Research on the therapeutic use of parasites has been ongoing since the development of the \"hygiene hypothesis\". Parasites can stimulate the Th2-dependent response and suppress the Th1-dependent response, which is intensified in many diseases, especially allergic and autoinflammatory ones. In this review, we present the types of parasites used in helminth therapy and the range of diseases in which they may be useful. We also present the results of clinical trials conducted so far, which confirm the safety of such therapy and provide promising outcomes.

Helminth infections of swine regain clinical and economic importance due to the increasing demand for pork from extensive husbandry. Infections with Trichuris suis in pigs can lead to wasting and diarrhoea. This was demonstrated by a case of clinical trichurosis on a conventional fattening farm, where pigs were kept on pasture. While all pre-fattening pigs, which had not been on the pasture yet, had a good body condition and firm faeces, diarrhoea and poor body condition were observed in approximately half of the fattening pigs kept on pasture. Rectally collected faecal samples from all animals were investigated using faecal flotation. High numbers of T. suis eggs were detected in 17 out of 32 faecal samples, while all samples from pre-fattening pigs were negative. The highest number of eggs per gram of faeces was 778,000. Two out of three environmental samples were also positive for T. suis in faecal flotation. This case demonstrates that T. suis must be considered as an enteropathogen in pigs kept on pasture, as favourable environmental conditions, and the lack of removal of faeces from a pasture can lead to the accumulation of large numbers of infective eggs in the pigs\' surroundings.

BACKGROUND: An outdoor pig herd was affected by severe respiratory disease in one out of three pastures. At necropsy, Mycoplasma hyopneumoniae and Pasteurella multocida were detected in the lungs, as well as the lung worm Metastrongylus apri. The life cycle of Metastrongylus spp. includes earthworms as intermediate hosts, and since domestic pigs mainly are reared indoors, lungworm infections have not been diagnosed in domestic pigs in Sweden for decades, not even in pigs reared outdoors. Therefore, this disease outbreak was scrutinised from the view of validating the impact of Metastrongylus spp.
RESULTS: At the time of the disease outbreak, neither eggs of Metastrongylus spp., Trichuris suis nor Ascaris suum were detected in faeces of pigs aged ten weeks. In contrast, five-months-old pigs at the pasture with respiratory disease shed up to 3800 eggs per gram (Epg) of Ascaris suum and up to 1100 Epg of Trichuris suis, whereas eggs of these parasites were not demonstrated in healthy pigs aged six months at another pasture. Low numbers of eggs from Metastrongylus spp. (< 150 Epg) were seen in faecal samples from both these age categories. At slaughter, seven weeks later, ten normal weighted pigs in the preceding healthy batch were compared with ten normal weighted and five small pigs from the affected batch. Healing Mycoplasma-like pneumonic lesions were seen in all groups. All small pigs shed eggs of Ascaris suum in the faeces, compared to around 50% of the larger pigs. Metastrongylus spp. were demonstrated in 13 of the 25 pigs (52%), representing all groups included.
CONCLUSIONS: As Metastrongylus spp. were demonstrated regardless of health status, and also in another healthy outdoor herd, the impact of Metastrongylus spp. on the outbreak of respiratory disease was depreciated. Instead, a possible association with a high burden of Ascaris suum was suggested to have preceded the severe outbreak with respiratory disease in the affected herd. Further, it was concluded that Metastrongylus spp. will escape detection at routine meat inspections made at slaughterhouses, and as they appeared to generally not induce clinical signs of respiratory disease Metastrongylus spp. may be more common in outdoor production than previously believed.

The global pig production has undergone major changes over the past 30 years with larger farms, more intensified production as well as improved hygiene and biosecurity practices. To investigate whether these changes, along with expanded pig welfare, have had an impact on parasite occurrence, a cross-sectional study was conducted in Sweden on farms where the pigs are always loose-housed, floors are solid and bedding material is provided. A total of 1615 faecal samples were collected on 42 conventional indoor farms from a) post-weaning piglets (n = 337); b) growers (n = 345); c) fatteners (n = 308); d) dry sows (n = 277) and e) pre-partum sows (n = 348). Samples were analysed using centrifugal flotation with a saturated glucose-salt solution and a modified McMaster technique, with a lower detection limit of 50 eggs or oocysts per gram. Samples positive for strongyle-type eggs were cultured to third stage larvae for genus identification. Farms also responded to a questionnaire regarding biosecurity, hygienic measures, and other management routines. Risk factors for parasite occurrence were assessed using mixed-effects logistical regression to account for farm-level clustering of samples. Interestingly, the prevalence of Ascaris suum was reduced compared to a similar investigation in the 1980s. In the present study A. suum was detected only in 43 % of the herds, with the highest prevalence in pre-partum sows (37 %) followed by fatteners (25 %). Small sized farms were associated with higher odds of being positive, compared to large sized farms (OR = 159.1, P = 0.010). Oesophagostomum spp. were detected in 64 % of the herds and again mainly in pre-partum sows (63 %). Trichuris suis was detected in 10 % of the herds but only in <1% of the samples. Moreover, Cystoisospora suis and Eimeria spp. were detected on 60 % and 64 % the farms, with the highest prevalence in post-weaning piglets and sows, respectively. Anthelmintic drugs (ivermectin or fenbendazole) were commonly used and administered mainly to pre-partum sows on 93 % of the farms. Toltrazuril against neonatal coccidiosis was administered to piglets on 14 % of the farms. The use of antiparasitic drugs did not significantly affect parasite prevalence. Overall, it appears that the altered farming routines with focus on improved pig welfare have not solely resulted in a higher occurrence of parasites, most likely due to the adequate biosecurity and hygiene practices instituted. Thus, there seems to be no conflict between implementing measures to promote pig welfare and adequately control the more pathogenic and economically important parasites.

Considering their potent immunomodulatory properties, therapeutic applications of Trichuris suis ova (TSO) are studied as potential alternative treatment of autoimmune disorders like multiple sclerosis (MS), rheumatoid arthritis (RA), or inflammatory bowel disease (IBD). Clinical phase 1 and 2 studies have demonstrated TSO treatment to be safe and well tolerated in MS patients, however, they reported only modest clinical efficacy. We therefore addressed the cellular and humoral immune responses directed against parasite antigens in individual MS patients receiving controlled TSO treatment (2500 TSO p.o. every 2 weeks for 12 month). Peripheral blood mononuclear cells (PBMC) of MS patients treated with TSO (n = 5) or placebo (n = 6) were analyzed. A continuous increase of serum IgG and IgE antibodies specific for T. suis excretory/secretory antigens was observed up to 12 months post-treatment. This was consistent with mass cytometry analysis identifying an increase of activated HLA-DRhigh plasmablast frequencies in TSO-treated patients. While stable and comparable frequencies of total CD4+ and CD8+ T cells were detected in placebo and TSO-treated patients over time, we observed an increase of activated HLA-DR+CD4+ T cells in TSO-treated patients only. Frequencies of Gata3+ Th2 cells and Th1/Th2 ratios remained stable during TSO treatment, while Foxp3+ Treg frequencies varied greatly between individuals. Using a T. suis antigen-specific T cell expansion assay, we also detected patient-to-patient variation of antigen-specific T cell recall responses and cytokine production. In summary, MS patients receiving TSO treatment established a T. suis-specific T- and B-cell response, however, with varying degrees of T cell responses and cellular functionality across individuals, which might account for the overall miscellaneous clinical efficacy in the studied patients.

Following a request from the European Commission, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was asked to deliver an opinion on viable embryonated eggs of the whipworm Trichuris suis as a novel food (NF) pursuant to Regulation (EU) 2015/2283. The applicant proposes to use the NF as a food supplement in the format of a 15-mL bottle containing 250 viable embryonated eggs of T. suis. The target population for the NF is the general population. Considering the compositional data and proposed conditions of use, the consumption of the NF is considered of no nutritional relevance. Available data suggest that most larvae of T. suis after hatching in the intestinal tract of humans remain immature and live for several weeks in the gastrointestinal tract of the human host. Nevertheless, under certain circumstances, T. suis can be invasive in human, being able to mature into adult size and reproduce in humans. Human studies have also shown that administration of T. suis ova may increase the incidence of adverse gastrointestinal reactions. The Panel considers that there are no studies available that demonstrate the safety of this NF intended for the general population at a proposed intake of 250 viable embryonated eggs of T. suis ova per day. Based on the available information, the Panel cannot establish a safe dose at which no safety concerns would be expected. The Panel concludes that the safety of the NF has not been established.

Consumption of fermentable dietary fibres, such as inulin, or administration of helminth products (e.g. Trichuris suis ova) have independently been shown to alleviate inflammation in vivo. We recently found that dietary inulin and T. suis infection in pigs co-operatively suppressed type-1 inflammatory responses in the gut, suggesting the potential of dietary components to augment anti-inflammatory responses induced by certain helminths. Here, we explored whether T. suis antigens and inulin could directly suppress inflammatory responses in vitro in a cooperative manner. T. suis soluble products (TsSP) strongly suppressed lipopolysaccharide (LPS)-induced IL-6 and TNF-α secretion from murine macrophages and induced an anti-inflammatory phenotype as evidenced by transcriptomic and gene pathway analyses. Inulin regulated the expression of a small number of genes and transcriptional pathways in macrophages after exposure to LPS, but did not enhance the suppressive activity of TsSP, either directly or in co-culture experiments with intestinal epithelial cells. Culture of macrophages with short-chain fatty acids, the products of microbial fermentation of inulin, did however appear to enhance TsSP-mediated inhibition of TNF-α production. Our results confirm a direct role for helminth products in suppressing inflammatory responses in macrophages. In contrast, inulin had little capacity to directly modulate LPS-induced responses. Our results suggest distinct mode-of-actions of T. suis and inulin in regulating inflammatory responses, and that the role of inulin in modulating the response to helminth infection may be dependent on other factors such as production of metabolites by the gut microbiota.

Autism is a neurodevelopmental disease included within Autism Syndrome Disorder (ASD) spectrum. ASD has been linked to a series of genes that play a role in immune response function and patients with autism, commonly suffer from immune-related comorbidities. Despite the complex pathophysiology of autism, Gut-brain axis is gaining strength in the understanding of several neurological disorders. In addition, recent publications have shown the correlation between immune dysfunctions, gut microbiota and brain with the behavioral alterations and comorbid symptoms found in autism. Gut-brain axis acts as the \"second brain\", in a communication network established between neural, endocrine and the immunological systems. On the other hand, Hygiene Hypothesis suggests that the increase in the incidence of autoimmune diseases in the modern world can be attributed to the decrease of exposure to infectious agents, as parasitic nematodes. Helminths induce modulatory and protective effects against several inflammatory disorders, maintaining gastrointestinal homeostasis and modulating brain functions. Helminthic therapy has been previously performed in diseases such as ulcerative colitis, Crohn\'s disease, diabetes, multiple sclerosis, asthma, rheumatoid arthritis, and food allergies. Considering gut-brain axis, Hygiene Hypothesis, and the modulatory effects of helminths I hypothesized that a treatment with Trichuris suis soluble products represents a feasible holistic treatment for autism, and the key for the development of novel treatments. Preclinical studies are required to test this hypothesis.

Recent studies have attempted to treat autoimmune diseases using Trichuris suis. whipworm) eggs. Large quantities of eggs can be obtained efficiently by collecting from the feces of the porcine hosts rather than by extracting from the female worm uterus. However, it is difficult to process large amounts of feces using the current methods. In the present study, we propose a method to collect the eggs from bulk feces more efficiently. Collecting the eggs using washing meshes (25 μm sieve) yields 65.7% (56.0-70.7) of eggs (median, min-max) from 100 g feces. Our method, which uses ethyl acetate and simulated gastric fluid, yielded 91.4% (91.4-94.0) of the eggs from 100 g feces into the separated aqueous solution. Egg collection using simulated gastric fluid (SGF) method was also 60 min faster than that using the sieve method. As the SGF used in the experiment is a strongly acidic reagent with a pH of 1-2, embryonation of the eggs was induced by the rapid pH change. As a result, 37.1% (8.0-77.8) of the eggs had embryonated two months after SGF stimulation. Using the developed method, we could process the feces quickly and efficiently. Furthermore, after purification, egg embryonation could be induced without any harmful reagent treatment. This method is expected to be helpful for further research using Trichuris suis eggs.

Trichuris suis infection in pigs is ubiquitous in intensive and extensive farms, which causes potential threat to human health. The objective of this research was to investigate the prevalence of T. suis in pigs in Hunan province. Total 2,267 fresh fecal samples distributed in 28 pig farms from 7 different administrative regions (Hunan province) were evaluated for the existence of T. suis eggs using saturated NaCl floating method. The average infection rate of T. suis in pigs was 8.91% in Hunan province. To determine genetic variation of the gained T. suis isolates in the present study, the internal transcribed spacer (ITS) regions from nuclear ribosomal DNA (rDNA) of 7 T. suis isolates were cloned and analyzed. Nucleotide diversities were 1.0-3.5% and 0-3.8% for ITS-1 and ITS-2, respectively. Phylogenetic analyses indicated that all isolates collected in the present study and T. suis available in Genbank generated a monophyletic clade. The present investigation revealed high infection rates of T. suis in pigs in Hunan province, which shed light on making effective measures to prevent and control T. suis infection in pigs in Hunan province.