Available online at www.sciencedirect.
com
Trained immunity: implications for vaccination
Büsranur Geckin 1,2,*, Friedrich Konstantin Föhse 1,2,*,
Jorge Domínguez-Andrés 1,2 and Mihai G Netea 1,2,3
The concept that only adaptive immunity can build
immunological memory has been challenged in the past
decade. Live attenuated vaccines such as the Bacillus
Calmette–Guérin, measles-containing vaccines, and the oral
polio vaccine have been shown to reduce overall mortality
beyond their effects attributable to the targeted diseases. After
an encounter with a primary stimulus, epigenetic and metabolic
reprogramming of bone marrow progenitor cells and functional
changes of tissue immune cell populations result in augmented
immune responses against a secondary challenge. This
process has been termed trained immunity. This review
describes the mechanisms leading to trained immunity and
summarizes the most important developments from the past
few years.
Addresses
1
Department of Internal Medicine and Radboud Center for Infectious
Diseases, Radboud University Medical Centre, Nijmegen, The
Netherlands
2
Radboud Institute for Molecular Life Sciences, Radboud University
Medical Center, 6525 GA Nijmegen, The Netherlands
3
Department of Immunology and Metabolism, Life & Medical Sciences
Institute, University of Bonn, Bonn, Germany
Corresponding author: Mihai G Netea (Mihai.Netea@radboudumc.nl)
*
These two authors contributed equally.
Current Opinion in Immunology 2022, 77:102190
This review comes from a themed issue on Vaccines
Edited by Mariagrazia Pizza and Rino Rappuoli
For complete overview of the section, please refer to the article
collection, “Vaccines (August 2022)”
Available online 18th May 2022
https://doi.org/10.1016/j.coi.2022.102190
0952-7915/© 2022 The Author(s). Published by Elsevier Ltd. This is
an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
Introduction
For a long time, immune memory was considered an
exclusive feature of the adaptive immune system.
However, a growing number of epidemiological and
immunological studies have started to accumulate,
showing the effects of vaccines beyond their target in-
fection. These heterologous effects could not be ex-
plained by the induction of antigen-specific adaptive
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]]
]]]]]]
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immune memory. One mechanism that is likely involved
in these off-target effects of vaccine is represented by
heterologous T-cell immunity in which antigens lead to
the formation of cross-reactive T-cells capable of re-
cognizing multiple and different ligands [1]. For ex-
ample, in the case of COVID-19, there is 80% similarity
between SARS-CoV-2 open reading frame 7a protein
epitope with the human poliovirus type 3 Sabin strain
epitope [2]. A second potential mechanism, and the
focus of this review, is represented by the new experi-
mental evidence demonstrating that cells of the innate
immune system can also adapt after infections or vacci-
nations, a process that is antigen independent. Such
adaptive characteristics in innate immune cells that
amount to a de-facto innate immune memory are non-
specific, resulting in improved host defense. The process
in which innate immune cells display enhanced immune
responses to a subsequent insult has been termed trained
immunity [3,4]. In this review, we will describe the im-
munological processes leading to trained immunity and
discuss the importance of trained immunity in the con-
text of vaccination and its implications on global health.
Trained immunity as an immunological
process
Trained immunity is a long-term functional reprogram-
ming of innate immune cells following an encounter
with a primary stimulus, which results in an augmented
response against a secondary challenge. The induction of
trained immunity has been observed in many cell types
and is mediated by extensive metabolic and epigenetic
remodeling (Figure 1) [5]. The functional changes as-
sociated with the induction of trained immunity have
been shown to last for at least a year; on the other hand,
epidemiological studies have shown long-term effects
for up to 5 years in the case of nonspecific protection
induced by vaccination [5,6].
Induction of trained immunity has been demonstrated in
both mononuclear myeloid cells such as monocytes [3,7],
macrophages [8], dendritic cells [9], and neutrophils [10•],
as well as in lymphoid cells such as natural killer (NK) cells
and innate lymphoid cells (ILCs) [11,12]. The enhance-
ment of the antimicrobial properties of myeloid cells is
expressed through increased cytokine production capacity
and enhanced synthesis and release of reactive oxygen
species [13], leading to improved phagocytosis and killing
of pathogens. One of the earliest immunological observa-
tions of differential response of phagocytic cells to
Current Opinion in Immunology 77 (2022) 102190
2 Vaccines
Figure 1
Current Opinion in Immunology
Induction of trained immunity. The primary challenge includes the
encounter of innate immune cells (monocytes, macrophages, NK cells,
neutrophils, and dendritic cells) with vaccines, pathogens or sterile
damage-associated molecules. During the primary immune response,
the cells undergo a series of metabolic and epigenetic reprogramming
events, that partially persist (e.g. in bone marrow progenitors) also
after the initial stimulus is eliminated. When the organism meets a
secondary challenge, the ‘trained’ innate immune cells elicit a more
robust and more prompt response than the initial response.
consecutive challenges is reported by Howard et al. in
1959, showing the cells are either resistant or susceptible to
bacterial endotoxin and Salmonella enteritidis infection after
Bacillus Calmette–Guérin (BCG) infection [14]. Another
study in 1986 showed that a noninvasive Candida albicans
strain can provide protection against subsequent infection
with a highly virulent strain through activation of macro-
phages [15].
Not only myeloid cells but also lymphoid cells with in-
nate characteristics can develop immune memory prop-
erties. NK cells are described among the first innate
immune cells to possess memory-like characteristics
[11,12]. Vaccines like BCG and influenza induce
memory responses in NK cells, leading to enhanced
cytokine production improving pathogen clearance
[16,17]. Memory-NK cells contribute to the survival of
the Severe combined immunodeficiency murine model
subjected to candidiasis [17]. ILCs also show innate
immune memory [18].
Two mechanisms explain the long-term protection induced
by trained immunity: the reprogramming of bone marrow
progenitor cells (central trained immunity) and the func-
tional changes of tissue cell populations (peripheral trained
immunity) (Figure 2) [5]. In murine models, BCG vacci-
nation and β-glucan administration altered transcriptional
and functional profiles of hematopoietic stem and progenitor
cells (HSPCs) and enhanced myelopoiesis [19,20]. Inter-
estingly, bone-marrow-derived macrophages of BCG vacci-
nated mice offered better protection against Mycobacterium
tuberculosis [19]. Building on these findings, Cirovic et al.
reported an upregulation in genes associated with myeloid
cell linage priming in human HSPCs 90-days after BCG
vaccination compared to baseline. After vaccination, the
Current Opinion in Immunology 77 (2022) 102190
Figure 2
Current Opinion in Immunology
Central versus peripheral trained immunity: sustaining long-term innate
immune memory. Upon processing of the stimulus inducing trained
immunity, changes will be induced at the level of both the bone marrow
progenitor cells and the tissues. Central trained immunity defines altered
transcriptional profile in progenitor cells with an enhanced rate of
myelopoiesis. This results in the production of innate immune cells with
memory. On the other hand, peripheral trained immunity resides in
tissue-resident cells. These long-living, activated, and differentiated
cells carry transcriptional modifications which establish functional
changes.
monocytes of the subjects display higher DNA accessibility
on several inflammation-associated genes [21•]. Similarly,
Laval et al. demonstrated a protective memory against
Pseudomonas aeruginosa infection in mice following the
transplantation of LPS-exposed stem cells [22].
Peripheral trained immunity is induced in tissue-resident
macrophages and ILCs, which in turn contribute to long-
term protection. Adenovirus infection can induce long-
lasting memory on alveolar macrophages [23]. Conversely,
previous gammaherpesvirus infection led to replacing re-
sident alveolar macrophages with regulatory monocytes, re-
sulting in a decrease in the severity of house dust-mite-
induced asthma symptoms [24]. Type 2 ILCs also persist
3 weeks after infection, and they respond to subsequent
heterologous infections and contribute to exacerbated
asthma responses [25]. Altogether, these studies help us
understand the mechanisms allowing induction of long-term
memory in trained immunity.
Metabolic and epigenetic pathways in the induction of
trained immunity
After initial exposure to a stimulus, a series of intracellular
pathway cascades are triggered to elicit, mediate, and
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regulate the innate immune response. In 2007, Foster et al.
demonstrated that primary exposure of mouse bone
marrow-derived macrophages to LPS initiate a Toll-like
receptor signaling cascade that leads to transcription of
class NT genes ensuring the response to secondary LPS
stimulation is faster and greater in magnitude. They sug-
gested that this transcriptional memory can be considered
as an adaptive component of innate immunity [26]. Today,
we know that the two major molecular mechanisms in the
cells that underpin trained immunity are metabolic and
epigenetic processes (Figure 3).
The function of immune cells depends on their ability to
ensure energy needs. During the resting period, immune
cells mainly rely on oxidative phosphorylation (OXPHOS)
to produce ATP. Upon activation, cellular metabolism un-
dergoes important changes that depend on the type of cells
and stimulus. Regulatory cells such as type 2 macrophages
and T-regulatory cells use fatty acid oxidation for the gen-
eration of the necessary energy [27,28], while strongly in-
flammatory cells such as type 1 macrophages, neutrophils,
and Th1/Th17 cells largely rely on glycolysis [28–30]. Some
stimuli, such as LPS, determine a shift from OXPHOS to
glycolysis [31], while others upregulate both glycolysis and
OXPHOS [32]. Similar differences characterize the cellular
metabolism of trained immune cells. In this regard, β-glucan
is recognized by Dectin-1, and has been known to lead to a
shift from OXPHOS to glycolysis as an ATP source [33].
However, a more recent study reported an increase in both
glycolysis and oxygen consumption following training, which
signals a higher rate of OXPHOS [34]. This discrepancy is
explained by the difference in concentration of β-glucan
used in the experiments [34]. Similarly, BCG training yields
upregulation in glycolysis and OXPHOS, accompanied by
elevated lactate production and simultaneous upregulation
in glutaminolysis [35]. Glutaminolysis leads to the accumu-
lation of fumarate, a downstream tricarboxylic acid (TCA)
cycle metabolite, that induces trained immunity phenotype
itself [35]. Moreover, itaconate, which has antimicrobial
properties and was recently described as contributing to
inflammation resolution [36], is also impacted in trained
immunity: a recent study reported that β-glucan blocks the
itaconate pathway and reverses monocyte tolerance [37].
The metabolic changes during induction of trained im-
munity have a long-term impact on the function of innate
immune cells through modulation of epigenetic pro-
cesses. In this respect, TCA metabolites act as cofactors
for enzymes involved in epigenetic regulation: DNA
methylases, histone methyl- and acetyltransferases, de-
methylases, and deacetylases [8,38,39]. Main epigenetic
events during induction of trained immunity are (1) the
chromosomal reorganization on the level of topologically
associated domains (TADs), (2) induction of long non-
coding RNA (lncRNA) activity, (3) histone modifications
and chromatin accessibility, and (4) DNA (de)methylation
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Trained immunity and vaccines Geckin et al. 3
[40]. TADs are domains enriched in chromosomal loops,
and they allow DNA elements like lncRNAs to gain
proximity to the gene promoter and regulate its tran-
scription. Certain lncRNAs, named immune gene-
priming lncRNAs, come in close contact with innate im-
mune genes before the transcription [41]. Important
epigenetic marks of open chromatin associated with a
trained immunity phenotype are histone 3 lysine 4 tri-
methylation that characterizes active promotors of proin-
flammatory cytokine genes, histone 3 lysine 4
monomethylation that marks distal enhancers, and his-
tone 3 lysine 27 acetylation marking both active en-
hancers and promoter regions (e.g. promoters of genes
related to glycolysis and cytokine production) [5,38,42].
Epigenetic enzymes play a crucial role throughout the
course of trained immunity. Lysine demethylase sub-
family 5 (KDM5) is responsible for the demethylation of
H3K4 [43]. KDM5 family is downregulated by the ac-
cumulation of fumarate, which supports the generation
of trained immunity by allowing the persistence of his-
tone methylation marks [44]. More recently, KDM4 has
been identified as an essential enzyme mediating the
induction of trained immunity via alteration in
H3K9me3 [45••]. In addition, an epigenetic enzyme
belonging to the lysine methyltransferase family, Set7,
also possesses vital function in β-glucan training of
monocytes; when inhibited, trained immunity pheno-
type is diminished, while Set7 deficient mice cannot
establish innate immune memory [34••].
Lastly, Verma et al. observed that the DNA methylation
profile is altered following BCG vaccination; however,
more studies should be conducted to explore the impact
of these changes at the DNA level [46].
Epidemiological consequences of trained
immunity induction by vaccines
From almost the beginning of the vaccination era,
epidemiological observations indicate that live atte-
nuated vaccines offer protection against heterologous
infections and reduce overall mortality. Such protective
effects were first noticed when smallpox was in-
troduced approximately 200 years ago [47], and it has
since then been shown for several vaccines such as
BCG, measles-containing vaccines, and polio vaccines
[48]. Soon after the introduction of BCG in Europe in
the 1930s, epidemiological studies reported a ‘non-
specific’ effect of BCG with a strongly reduced infant
mortality, independent of its effect on tuberculosis
[49]. Later on, studies in West Africa showed an up to
50% reduction of mortality induced by BCG in young
infants [50]. Similar observations were made over the
years in low-income countries, showing a reduction of
infections [51,52]. Randomized controlled trials
Current Opinion in Immunology 77 (2022) 102190
4 Vaccines

Figure 3

Current Opinion in Immunology

Cross-talk between metabolic and epigenetic pathways underlying trained immunity response. After initial recognition of trained immunity inducers
such as vaccines and pathogens, cells undergo a series of metabolic and epigenetic changes. Since the immune cell is activated, glucose
consumption increases to provide the energy needed through strong activation of glycolysis — higher glucose consumption yields lactate as a
byproduct. Downstream, the TCA cycle is replenished through glutaminolysis, which fuels the cycle with α-ketoglutarate (α-KG). This leads to the
accumulation of fumarate, which inhibits KDM5 demethylases, preventing demethylation of H3K4 allowing histone marking of promoters. In addition,
activation of KDM4 removes the repressive marker represented by methylation of H3K9. Lastly, Set7 methyltransferase is described as an essential
enzyme in the metabolic and epigenetic fate of the cell. Inhibition of Set7 has been shown to impair the induction of trained immunity. Overall, these
events underpin the molecular mechanisms which led to a trained state of innate immune cells.

performed in high-income countries give, however,
more inconsistent results: a phase III trial reported that
BCG vaccination significantly increases the time to the
first infection, with an incidence of new infections of
25% after BCG vaccination compared to 42% after
placebo vaccination in a population of elderly in-
dividuals [53••]. In contrast, randomized trials in
Denmark and Australia did not find a reduced risk of
hospitalization for somatic acquired disease and lower
respiratory tract infections, respectively [54,55]. These
epidemiological studies have been accompanied by
BCG protection in models of experimental human viral
[56] and parasitic [57] infections. BCG vaccination has
been suggested to protect against Staphylococcus aureus
and surgical site infections [58], as well as in Leishmania
infections [59]. Aside from infections, BCG is well
known to be the most effective therapy for treating
early-stage bladder cancer: it has recently been
proposed that trained immunity partly accounts for
these antitumor effects [60].
Similar to BCG, the introduction of the measles vaccina-
tion (MV) in Guinea–Bissau in 1979 led to a remarkable
decrease in childhood mortality that could not be ex-
plained solely by its effect on the measles epidemic itself
[61]. One study observed that infants who get an extra
early standard dose of MV do not have reduced all-cause
mortality [62]. By contrast, MV was reported to reduce the
number of outpatient consultations [63]. Studies in high-
income countries are scarce, but measles-containing vac-
cination led to high protection against hospitalizations for
all infectious diseases and particularly strong protection
against lower respiratory tract infections in Italian children
[64]. A recent analysis of demographic surveillance data in
Bangladesh did not find a favorable effect of vaccination
with measles in young children (0–2 years) [65]. In

Current Opinion in Immunology 77 (2022) 102190 www.sciencedirect.com

 Trained immunity and vaccines Geckin et al. 5

contrast, vaccination with polio was associated with a 30% adjuvanted zoster vaccine Shingrix has been suggested
reduced all-cause mortality [66••]. to have protective effects against COVID-19 severity
which are attributed at least partly to trained immunity
An extensive overview of all epidemiological studies [76•]. More results of RCTs with BCG, the recombinant
conducted on heterologous effects of childhood vaccines BCG vaccine VPM1002 and MMR will come available
has recently been provided by Aaby and Benn [67]. Al- during 2022, and those will hopefully provide more
though a WHO-SAGE committee concluded that the clarity regarding the clinical and immunological effects
evidence is not strong enough yet to change existing of trained immunity-inducing vaccines on COVID-19
vaccination recommendations, more randomized trials (NCT04327206, NCT04537663, NCT04351685 and
have been advised [68]. Besides live attenuated vac- NCT04333732).
cines, inactivated influenza induces transcriptional and
functional reprogramming of innate immune cells six
Implications and future perspectives
weeks after the vaccination, modulating cytokine re-
Here, we provide a high-level overview of the latest
sponses upon viral challenge with unrelated stimuli
developments in the field of trained immunity. Much
[69•]. Those findings are complemented by the study of
remains to be learned on the mechanisms of innate im-
Wimmers et al. who reported modulation of hetero-
mune memory to understand all factors influencing its
logous antiviral mechanisms after influenza vaccination,
effects. Age, sex, circadian rhythm, the composition of
accompanied by transcriptional and epigenetic repro-
the gut microbiome, vaccination technique, lifestyle, and
gramming of innate immune cells [70]. More studies are
the combination with other vaccines can impact the in-
needed for a broad, comprehensive assessment of the
duction of trained immunity. However, the relative
heterologous effects of various vaccines and the impact
contributions of these factors and how they act to in-
of trained immunity in these processes.
fluence vaccines’ heterologous effects in different po-
pulations remain to be investigated in future studies. In
addition, the current vaccines used to induce trained
Trained immunity-based approaches during
immunity have only partial effectiveness: only approxi-
COVID-19
mately half of individuals vaccinated with BCG respond
The SARS-CoV-2 virus emerged at the end of 2019 and
with a strong trained immunity response [56,77]. De-
evolved into a pandemic with grave consequences at a
veloping amplifiers of trained immunity effects after
worldwide scale. While development, testing, produc-
vaccination, or new, more effective vaccines, should be
tion, and distribution of anti-SARS-CoV-2 vaccines were
an important aim of future research [78]. There is a
very successful, more than a year was needed to ac-
particular need for randomized controlled trials since
complish that in the developed countries, while a much
most of the presented epidemiological studies are at
longer period of time was necessary to be able to dis-
high risk for bias.
tribute them in the developing world. Because in the
beginning of the pandemic it was unclear whether de-
Overall, evidence is strong that BCG, measles, and polio
velopment of successful vaccines could be accom-
have beneficial heterologous effects, especially in low-
plished, it has been hypothesized that trained-
income and middle-income countries. Therefore, stop-
immunity-based vaccines might have a protective role
ping vaccination with measles and polio once the pa-
against COVID-19 and act as a ‘bridge vaccination’.
thogens are eradicated, or replacing live attenuated polio
Among the trials performed, only a few have been
with inactivated polio, should be done with caution, as it
published so far, and the results of most others are still
may have a substantial impact on childhood mortality
expected. In one RCT in elderly, BCG vaccination of
[79]. Trained immunity may also represent an important
elderly in the Netherlands did not reduce the total
new approach to improve current vaccines or to develop
number of COVID-19 infections, although it improved
novel vaccines that combine the induction of classical
the serological response after infection [71••]. In con-
adaptive immune memory and innate immune memory.
trast, a BCG revaccination trial in Greece reduced the
Such approaches may prove especially useful in future
total number of COVID-19 cases [72]. The cause of this
new pandemics: it must be assumed that the SARS-
difference is unclear, although it may be hypothesized
CoV-2 pandemic will not be the last outbreak humanity
that differences between populations, or the fact that
has to face. Trained immunity-based vaccines may be a
these two populations had different BCG vaccination
very promising possibility to improve the efficiency of
histories at birth may be potential explanations. Im-
vaccines against outbreaks by emerging pathogens.
portantly, neither of the two studies had enough power
to draw any conclusions on the impact of BCG on
COVID-19 severity. Results of BCG vaccination effect Conflict of interest statement
on SARS-CoV-2 infection in animal models have been The authors declare the following financial interests/
also contradictory, with both positive effects and no personal relationships which may be considered as po-
impact being reported [73–75]. On the other hand, the tential competing interests: MGN is scientific founder of

www.sciencedirect.com Current Opinion in Immunology 77 (2022) 102190

6 Vaccines
TTxD, and has received scientific support from GSK,
Ono Pharma, TTxD.
Acknowledgements
This manuscript was partly supported by an European Research Council
(ERC) Advanced Grant (#833247) and a Spinoza Grant of the Netherlands
Organization for Scientific Research (to MGN).
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