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DOI: 10.1111/eci.12132

REVIEW

Training innate immunity: the changing concept of

immunological memory in innate host defence
Mihai G. Netea
Department of Medicine and Nijmegen Institute for Infection, Inflammation & Immunity (N4i), Radboud University Nijmegen
Medical Center, Nijmegen, The Netherlands

ABSTRACT
The inability of innate immunity to build an immunological memory is considered a main difference with adaptive
immunity. This concept has been challenged by studies in plants, invertebrates and mammals. Recently, a
paradigm shift in our understanding host defence has been triggered by the mounting evidence for innate
immune memory, leading to increased responses to secondary infections. Important differences between the
cell populations and the molecular mechanisms exist between the adaptive traits of innate host defence on the
one hand and immunological memory of adaptive immunity on the other hand. The lasting state of enhanced
innate immunity termed ‘trained immunity’ is mediated by prototypical innate immune cells such as natural killer
cells and monocytes/macrophages. It provides protection against reinfection in a T/B-cell-independent manner,
with both specific mechanisms and nonspecific epigenetic reprogramming mediating these effects. This con-
cept represents a paradigm change in immunity, and its putative role in resistance to reinfection may represent
the next step in the design of future vaccines.
Keywords Immunological memory, trained immunity, vaccine.
Eur J Clin Invest 2013; 43 (8): 881–884

Innate vs. adaptive immunity

For more than half a century, host defence has been considered
adaptive features and that these mechanisms can offer protec-
to be exerted by innate immune mechanisms on the one hand
tion to reinfection, independent of the classic adaptive immune
and adaptive immunity on the other. Innate immunity reacts
memory. In a recent review that details the arguments for the
instantly to an encounter with a pathogen, but has been viewed
protective effects of innate immune memory, we proposed the
as nonspecific and incapable of building an immunological
term trained immunity for this process [2]. Trained immunity is
memory. In contrast, adaptive immune responses can specifi-
manifested as protection against reinfection by the same or
cally recognize pathogenic microorganisms and build memory
different pathogens and occurs in organisms lacking adaptive
capable of protection against reinfection. During the last decade,
immune responses such as plants [3], invertebrates [4,5] and
the dogma of innate immunity being nonspecific has dramati-
mammals lacking functional T and B cells [6–8]. The discovery
cally changed, through the discovery of pattern recognition
of memory characteristics of prototypic innate immune cells
receptors (PRRs) such as the Toll-like receptors (TLRs), C-type
such as natural killer (NK) cells and monocytes/macrophages
lectin receptors (CLRs), NOD-like receptors (NLRs) and
has been viewed as a paradigm shift in immunity [9,10].
RigI-helicases. These receptors of innate immunity allow specific
Important questions to be asked at this point are whether the
recognition of different kinds of microorganisms, although not
enhanced state of innate immunity defined as trained immu-
individual microbial species [1]. The widespread conviction that
nity is different from adaptive immunity as well as from
innate immunity cannot adapt following a previous encounter
priming of innate immunity and thus whether it is justified to
with a pathogen, and is incapable of building the memory of a
propose a new concept and a new terminology. To that end, we
previous infection, has proved to be more entrenched.
need to clearly define the concept of trained immunity.
The easiest part of the problem is to distinguish trained
Trained immunity: the adaptive feature of innate
immunity from adaptive immunity. Adaptive immunity is the
host defence
long-term immunological memory, mediated by T and B
An unbiased survey of the immunological literature reveals lymphocytes. This process is highly specific for the antigen
important clues that innate immunity is able to display involved, and it is mediated by V-D-J gene recombination. In

European Journal of Clinical Investigation Vol 43 881


M. G. NETEA
contrast, trained immunity is mediated by innate immune cells
such as monocytes/macrophages and NK cells, and it is likely
to be of shorter duration. Trained immunity is often nonspe-
cific, and epigenetic reprogramming appears to be an important
mechanism for the enhancement of the functional state of the
cells [8,11]. It is well possible that, especially in NK cell mem-
ory, additional mechanisms such as gene recombination play a
role. If this is the case, an unexplored area of investigation
opens up, with the question arising whether NK cells should be
considered cells with both trained and adaptive immune
characteristics.
The other question regarding the definition of trained
immunity is whether trained immunity differs from priming of
innate immunity. Priming of innate immune responses (such as
in the so-called Sanarelli–Shwartzman reaction) is a well-
known phenomenon present during certain infections as well
as in other situations in which innate immune cells are
stimulated; it results in an enhanced response to secondary
stimulations [12]. Priming of innate immunity, however,
rapidly declines after the infection is resolved. When, however,
after recovery from infection, the functional status of innate
immune responses does not return to the steady-state level, but
remains enhanced because of functional reprogramming of
innate immune cells, we define this status as trained immunity
Primed innate immunity
Innate immune response
Trained immunity
Homeostasis
Tolerance
Time
Figure 1 During certain infections or shortly after exposure to
certain stimuli, innate immune responses can be primed to
respond more strongly upon challenge with a second stimulus
(primed innate immunity). Priming of innate immunity declines
rapidly after the infection is resolved. However, the state of
innate immune responses often does not return to basal levels
after the infection, remaining enhanced through medium- and
long-term reprogramming effects at the level of innate immune
cells, a state identified as trained immunity. Trained immunity
can also be considered the opposite of the immune tolerance
state in which innate immunity can be directed by severe
infections such as sepsis.
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(Fig. 1). Thus, long-term, trained immunity is fundamentally
different for the short-lived change in the state of innate
immunity that is defined as priming. Trained immunity may be
considered as the opposite of immune tolerance, the state in
which innate immunity is suppressed during and after severe
infections such as sepsis.
Molecular mechanisms driving trained immunity
The importance of immune adaptation as an evolutionarily
driven property of complex defence systems is underlined by
the existence of an independently developed second type of
adaptive immune response in jawless vertebrates. This
response is based on variable lymphocyte receptors [13].
Complementary to this phylogenetic support, studies dealing
with the ontology of the immune system have demonstrated
that TLR-induced maturation of innate immunity (as assessed
by cytokine profiles) is an adaptive feature of mammalian host
defence that has developed to reduce the impact and severity of
subsequent infections [14,15].
Building on these evolutionary arguments, there is a rich
body of research documenting adaptive traits of innate immu-
nity in plants and invertebrates that provides strong support
for the relevance of innate immune memory and the molecular
mechanisms that drive it [2,5]. Systemic acquired resistance
(SAR) has been described as the pivotal process providing
protection against reinfection in plants. Studies of the
biochemical mechanisms mediating SAR have provided the
first evidence that epigenetic processes are at the basis of innate
immune memory [11,16]. A remarkable recent finding is that
epigenetic changes are able to provide trans-generational
transmission of resistance, with acetylation of H3K9 being
central for this process [17]. The epigenetic programmes that
mediate systemic acquired resistance in plants represent a lead
discovery regarding the mechanisms responsible for the long-
term changes in the functional phenotype of innate immune
cells in plants, as well as in animals.
Despite old studies that suggested resistance to reinfection in
nude mice [18], it was not until recently that innate immune
memory was studied in depth in mammals. Three main
populations function as cellular effectors of innate immunity:
the neutrophils, the monocytes/macrophages and the NK cells.
Neutrophils are cells in a state of final differentiation and a
short life span; inherently their capacity to participate in long-
term immunological memory is very limited. In contrast, recent
studies revealed that the other two innate immune cell types,
mononuclear phagocytes and NK cells, display memory char-
acteristics. Several elegant studies, published in the last three
years, have demonstrated that NK cells afford protection to the
host in a T/B-cell-independent manner; the protection is
dependent on the Ly49 expression on NK cells. This leads to

recruitment of Syk and SAP70 for long-term activation of the
NK cell and specific protection to reinfection with
herpesviruses, such as cytomegalovirus (CMV) [6]. During
CMV reactivation in patients, expansion of NKG2C+ NK cells,
the human counterpart of the memory NK cells in mice, has
been demonstrated [19]. Additional insights into the mecha-
nisms of protection based on NK cell memory have been pro-
vided by studies demonstrating the role of CXCR6+ memory
NK cells from the liver [7].
Modulation of the function of monocytes by microbial stimuli is
an important determinant in host defence. Recent studies have
shown that the dose of lipopolysaccharide (LPS) to which mono-
cytes are exposed determines whether tolerance (as occurs with
high LPS concentrations) or priming (with ultra-low LPS con-
centrations) is attained [20]. Epigenetic mechanisms have been
reported earlier as being central in the development of LPS toler-
ance [21]. Important insight into these processes has been recently
obtained: LPS appears to induce several types of epigenetic
modification in a cell type- and stimulus-specific manner. While
most of the epigenetic markers fade in time, histone methylation at
H3K4me1 in so-called latent enhancers remains active as an epi-
genetic marker, conferring long-term immunological memory
[22]. Very recently we demonstrated the importance of histone
methylation for the epigenetic reprogramming of monocytes at
the H3K4 level following exposure to b-glucans [8]. The trained
immunity induced in vivo through epigenetic reprogramming
was found to result in the protection of T/B cell-deficient Rag1 /
mice against lethal systemic candidiasis, underlining the
therapeutic potential of trained immunity [8]. An important
observation in these studies is that trained immunity lacks
specificity: protection is provided not only against the original
microorganism, but also against unrelated microorganisms.
To conclude, these data compose a picture in which the innate
immune system exhibits adaptive features, as it can be trained to
provide partial protection against infection in a way independent
of classical T/B-cell adaptive immunity. NK cells and monocytes
have emerged as the main mediators of trained immunity in
mammals, with functional reprogramming (e.g. through epige-
netically mediated mechanisms) mediating these effects.
The biological and therapeutic relevance of
trained immunity
There is little doubt that innate immune memory in plants and
invertebrates plays a key role in host defence, but it is tempting
to speculate that in mammals the biological relevance of trained
immunity was lost during evolution, because adaptive immu-
nity provides the specificity needed during reinfection. How-
ever, there are several arguments to assume that trained
immunity has persisted as an important component of host
defence. For example, certain commensal microorganisms may
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TRAINED INNATE IMMUNITY
be beneficial for the mammalian host because they induce
nonspecific immune protection. This may be the case for
C. albicans, a very common colonizer of human skin and
mucosa and a strong inducer of trained immunity [8], and such
a favourable effect has also been suggested for latent
herpesviruses [23].
In addition, the relevance of trained immunity may be
inferred from the effect of vaccines. A prime example is BCG
vaccine that has been shown to provide nonspecific protection
of animals against fungal sepsis [24] and against influenza
infection [25]. Such effects have also been observed in humans:
children vaccinated with BCG benefit from nonspecific protec-
tive effects against infections other than those caused by
mycobacteria [26,27]. Similar protection has been attributed to
measles vaccine. These effects observed in humans open up
new strategies for vaccination. An unorthodox approach would
be to exploit trained immunity in situations where specific
vaccines are not (yet) available, such as in pandemic influenza.
When vaccines are relatively ineffective, to train immunity may
help. Vaccination programmes in settings of high infectious
pressure in developing countries, vaccination of elderly people
and of patients with a dysfunctional immune system (e.g. HIV
patients) are situations that also come to mind. A most impor-
tant area is vaccine development. Here, training the innate
immunity could be used to optimize the adaptive immune
response to classical vaccines.
In addition, there are potential therapeutic effects of induc-
tion of trained immunity. Refractory infections and the
immunoparalysis in sepsis are examples in which training
immunity might help. The challenge for the coming years is
thus to deconstruct the molecular mechanisms of trained
immunity, as well as to explore the protective effects of trained
immunity in clinical practice.
In conclusion, the adaptive characteristics of innate immu-
nity or trained immunity have emerged as an important new
property of innate host defence mechanisms. Its study in the
coming years promises to become an area of very active
immunological research, with a direct impact on our under-
standing of immune responses and on the design of novel
immunoprophylactic and therapeutic strategies.
Acknowledgements
M.G.N. was supported by a Vici Grant of the Netherlands
Organization for Scientific Research.
Address
Department of Medicine and Nijmegen Institute for Infection
Inflammation & Immunity (N4i), Radboud University
Nijmegen Medical Center, Nijmegen, The Netherlands (M. G.
Netea).
European Journal of Clinical Investigation Vol 43 883

M. G. NETEA
Correspondence to: Mihai G. Netea, Department of Medicine
(463), Radboud University Nijmegen Medical Center, PO Box
9101, 6500 HB Nijmegen, The Netherlands.
Tel.: +31-24-3618819; fax: +31-24-3541734;
e-mail: m.netea@aig.umcn.nl
Received 25 June 2013; accepted 27 June 2013
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