, Farez M. (2007). "Association between parasite infection and immune responses in multiple sclerosis". Annals of Neurology. 61 (2): 97–108. doi:10.1002/ana.21067. PMID 17230481.
  19. ^ Falcone FH, Pritchard DI (2005). "Parasite role reversal: worms on trial". Trends Parasitol. 21 (4): 157–60. doi:10.1016/j.pt.2005.02.002. PMID 15780835.
  20. ^ a b Leonardi-Bee J, Pritchard D, Britton J (2006). "Asthma and current intestinal parasite infection: systematic review and meta-analysis". American Journal of Respiratory and Critical Care Medicine. 174: 512–523. doi:10.1164/rccm.200603-331OC. PMID 16778161.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  21. ^ Summers RW, Elliott DE, Urban JF, Thompson RA, Weinstock JV (2005). "Trichuris suis therapy for active ulcerative colitis: a randomized controlled trial". Gastroenterology. 128 (4): 825–32. doi:10.1053/j.gastro.2005.01.005. PMID 15825065.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  22. ^ Aoyama H, Hirata T, Sakugawa H; et al. (2007). "An inverse relationship between autoimmune liver diseases and Strongyloides stercoralis infection". Am. J. Trop. Med. Hyg. 76 (5): 972–6. PMID 17488925. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  23. ^ Magen E, Borkow G, Bentwich Z, Mishal J, Scharf S (2005). "Can worms defend our hearts? Chronic helminthic infections may attenuate the development of cardiovascular diseases". Med. Hypotheses. 64 (5): 904–9. doi:10.1016/j.mehy.2004.09.028. PMID 15780483.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  24. ^ Pugliatti M, Sotgiu S, Rosati G (2002). "The worldwide prevalence of multiple sclerosis". Clin Neurol Neurosurg. 104 (3): 182–91. doi:10.1016/S0303-8467(02)00036-7. PMID 12127652. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)Zaccone P, Fehervari Z, Phillips JM, Dunne DW, Cooke A (2006). "Parasitic worms and inflammatory diseases". Parasite Immunol. 28 (10): 515–23. doi:10.1111/j.1365-3024.2006.00879.x. PMC 1618732. PMID 16965287. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  25. ^ Pugliatti M, Sotgiu S and Rosati G. (2002). "The worldwide prevalence of multiple sclerosis". Clin Neurol Neurosurg. July (104): 182–91. doi:10.1016/S0303-8467(02)00036-7. PMID 14684567.
  26. ^ Weinstock JV, Summers R, Elliott DE (2004). "Helminths and harmony". Gut. 53 (1): 7–9. doi:10.1136/gut.53.1.7. PMC 1773927. PMID 14684567. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  27. ^ Juckett DA, Aylsworth CF, Quensen JM (2008). "Intestinal protozoa are hypothesized to stimulate immunosurveillance against colon cancer". Med. Hypotheses. 71 (1): 104–10. doi:10.1016/j.mehy.2008.01.024. PMID 18343044.{{cite journal}}: CS1 maint: multiple names: authors list (link)

Additional references

  1. Camateros P, Moisan J, Hénault J; et al. (2006). "Toll-like receptors, cytokines and the immunotherapeutics of asthma". Curr Pharm Des. 12 (19): 2365–74. doi:10.2174/138161206777698918. PMID 16842184. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)

External links

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