PERSPECTIVES

On the basis of immune equilibrium,

E S S AY
it can be assumed that the immune system
is able to distinguish between ‘good’ and
Immunity by equilibrium ‘bad’ — for example, between mutualistic
and pathogenic microorganisms — and
develop either anti-inflammatory or pro-­
Gérard Eberl inflammatory immune responses11,12.
However, how it would be able to distinguish
Abstract | The classical model of immunity posits that the immune system reacts to
good from bad is still an open question16.
pathogens and injury and restores homeostasis. Indeed, a century of research has In fact, there are three, possibly four, types
uncovered the means and mechanisms by which the immune system recognizes of immune response that are mutually
danger and regulates its own activity. However, this classical model does not fully inhibitory. These include type 1 responses
explain complex phenomena, such as tolerance, allergy, the increased prevalence against intracellular threats (such as viruses,
of inflammatory pathologies in industrialized nations and immunity to multiple intracellular bacteria and tumours), type 2
responses against large extracellular threats
infections. In this Essay, I propose a model of immunity that is based on equilibrium, (such as helminths) and type 3 responses
in which the healthy immune system is always active and in a state of dynamic against extracellular microorganisms (such as
equilibrium between antagonistic types of response. This equilibrium is regulated extracellular bacteria and fungi). Activation
both by the internal milieu and by the microbial environment. As a result, alteration of one type of response inhibits another type,
of the internal milieu or microbial environment leads to immune disequilibrium, and the immune equilibrium is maintained
by the competing immune responses. This
which determines tolerance, protective immunity and inflammatory pathology.
principle forms the basis of the equilibrium
model of immunity. In contrast to earlier
How does the immune system recognize the very existence of autoimmunity and immunological principles, the equilibrium
a wide variety of microorganisms but Treg cells suggests a failure to avoid the model of immunity does not predict how
avoid attacking the body’s own tissues recognition of self, and thus a need for an immune response is triggered (as all
(which are referred to as ‘self ’)? A century tolerance mechanisms. Furthermore, these types of immune response are already active
of research into this question led to principles cannot explain why the immune during the steady state) but instead predicts
two central principles of immunology. system develops self-threatening allergic how this active immune system behaves
The first principle of immunology is reactions, and why allergies and autoimmune when facing new threats, which are almost
self–non-self discrimination1,2, or the pathologies are increasing in industrialized always present in combination. I believe that
recognition of danger 3, altered self and nations in association with greater hygiene the equilibrium model of immunity provides
discontinuity 4. This is achieved through and less exposure to infectious diseases10. a broad but simple and testable framework
several mechanisms, such as the expression On the basis of the principle of self– to explain complex immune phenomena
of innate immune receptors that recognize non-self discrimination, it was assumed such as tolerance, autoimmunity, allergy
microorganism-associated molecular that the immune system is at rest when not and resistance or susceptibility to secondary
patterns (MAMPs) or danger-­associated exposed to pathogens, danger signals or infections. It might also open up new
molecular patterns (DAMPs), the altered self. However, it is now clear that the approaches for immunotherapy.
elimination of developing T cells that react immune system is never at rest, in particular
with self (a process that is known as thymic at mucosal sites11,12 but also systemically 13 The equilibrium model of immunity
selection) and the generation of regulatory and in germ-free conditions14. Indeed, self is The foundations of immunology are rooted
T (Treg) cells. The second principle is the constantly altered and danger is continually in the work of Metchnikoff (1845–1916)
generation and selection of diverse immune present as cells die, tissues are injured, and Paul Ehrlich (1854–1915), who drew on
repertoires5–7. To recognize the large diversity and microorganisms proliferate within and the discovery by Louis Pasteur (1822–1895)
of viral, bacterial, fungal and eukaryotic outside the body. More than a century ago, and Robert Koch (1843–1910) of the
microorganisms, as well as altered self, the Élie Metchnikoff stated that “physiological pathogenic potential of microorganisms
process of somatic V(D)J recombination inflammation” is required to maintain (BOX 1). Therefore, the immune system is
leads to the generation of a large repertoire harmony in animals15. These observations primarily viewed as a system that opposes
of receptors on B cells and T cells8,9, which prompted a third principle of immunology pathogens through elaborate mechanisms
are then selected for by antigens from — immune equilibrium — in which anti-­ of recognition and destruction. However,
microorganisms and altered self. inflammatory forces of the immune system the realization that the immune system
However, these two principles are not regulate pro-inflammatory forces to maintain is in a constant state of activation, even
sufficient to understand several intriguing homeostasis. When the anti-inflammatory in the absence of pathogens, indicates that
aspects of the immune system. For example, forces fail, severe pathology occurs. the immune system does not react only to

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pathogens. At mucosal sites in particular,
symbiotic microorganisms induce diverse
immune effector cells that establish a
vital equilibrium between the host and its
microbiota11,12. This is also the situation
systemically, where symbiotic viruses
chronically activate the immune system13.
Negative regulation has a crucial role
in the immune system, a concept that was
first proposed in the 1970s by Niels Jerne,
Heinz Kohler and Geoffrey Hoffmann
in the context of the immune network
theory 17–19, and by Richard Gershon in the
context of the suppressor T cell theory 20,21.
Negative regulation has now become an
immunological paradigm through the
characterization of Treg cells, the absence
of which leads to dramatic inflammatory
pathology 22–25. It is generally agreed that
a healthy immune system, as well as a
healthy immune response, is based on an
equilibrium between effector T cells and
Treg cells, and that it involves regulation
through a variety of molecules, such as
interleukin‑10 (IL‑10), transforming growth
factor‑β (TGFβ), programmed cell death 1
(PD1; also known as PDCD1), cytotoxic
T lymphocyte antigen 4 (CTLA4) and CD25
(also known as high-affinity IL‑2 receptor
(IL‑2RA))26,27.
However, Treg cells are not the only
cells to regulate immune responses. Other
types of immune cells have regulatory
functions, such as regulatory B cells28
and myeloid-derived suppressor cells29.
Furthermore, it is well known that T helper 1
(TH1) cells, TH2 cells30–32 and TH17 cells
negatively regulate each other in in vitro
differentiation assays, and that one type of
T helper cell characteristically dominates
a particular immune response in vivo33.
More generally, immune responses can be
characterized as antagonistic type 1, type 2
or type 3 responses (with type 3 responses
defined as those inducing TH17 cells) (BOX 2),
which involve an array of lymphoid, myeloid
and stromal cells that are adapted to the type
of microorganism, pathogen or injury that is
affecting the organism.
The equilibrium model of immunity
proposes that the immune system relies
on an equilibrium between these different
types of immune response: an equilibrium
that defines homeostasis. As a consequence,
a microorganism or injury that triggers one
type of response induces the suppression
of the other types of response. Conversely,
an absence of stimulation of one type of
response leads to the exacerbation of the
other types of response, with potentially
pathological consequences (FIG. 1).
NATURE REVIEWS | IMMUNOLOGY
PERSPECTIVES
Box 1 | A brief history of pathology and immunology
The Greek physician Hippocrates (460–370 BCE) is credited as being among the first to propose that
diseases are not caused by the Gods but by environmental factors, diet and living habits. His medical
system was based on humourism, which states that health is determined by the equilibrium, within
an individual, of four fundamental body fluids, the humours. This notion of internal equilibrium is
central to the more recent concept of ‘milieu intérieur’, defined by Claude Bernard (1813–1878).
In his view, an organism has to ensure internal stability, or homeostasis, as defined later by
Walter Cannon (1871–1945)63, to maintain health in the face of external variations.
Directly contradicting humourism, Louis Pasteur (1822–1895) and Robert Koch (1843–1910)
demonstrated the germ theory of disease, in which the environment is a source of diseases through
infectious microorganisms. The proponents of this theory had to postulate the existence of an
immune system that protects the body from pathogenic microorganisms. Élie Metchnikoff
(1845–1916), who was recruited by Pasteur in 1888, demonstrated the existence of phagocytes
that destroy microorganisms by ingestion. Paul Ehrlich (1854–1915), a close friend of Koch, showed
the role of humoral immunity, conveyed by antibodies, in the defence against microorganisms and
bacterial toxins.
A century of immunology research followed to try to understand how the immune system
recognizes the enormous diversity of microorganisms, and how it destroys pathogens without
destroying the organism that it means to protect. Paradigms emerged, such as the self–non-self
discrimination principle proposed by Frank Macfarlane Burnet (1899–1985)1 and Niels Jerne
(1911–1994)2. More recently, Polly Matzinger formulated the danger model3, which proposes that
the immune system is triggered not only by the recognition of invading microorganisms (non-self),
as discussed by Charles Janeway (1943–2003)131, but also by the danger associated with these
microorganisms and, more generally, by injured tissue. Finally, Thomas Pradeu, Sébastien Jaeger
and Eric Vivier proposed that the immune system is fundamentally activated by a change in
normality or discontinuity4.
An alternative view of immune reactivity, known as the immune network theory, was proposed in
the 1970s by Jerne, Heinz Kohler and Geoffrey Hoffmann17–19. According to this theory, the immune
system is composed of a network of cells and antibodies, recognizing both non-self antigens and
new self-antigens (such as hyper-variable regions of antibodies). This network of recognition
includes both activators and suppressors that maintain the system in a state of equilibrium during
homeostasis. Disturbance of that equilibrium by a new antigen induces a response, which is
followed by a gradual return to homeostasis. Although this theory has been generally abandoned
by the immunological community, the idea of an equilibrium within the immune system that is
maintained by a network of activators and suppressors is a concept that is supported by more
recent studies, and encapsulated by the view that an equilibrium between pro-inflammatory and
anti-inflammatory immune responses is required to maintain health.
Type 1 and type 3 responses are induced of strong inflammation and extensive tissue
by microorganisms, and they fit the injury, during which both intracellular and
original defensive role that was assigned extracellular threats may be recognized,
to the immune system by Metchnikoff and lymphoid cells produce both IFNγ and
Ehrlich. Type 1 responses are shaped by IL‑17 and therefore have a mixed type 1
the production of IL‑12 by dendritic cells and type 3 phenotype38,39.
(DCs) and macrophages34 and lead to the Type 2 responses that develop against
activation of natural killer (NK) cells and large organisms, such as helminths, seem
group 1 innate lymphoid cells (ILC1s)35, to have a different nature and purpose.
followed by the activation of TH1 cells, The destruction of these large organisms by
cytotoxic CD8+ T cells and, in mice, IgG2+ immune cells is difficult, and so the immune
B cells. The main molecular effectors of system constructs a barrier using tissue-
type 1 responses are interferon‑γ (IFNγ) repair mechanisms to provide protection40.
that is produced by lymphoid cells and For example, at mucosal surfaces, type 2
cytotoxic molecules, such as perforin responses induce mucus production and
and oxygen radicals. Type 3 responses collagen deposition. These responses are
are shaped by the production of IL‑1β shaped by the production of IL‑25, IL‑33
and IL‑23 by DCs and macrophages36,37, and thymic stromal lymphopoietin (TSLP)
which leads to the activation of ILC3s35 by non-haematopoietic cells41, leading to
and TH17 cells. The type 3 effector phase is the activation of ILC2s35 and eosinophils,
characterized by the production of IL‑17 resulting in the development of TH2 cells and
and IL‑22 by lymphoid cells, antimicrobial IgG1+ or IgE+ B cells and the production of
peptides (AMPs) by epithelial cells and the IL‑4, IL‑5 and IL‑13. Alternatively-activated
recruitment of neutrophils. In the context macrophages (AAMs)42 have an important
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Box 2 | Molecular regulation of type 1, type 2 and type 3 immunity that represses the others until the infection
is cleared. By contrast, following a decrease
The molecular regulation of type 1, type 2 and type 3 immunity has been extensively studied in one type of trigger, for example, during
in T helper (TH) cells and their innate counterparts, the innate lymphoid cells (ILCs). Each type antibiotic therapy to eliminate extracellular
of TH cell and ILC is induced by one of the master regulator transcription factors: T‑bet induces bacteria that induce type 3 responses, the
TH1 cells and ILC1s, GATA binding protein 3 (GATA3) induces TH2 cells and ILC2s, and retinoic acid
other types of response are dysregulated
receptor-related orphan receptor-γt (RORγt) induces TH17 cells and ILC3s132,133. During
inflammation, the cytokine environment activates specific signal transducers and activators of and exacerbated to levels that may lead
transcription (STATs) that favour the expression of a particular master regulator in naive or to pathological inflammation. I propose
precursor cells. For example, interleukin‑23 (IL‑23) induces the phosphorylation and activation of that the original and intuitive concept of
STAT3 that drives the expression of RORγt, which in turn induces the expression of the effector equilibrium — the basis of Claude Bernard’s
cytokines IL‑17 and IL‑22 (REF. 134). These master regulators function within a network of (1813–1878) principle of ‘milieu intérieur’,
transcription factors that support their lineage-determination function135 and negatively regulate and of Walter Cannon’s (1871–1945) concept
the expression and function of the ‘competing’ master regulators. T‑bet inhibits GATA3 (REF. 136) of homeostasis63 — is a core principle of
and the differentiation of TH17 cells137, whereas GATA3 inhibits both type 1 and type 3 responses132. immunity (BOX 1).
In type 3 cells, STAT3 suppresses type 2 responses56,138,139. The master regulator of regulatory T (Treg)
cells is forkhead box P3 (FOXP3), which binds GATA3 (REF. 140), RORγt27,141 and STAT3 (REF. 140)
Evidence for the equilibrium model
and which dominates to induce its regulatory programme. It should be noted, however, that these
master regulators can have additional roles during the development of lymphoid cells and in Inflammatory pathologies. Type 2 responses
mature effector cells142. For example, GATA3 expression is also required for the development of the drive allergic and pro-fibrotic pathologies
common ILC precursor143 and for the further differentiation of ILC3s into a type 1‑like NKp46+ through the production of IL‑4, IL‑5 and
subset that co‑expresses T‑bet, possibly through the regulation of RORγt144. IL‑13 (REF. 64). By contrast, type 3 responses
are involved in autoimmune inflammatory
diseases, such as inflammatory bowel
role in type 2 responses during tissue (GATA3))54,55 and TH17 cells (retinoic disease, rheumatoid arthritis and multiple
repair 43,44 and were originally described by acid receptor-related orphan receptor-γt sclerosis39,65,66, through the production
Metchnikoff as the phagocytes that eliminate (RORγt))27,56, as well as chemokine receptors of IL‑17, granulocyte–monocyte colony-­
abnormal cells during fetal development45. that are associated with these T helper stimulating factor 36 and lymphotoxin67,
Mixed type 2 and type 3 responses may occur cell subsets. It has been suggested that the whereas type 1 responses are involved
during allergic responses, possibly induced by cytokine environments that induce type 1, in systemic lupus erythematosus (SLE)
concomitant tissue damage and the presence type 2 or type 3 responses also promote a and type 1 diabetes (T1D) through the
of extracellular microscopic particles46. partial differentiation of Treg cells into these production of IFNs68. In industrialized
A type 4 immune response has also been types, allowing them to migrate to effector nations, the decreased incidence of
proposed33,47. This response does not develop sites and to efficiently regulate the associated infectious diseases thanks to better hygiene,
against microorganisms or parasites that T helper cell functions57. In addition, the vaccines and antibiotics, is associated with
infect or injure tissues, but rather aims to generation of Treg cells, in particular, type 3 an increase in the incidence of allergic
block microorganisms and parasites before Treg cells, is induced at the expense of the and autoimmune inflammatory diseases
they reach sensitive tissues. For example, associated effector cells56,58. Nevertheless, this — an association that is described by
in the eye, inflammation is poorly tolerated does not occur during inflammation27, and the hygiene hypothesis10. I propose that
and causes irreversible damage48, and in the type 3 Treg cells do not regulate TH17 cells, but inflammatory pathologies may not only
intestine, the extensive microbiota must instead regulate TH2 cells, in accordance with be a consequence of exacerbated type 1,
be kept away from the epithelium to avoid the equilibrium model of immunity 56. The type 2 or type 3 responses, but may also be
the induction of tissue-damaging chronic inverse situation is also true: type 2 Treg cells a consequence of diminished type 1, type 2
inflammation49,50. Type 4 immunity requires regulate TH17 cells54. or type 3 responses.
secretory IgA, which is released in large Finally, and importantly, although one Epidemiological and experimental
quantities into the intestinal lumen, and type of immune response is dominant at data show that a loss of exposure to
is also released in tears, saliva, sweat one site at a particular moment, different microorganisms (not necessarily pathogens)
and secretions from the genitourinary responses can simultaneously develop at leads to an increased susceptibility to allergic
tract and the respiratory epithelium. IgA different sites or sequentially develop at the responses69. For example, children raised
has a broad ‘anti-inflammatory’ effect51, same site. For example, a type 3 response that on farms are less susceptible to developing
partly because it neutralizes microorganisms is induced by symbiotic microbiota in the allergies than those not raised on farms70.
before they reach the host tissues where intestine does not preclude the presence of a Conversely, children who are treated at an
they would induce type 1 or type 3 immune type 2 response in adipose tissues59,60, at least early age with multiple doses of antibiotics
responses52. Other elements of the proposed in the steady state61. Furthermore, destructive are more susceptible to allergies than those
type 4 responses include the production of type 1 and type 3 responses must be followed who are not exposed to repeated antibiotic
mucus49 and AMPs, which are also secreted by repair-associated type 2 responses to therapy 71,72. The same effect is found in
in substantial amounts by epithelial cells50. restore homeostasis in the affected tissue40,62. mice treated early in life with antibiotics73
So, do Treg cells constitute a separate type In summary, the four arms of the or maintained in germ-free conditions
of response that is dedicated to suppressing all immune system are balanced in the healthy until weaning 74, and germ-free mice also
other responses? Treg cells have been described state. The normal microbiota induces all four develop high levels of serum IgE14. Several
that express the signature transcription types of response and thereby establishes a mechanisms have recently been reported
factors of TH1 cells (T‑bet; also known as healthy balance. During infection or injury, to explain how the microbiota inducing
TBX21)53, TH2 cells (GATA binding protein 3 one arm of the immune system is stimulated type 3 responses represses pro-allergic type 2

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responses. First, exposure of pre-weaned
mice to the microbiota leads to long-term
epigenetic modification of the gene encoding
CXC-chemokine ligand 16 (CXCL16),
which recruits invariant NKT cells that
produce IL‑13 and increase susceptibility to
type 2 inflammation74. Second, we showed
that the microbiota induces TH17 cells and
RORγt+ Treg cells that inhibit the generation
of type 2 T cell responses56. Third, it has
been shown that B cells respond directly to
bacterial signals to limit serum IgE levels
and basophil numbers75. In addition, type I
IFNs that are induced by murine norovirus
(MNV) block the elevated type 2 response
that is found in germ-free mice76, and IFNs
directly block ILC2s77,78.
Another case of pathological interference
between type 2 and type 3 responses
involves fat metabolism, and the regulation
by AAMs of blood glucose consumption
to generate heat 79. Monocytes that are
recruited to fat are converted to AAMs
by IL‑4 that is produced by eosinophils80,
which are themselves recruited by IL‑5 that
is produced by ILC2s81,82. However, type 3
responses are enhanced if the adipose tissue
is inflamed — for example, after a diet- and
inflammation-induced increase in intestinal
permeability that causes microorganisms
and microbial products to access the
circulation and to reach fat tissues61,83,84. As a
consequence, type 2 responses are inhibited
and blood glucose levels rise, increasing the
risk of type 2 diabetes.
Type 3 immunity is regulated by
viral and bacterial infections that induce
type 1 responses85. In particular, IL‑17
production that is required against bacterial

a Extracellular
microorganisms
Helminths

Type 2 response Type 3 response

IL-33 IL-23

IL-4 IL-17 Exclusion of

microorganisms

Intracellular viruses
and bacteria, and
tumours IFNγ
sIgA
IL-12
TGFβ
Type 1 response

Type 4 response

b Health Autoimmunity Allergy

1 2 3 4 1 2 3 4 1 2 3 4
Type of response Type of response Type of response
Figure 1 | The equilibrium model of immunity. a | The equilibrium model microorganisms and to protect sensitive tissues from potentially destructive
of immunity is based on the idea that the immune system is never at rest but inflammation, through the secretion of, for example,
Naturelarge amounts
Reviews of IgA and
| Immunology
instead relies on a dynamic equilibrium between four types of competing and antimicrobial peptides into the gut lumen or eye secretions. b | Health is
mutually inhibitory immune responses. Type 1 responses are directed against determined by an equilibrium between these four types of response.
intracellular threats, such as viruses, some bacteria and tumours, whereas Following an infection that induces one type of response, the other types of
type 3 responses are directed against extracellular micro­organisms, such as response are inhibited. Conversely, the absence of one type of response leads
most bacteria and fungi. Type 2 responses are directed against large parasites, to the exacerbation (red) of the other types, potentially leading to
such as helminths, which cannot be destroyed by type 3 responses but that inflammatory pathologies, such as autoimmunity and allergy.
can be kept at bay by the construction of barriers through the production of IFNγ, interferon-γ; IL, interleukin; sIgA, secretory IgA; TGFβ, transforming
mucus and collagen. Finally, type 4 responses develop to exclude growth factor-β.

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infections is inhibited by type 1 and type 2
IFNs86–88. Furthermore, helminth-induced
type 2 responses limit autoimmune
inflammation, at least in rodent models89,90.
These mechanisms might explain the
increased incidence of arthritis, multiple
sclerosis and inflammatory bowel disease
in industrialized countries, where there
is a decreased incidence of infections by
helminths, viruses and intracellular bacteria
such as Mycobacterium tuberculosis 10.
Conversely, a loss in the diversity of bacterial
symbionts, as a consequence of increased
antibiotic use, may lead to a loss of type 3
responses and, therefore, to an increase
in autoimmunity that is driven by type 1
responses, such as SLE and T1D68. In
support of this mechanism, segmented
filamentous bacteria, intestinal symbionts
and potent inducers of type 3 responses91,92,
are associated with protection from T1D
in mice93,94.
Infectious pathologies. Recent data
have provided evidence to explain how
a pre-existing infection can influence
the outcome of a second infection (or
superinfection). For example, mice that are
latently infected with a γ‑herpesvirus develop
increased resistance to superinfection
by the bacteria Listeria monocytogenes 95.
Both microorganisms elicit a type 1 response
by the host, and the increased level of IFNγ
that is induced by the latent (symbiotic) virus
confers protection against L. monocytogenes.
However, the presence of a virus can also
increase susceptibility to superinfection
by a microorganism that is controlled by a
different type of response. For example,
a previous infection with lymphocytic
choriomeningitis virus (LCMV) increases
the susceptibility of mice to a subsequent
infection with L. monocytogenes or
Staphylococcus aureus through a mechanism
that involves the type 1 IFN-mediated
apoptosis of granulocytes96. In this
case, the type 1 response that is induced
by the virus blocks the type 3 response
that is mediated by the granulocytes to
limit the early spread of bacteria. Similarly,
a previous infection with influenza A
virus or respiratory syncytial virus renders
mice highly susceptible to superinfection
with pneumonia-inducing bacteria, such
as Neisseria meningitides 97, Streptococcus
pneumoniae, Haemophilus influenzae,
Streptococcus pyogenes and S. aureus 98.
These viruses may also induce type 2 repair
responses during later stages of infection
that further interfere with the antibacterial
type 3 response.
Conversely, helminths that induce
type 2 responses impair antiviral type 1
responses. Mice that are infected with MNV
develop virus-specific CD8+ T cell and
TH1 cell responses. However, pre-infection
with the helminth Trichinella spiralis
blocks the generation of virus-specific
T cells and leads to increased viral loads99.
Microbiota-induced type 3 responses also
block antiviral type 1 responses. Mice
treated with antibiotics resist MNV
infection through the production of
IFNλ by epithelial cells and the activation
of the transcription factors signal
transducer and activator of transcription 1
(STAT1) and interferon-­regulatory factor 3
(IRF3), which are mediators of type 1
immunity. However, in untreated mice,
the microbiota induces type 3 immunity
and blocks this type 1 response100. Finally,
infectious microorganisms or helminths
can manipulate the immune system for
their own benefit. For example, the fungus
Aspergillus fumigatus induces a potent
pro-allergic type 2 response in the lungs101,
but neutrophils and IL‑17‑mediated
type 3 responses are required for its
efficient elimination102.
Tumours. Type 1 cytotoxic responses, which
involve CD8+ T cells and NK cells, are most
effective for fighting tumours. However,
tumours induce several responses that
inhibit antitumour type 1 responses.
Tumour-induced type 3 responses favour
tumour growth through the activation of the
anti-apoptotic transcription factor STAT3.
In a mouse model of spontaneous breast
cancer, tumour-infiltrating macrophages
produce IL‑1β, which induces the production
of IL‑17 by γδ T cells and the recruitment of
neutrophils103. The neutrophils inhibit the
activation of tumour-specific CD8+ T cells
and thereby facilitate tumour metastasis.
Tumours also induce TGFβ-driven
‘anti-inflammatory’ responses, which inhibit
tumour-specific CD8+ T cells by promoting
the generation of Treg cells (which type
of Treg cell remains to be determined)104.
TGFβ also promotes the generation of
IgA+ B cells, which are the proposed main
effectors of type 4 responses105. Recently, IgA+
B cell responses were found in the tumour
microenvironment of mice treated with the
chemotherapeutic drug oxaliplatin. The
generation of such B cells was dependent
on TGFβ receptor signalling and led to the
expression of IL‑10 and PD1 ligand 1 (also
known as CD274), which inhibited the
cytotoxic T cell-mediated response against
the tumour 106.
Predictions from the equilibrium model
Thymus-derived Treg cells and repair
responses. A key principle of adaptive
immunity is the clonal selection of
immature T cells in the thymus107–109,
during which T cells that recognize
self-antigens are eliminated (through
negative selection). An apparent
violation of this rule is the generation in
the thymus of Treg cells that react against
self 110,111. It is generally thought that
thymus-derived Treg (tTreg) cells are generated
to suppress responses by effector T cells
that weakly react to self-antigen; these cells
react with self-antigen too weakly to be
eliminated during negative selection, but do
react strongly enough to have the potential
to become autoreactive disease-causing
cells during inflammation112. So, tTreg cells
are selected in the thymus owing to their
intermediate reactivity to self.
The equilibrium model of immunity
suggests an alternative explanation for
the generation of tTreg cells, as well as a
new classification for thymus-derived
and peripherally derived Treg (pTreg) cells
(FIG. 2). We have recently reported that, in
the intestine, microbiota-induced pTreg cells
express RORγt, which is the marker for type 3
lymphoid cells, and initially differentiate
along a pathway that is common to TH17 cells
and then through a distinct pathway in
the presence of retinoic acid56. By contrast,
Treg cells that express GATA3, the marker
for type 2 lymphoid cells, can develop in the
absence of the microbiota56 and constitute
another major population of Treg cells in
the intestine54,55 and adipose tissue113,114.
On the basis of these observations, we
proposed that Treg cells differentiate according
to the associated effector T cells into type 1,
type 2 or type 3 Treg cells, and thus determine
the level of the local immune response56. This
suggests that recognition of self by developing
tTreg cells, which occurs in the absence of
microbiota-derived antigens, should lead to
the generation of type 2 Treg cells, which may
contribute to tissue repair when activated in
the context of sterile tissue injury. During the
late stages of an infection that require tissue
repair, type 2 Treg cells may also contribute
to the inhibition of type 1 and type 3
responses54,115. This idea could be tested by
assessing the expression of molecules that are
associated with type 2 immunity and tissue
repair by tTreg cells.
Neonatal and oral tolerance. Immune
tolerance is considered to be a general
mechanism of immune control that is
required to avoid inflammatory pathology.

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 PERSPECTIVES

However, as in the case of Treg cells,
tolerance may instead reflect an inhibition
of one type of immunity by another
type33 (FIG. 2).
For example, neonatal tolerance occurs
on the exposure of neonates to antigens116.
It is commonly accepted that the immature
status of the neonatal adaptive immune
system leads to the elimination rather
than to the activation of T cells specific for
such antigens. This view is an extension
of the principle, formulated by Frank
Macfarlane Burnet (1899–1985), that
embryonic antigens are defined as self
and should therefore induce tolerance1.
However, as discussed above for the
generation of tTreg cells, neonatal antigens,
as well as embryonic antigens, may induce
type 2 cells (TH2 cells, type 2 Treg cells,
ILC2s and AAMs) and thereby induce
the repair responses that are required
to control developing tissues. Neonatal
type 2 responses are predicted to inhibit
the type 1 and type 3 responses induced
by most experimental challenges33. It may
also be predicted that an absence of type 2
responses during the neonatal period
increases susceptibility to pathological
tissue damage and life-threatening
organ dysfunction.
Oral tolerance is a mechanism by
which antigen delivered through the
­gastrointestinal tract suppresses effector
responses against that antigen throughout
the organism117. However, although
tolerance suggests an absence of response,
intestinal responses to orally-delivered
antigens are not eliminated but instead
comprise type 3 Treg cells56 and the
production of IgA47,118. Consistent with
the equilibrium model of immunity, the
induced type 3 response inhibits type 1 and
type 2 responses against the orally-delivered
antigen. Accordingly, RORγt-deficient
mice, which lack type 3 immunity, develop
a pathological form of type 1 immunity
against intestinal antigens119. Similarly, the
type 4 response comprising IgA inhibits
the other types of response. Oral tolerance
can be breached by the administration of
antigen together with mucosal adjuvants,
such as cholera toxin, which shifts the type 4
IgA response to a local type 3 response120
or to a systemic type 2 response121.
Resistance to infection. An important
implication of the equilibrium model of
immunity is that resistance to infection
is partly determined by the state of
the immune system before infection
(FIG. 3). For example, a primary infection
confers resistance or susceptibility to
a subsequent infection, depending on
the types of response that are engaged
by the two infectious agents. This idea
may be generalized to the modulation
of the immune system by the symbiotic
microbiota, which includes type 1‑inducing
viruses, type 2‑inducing helminths and
allergens, and type 3‑inducing bacteria
and fungi. Therefore, analysis of the immune
state of an organism before infection, in
terms of the balance between the different
types of immune response, may allow
researchers to predict the outcome of an
infection or the efficiency of immunotherapy
and vaccination.
Preventive and therapeutic avenues
On the basis of the equilibrium model of
immunity, novel types of preventive and
therapeutic strategies may be developed.

Extracellular
Tissue microorganisms
repair

Thymic and Bacteria- and fungi-

neonatal tolerance induced tolerance

pTreg cell
Type 2 response Type 3 response
tTreg cell

RORγ t
GATA3
Intracellular Exclusion of
microorganisms microorganisms
and tumours sIgA
pTreg cell B cell

T-bet

Oral
Virus- and tumour- tolerance
Type 1 response induced tolerance
Type 4 response

Figure 2 | Tolerance in the equilibrium model of immunity. The four
types of immune response are mutually inhibitory. Therefore, tolerance, as
measured by the elimination of one type of response, may in many cases
reflect inhibition by another type of response rather than a total absence of
immune responses. For example, measures of the type 1 response against a
virus (interferon-γ (IFNγ) levels and antigen-specific cytotoxic T lymphocyte
responses) can be significantly decreased by the presence of symbiotic
bacteria that induce type 3 responses and helminths that induce type 2
responses. Regulatory T (Treg) cells are an important component
Nature Reviews of mutual
| Immunology
regulation, but they do not lack effector functions: thymus-derived Treg (tTreg)
cells react to self-antigens, not only to inhibit type 1 and type 3 responses,
but also to promote tissue repair115, which is a trait of type 2 responses.
GATA3, GATA binding protein 3; pTreg , peripherally derived Treg ;
sIgA, secretory IgA.

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PERSPECTIVES

For example, to protect against viruses response that is induced by the bacterial
or tumours type 1 responses need to be microbiota (which is inhibited by the
induced. This can be achieved either by antibiotics) inhibits the production of
directly enhancing type 1 responses or antiviral IFNλ by epithelial cells100. Type 2
by blocking type 2 and type 3 responses. or type 3 responses can be further targeted
William Coley famously used S. pyogenes using neutralizing antibodies against key
to treat patients with cancer in the cytokines, such IL‑33 or IL‑23, or using
1890s122, a strategy that was later shown antagonists against key transcription factors
to involve either tumour necrosis factor such as RORγt 125,126. Similar strategies may
(TNF) or IL‑12 (REF. 123). In addition, one be developed to enhance antihelminth type 2
of the most effective treatments against responses or antibacterial and antifungal
non-invasive bladder cancer is intravesical type 3 responses.
delivery of Mycobacterium bovis bacillus Conversely, the immune equilibrium
Calmette-Guérin (BCG), which is a strong could be manipulated to dampen
inducer of type 1 responses124. To increase allergic and autoimmune inflammation.
the safety and feasibility of this approach, Current strategies for treating allergy and
MAMPs could be used or synthesized inflammation rely on targeting effectors, such
to promote type 1 responses. Antibiotic as histamine and TNF, or the use of broad
treatment has been shown to prevent anti-inflammatory drugs. Instead, it might be
persistent infection by MNV, as the type 3 possible to induce type 1 or type 3 responses
• Increased resistance to
viruses, intracellular
bacteria and tumours
• Decreased susceptibility
to allergy
• Decreased resistance to
helminths, extracellular
bacteria and fungi
• Decreased tissue repair
1 2 3 4
Type of response
• Increased resistance
to helminths
• Increased tissue repair
• Decreased resistance to
viruses, tumours, bacteria
and fungi
• Increased susceptibility
to allergy
1 2 3 4 1 2 3 4
Type of response Type of response
• Symbionts (viruses, bacteria
and helminths)
• Homeostatic tissue repair
• Increased resistance to
• Allergens and oral antigens extracellular bacteria
and fungi
• Decreased susceptibility
to allergy
• Decreased resistance
to viruses, tumours and
helminths
• Decreased tissue repair
1 2 3 4
Type of response
Figure 3 | Microorganisms in the equilibrium model of immunity. The induction of one type of
response by microorganisms or helminths inhibits the other types of response.
Nature Thus,
Reviews viruses are
| Immunology
predicted to decrease susceptibility to allergy, but at the same time to decrease tissue repair
(a property of type 2 responses) and increase susceptibility to infection by helminths, bacteria and
fungi. By contrast, helminths are predicted to increase tissue repair, but at the same time decrease
resistance to viruses and bacteria and increase susceptibility to allergy. Following the same logic, most
bacteria and fungi are predicted to decrease susceptibility to allergies, but also to increase
susceptibility to viruses, tumours and helminths, and to inhibit tissue repair.
using non-pathogenic bacteria, fungi or
viruses, or MAMPs derived from these
microorganisms127, that inhibit pro-allergic
type 2 responses. Furthermore, the induction
of type 1 or type 2 responses using viruses,
helminths, allergens or related MAMPs,
could be used to inhibit autoimmune
type 3 inflammation, an approach that has
been investigated using helminths128,129
and helminth-derived proteins89,130.
Approaches that are based on the positive
manipulation of the immune equilibrium
have an important benefit compared with
the use of drugs that target microorganisms
or inflammation. These approaches
re‑equilibrate the immune system and
strengthen the equilibrium through the
presence of ‘regulatory’ microorganisms,
rather than weaken it through drugs or
losses to the host microbiota.
Gérard Eberl is at the Institut Pasteur,
Microenvironment and Immunity Unit, 75724 Paris,
France, and the Institut National de la Santé et de la
Recherche Médicale (INSERM) U1224,
75724 Paris, France.
Correspondence to G.E.
gerard.eberl@pasteur.fr
doi:10.1038/nri.2016.75
Published online 11 Jul 2016
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Acknowledgements
The author thanks M. Daëron, T. Pradeu, N. Cerf-Bensussan,
A. Freitas and B. Marsland for the many discussions, ideas,
corrections and critical reading of the manuscript. The author
also thanks members of the Microenvironment and Immunity
unit of the Institut Pasteur for discussions and experiments
over the years that led to the ideas presented in this Essay, as
well as the students and postdoctoral researchers of
the Department of Immunology of the Institut Pasteur for the
Forest seminar series and critical reading of the manuscript.
Competing interests statement
The author declares no competing interests.

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