Immunology: Update for Clinicians

Dr. Paul S. Anderson ConsultDrA Webinar May 2020 © PS Anderson and www.ConsultDrA.com 2020

ALL of these webinars will have AANP CE Accreditation. • The certificate at the end (last slide) will have the total and Pharm hours. • The AANP Accreditation has applied for ALL US States to date. • All webinars for the past 12 months have active AANP CE (for example this is 02-2020 so 03-2019 through this webinar are all active). • Past webinars will be re-accredited based on their viewership due to the high cost of re-accreditation of all the webinars. WE WILL DENOTE THIS ON THE WEBSITE AS WE RE-ACCREDIT WEBINARS.

(c) PS Anderson - www.ConsultDrA.com 2020 2 Conflict of interest: • None –I have no financial connection to ANY lab, product or company mentioned –Specific products (IF mentioned) are examples of items I use commonly in practice • © Images will be credited. If no credit given they are (a) mine or (b) in the public domain ** Professional Images not credited in THIS presentation are complements of Mosby (2005) Anatomy & Physiology by Patton & Thibodeau

(c) PS Anderson - www.ConsultDrA.com 2020 3 Next Webinars All are Tuesday PM – 5:30 – 7:00 PM Pacific Time NOTE – All are third Tuesday of the month unless noted “*” *Bonus 06-02-2020 (Controversies in integrative and naturopathic oncology) 06-16-2020 07-21-2020 08-18-2020

19. Autoimmunity-2: Management 53. Neuro-AI Part-1 1. EBV diagnosis and Treatment 36. Organic Acid Testing 2. Histamine – CNS 20. Chronic Infections – Testing, assessment and re-assessment 37. Migraine 54. Neuro AI Part-2 3. Cortisol 38. PCOS 21. Lyme Illness – A top down approach 55. Interrelationships in Chr-Dz 4. Iodine & T3 39. Fluoroquinolone Toxicity 5. Biofilms (#1) 22. Chronic Infection Bundle 40. GI Absorption and Rx 56. Neuro Manifest. Chron. Illness 6. Desiccated Thyroid 23. Oral Chelation 41. Dysautonomia and EDS 7. Autoimmunity 57. Benzodiazepine Rx and 24. Pain Medication Weaning 42. Low Dose Immunotherapy Management 8. Histamine – Peripheral 43. Detox of Unusual Metals 25. Assessment of Chronic Cases 9. Mitochondria 44. NAD 58. Anti-ID Rx Pharmacology 10. ReDox and Inflammation 26. Nutrigenomic basics 45. Lab testing for B6, B12 and Folates 59. Eclectic and Low Dose Botanicals 11. IV and Injection Q&A 27. IV Therapy Q&A and Latest Updates 46. Acute Use of Thyroid and Adrenal-Rx 12. Sulfation Pathways 47. Assessing the Complex Patient 60. Natural Medicines for Chronic 28. ADHD Medications and Weaning Infections 13. Antidepressant Rx and Taper 48. Optimizing 21st Century 29. Seizure Medications and Weaning 14. Pediatric Rx and dose ND/Integrative Medicine 61. Metabolic Toxins adjustment 30. Low Dose Naltrexone – 49. Nasal & Respiratory Therapies 15. Renal Rx and Dose pharmacology, uses and cases 50. USP-FDA 2019 Update 62. Adrenal Assessment and adjustments Therapeutics: Clinical Diagnosis 31. Medical Cannabinoids 51. Bipolar Medications and Management 16. Biofilms #2 32. Neurological Inflammatory Therapies 52. HBOT-2 Cancer and Neuro 17. Cardiac Rx dosing and tapering 63. Red Flags and Critical Diagnoses 18. Steroids and Respiratory Med’s 33. Food Allergy and Sensitivity 64. COVID-19 Updates 34. Hyperbaric Oxygen Therapies 35. Kidney and Liver Functions – Effect 65. Managing Comorbidities in on Rx and Labs Chronic Illness 66. Repurposed Drugs in Oncology

(c) PS Anderson - www.ConsultDrA.com 2020 5 A quick note: If you are “reading the slides” only you’ll miss a lot as most of what I attempt to transmit is done verbally (the slides are a prop to keep me on track and to tell stories that illustrate my points. (I mean, please do read the(c) PSslides Anderson - www.ConsultDrA.com – but2020 know 6 that the audio is more than 50% of the presentation.) Abstract

Immunology is one of the most rapidly changing disciplines in clinical medicine. In this CME Dr. Anderson will break down the commonly understood processes in the human immune response and how those relate to factors such as cytokines and chemokines, growth factors and other immunobiology. Where appropriate immunological crossover with common drug classes will be discussed.

• Overview of the human immune response – Non-specific immunity – Specific immunity • Antibody (Humoral) functions including Ig G/M/A/E • Cell-mediated functions • Complement – Updates • Cytokines of note and their functions – Cytokine functions – Chemokine functions – Other immunochemistry – Updates • Developing immune memory – Antigen presentation – Humoral memory – Cell mediated memory – Activity of lymphatic system • Natural agents that mimic immune functions and their relative impacts – Relative rise of cytokines – examples of Viral versus natural agent impact – Other factors

• Intravenous Ascorbic Acid for Supportive Treatment in Hospitalized COVID- 19 Patients – https://isom.ca/article/intravenous-ascorbic-acid-for-supportive-treatment-i n-hospitalized-covid-19-patients/

• WEBINAR: Corona Virus COVID-19 Clinician Update (2-hour CE – some cost for nonsubscribers) – https://www.consultdranderson.com/product/covid-19-update/ • WEBINAR: Free ISOM Vitamin C and COVID (webinar and slides) see next slide for information.

N = Nausea V = Vomiting

D = Diarrhea St. = Stomach

Ab = Antibody Ag = Antigen

Mac. = Macular Pap. = Papular

“Flu-Like” = Fever, chills / rigors, body ache, fatigue, anorexia….

• GI Tract – Stomach: Acid tolerant organisms; lactobacilli, streptococci, [H. pylori] – Small intestine: ANAEROBIC BACTERIA (not as much air availableso makes sense), many parasites / fungi, [campylobacter jejuni, Salmonella]. Mostly small #’s – Large intestine: (most metabolism here is due to the bacteria hence all the bacteria) Bifidobacter, Eubacter, Enterobacter, Peptostreptococci, Bacteroides fragilis. [post antibiotic:Clostridium difficile, fungi infections] • GU Tract – Anterior urethra: Lactobacilli (more in women then men), Corynebacteria, coag – staph. – Vagina: Lactobacilli [Staph and Strep] • Skin: Staph (coag -, & aureus) [Candida, Clostridia, Acinetobacter] • Nose / Nasopharynx & Mouth / Oropharynx : ANEROBES MOST COMMON (Peptostreptococci, Actinomyces, Fusobacterium…) AEROBES (Strep. viridans, coag – Staph) also many potential pathogens. • Conjunctiva: coag – Staph, and some nasopharynx bacteria occasionally. Tears have a lot of antibiotic material in them, the eye is set up to protect self pretty well

• Attachment – May be extra or intracellular – Nutrition sources (attachment sites) • Replication – Host nutrition + pathogenic(bug wants more then his share of the area) organism • Spread – Local tissues or Systemic • Shedding / Elimination – Post immune function clean up Extra note (and see below): Exotoxin- all major gram-+ except listeria, also include gram – such as Vibrio cholera, E. coli, and other subgroups include: neurotoxins, enterotoxins, pyrogenic exotoxins, tissue invasive Endotoxins- gram neg and listeria monocytogenes

(c) PS Anderson - www.ConsultDrA.com 2020 16 Endotoxin –vs- Exotoxin PROPERTY ENDOTOXIN EXOTOXIN Lipopolysaccharide(mw = Protein (mw = 50- CHEMICAL NATURE 10kDa) 1000kDa) RELATIONSHIP TO CELL Part of outer membrane Extracellular, diffusible

DENATURED BY BOILING No Usually

ANTIGENIC Yes Yes

FORM TOXOID No Yes

POTENCY Relatively low (>100ug) Relatively high (1 ug)

SPECIFICITY Low degree High degree

ENZYMATIC ACTIVITY No Usually

PYROGENICITY Yes Occasionally

• Virulence – EXPOSURE, COLONIZATION (is the bug likely to replicate quickly or slowly), PENETRATION & GROWTH, TOXIN PRODUCTION • Time (course) – THE LONGER THE BUG HAS TO ‘SET UP HOUSE’ THE MORE PATHOGENIC • “Carrier” state – TYPICALLY A ‘RECOVERED’ (ASYMPTOMATIC) SUFFERER OF THE DISEASE THAT CONTINUES TO HARBOR AND SHED THE ORGANISM. [“Typhoid” Mary] Beta hemolytic strep, syphilis • Nosocomial (institutionally given) / Iatrogenic (provider given) Infection – Received from the Hospital / Facility (Nosocomial) or Provider (Iatrogenic) • Zoonotic infection – Infection shared with human by an animal host. – [Lyme, Trichinosis, Cat scratch dz….]

1 – ANTIGEN 1A – PRESENTATION ALTERNATE = COMPLIMENT cytokine 2 – T-CELL ACTIVATION / CMI 2A – KILLER T-CELL ACTION

3 – B-CELL ACTIVATION / Ab IMMUNITY 4 – CLASSIC 3A – ANTIGEN – ANTIBODY COMPLIME REACTION NT

ATTACK ON INVADER

• Responses to: – Acute viral infection • Induce a proliferation of lymphocytes and a reduction of PMNs in circulation.

• NK cells and Cytotoxic-T Cells are involved in killing virally infected cells. • Infected cells produce Interferons to stimulate antiviral response • Humoral response produces IgM/IgG to neutralize viral particles in the blood

– Chronic viral infection • Can result in reduced # of circulating lymphocytes

– Acute bacterial infections • Results in an increase of circulating PMNs to directly kill bacteria and lymphocytes decrease. • The humoral immune response produces antibodies to opsonize bacteria for phagocytosis, induce complement binding, and neutralize bacterial toxins. – Chronic bacterial infections • Result in neutropenia and an increase of monocytes – Fungal infections • Superficial fungal infections produce a delayed hypersensitivity reaction, whereas systemic mycoses induce a cell-mediated response to curb the spread of the infection – Tumors • T- cell response to tumor growth is the most important aspect of the immune systems defense against tumors. T-cells also active components of the immune system like NK cells, macrophages

• Physical barriers – Skin – Mucus membranes – Gastric acid and enzyme

• Physiological barriers – Inflammation • Redness, Swelling, Heat, Pain – Phagocytosis • Macrophages, Monocytes, PMN’s, Eosinophils • Granules contain enzyme to ‘eat’ the bacteria • Cells die causing pus.

(c) PS Anderson - www.ConsultDrA.com 2020 29 • Natural Killer (NK) Cells (Were “non-specific” now are ‘part NS and part Specific’ Immunity) – Key to effectiveness is Function not Number! – Cytotoxic cells. – Create a hole in antigen cell / create an osmotic cascade to kill it. – From common lymphoid stem cell in marrow – like B- Cells – Stimulated by the Complement cascade

• Thymus – Where fetal stem cells go to mature into “T-Cells” – Form the basis for cell mediated immunity (CMI) – Site where clonal deletion/selection and anergy occurs- any self- recognizing clones should be destroyed before they leave the thymus • Lymph nodes – Place where T-Cells and B-Cells “hang out” – ECF excess with antigens percolates through LN’s and memory T and B cells can activate against any antigen previously seen.

• Bone marrow – Origination of stem cells – The production of cytokines in BM serve as necessary signals to B-cells to differentiate by up-regulating B-cellular markers • Spleen – Detains and inactivates / kills antigens • Mucosa Immunity / GALT – Gut Associated Lymphoid Tissue – Enteroendocrine cells, IgA, local gut immunity – Peyer’s patch- encapsulated lymphoid tissue in the ileal submucosa, where they can detect large antigens that accidentally diffused across the intestinal epithelium

Myeloid Stem Lymphoid Stem Cells

Lymphoid Megakaryocyte T-Cell Lines Stem Proerythroblast Monoblast Myeloblast

B-Cells NK Cells Platelets Retic’s

Peripheral Tissues: PLT RBC’s WBC’s

Cell Mediated Immunity Ab (Humoral) Immunity Immunological Surveillance (c) PS Anderson - www.ConsultDrA.com 2020 34 Immune Response: Specific

1. Antigen triggers an immune response 2. Antigen Presenting Cells (APC’s) present Ag to T Cells 3. Activates T cells / CMI *T cells are activated after phagocytes exposed to antigen 4. T cells attack the antigen and stimulate B cells 5. Activated B cells mature and produce antibody 6. Antibody attacks antigen

• Neutrophils – PMN’s. First responders to bacterial infection.

• Monocytes in the blood / Macrophages in the tissues – Phagocytic. If activated, kill their intracellular pathogens – if not they become a reservoir for some bacteria. (Listeria, Brucella, Toxoplasma, Cryptococcus…) – Kupffer cells-liver, osteoclasts- bone, histiocytes in various tissues, microglial cells in the brain

• Basophils – Activated during compliment. Release Ig’s, and Heparin (like mast cells).

• Eosinophils – Increased in Allergy / Parasite / Inflammatory Bowel Disorder

• B-Lymphocytes – From common stem cell with T-Lymphocyte – Named for ‘bursa of Fabricius’ in birds – In humans, probable maturation is in fetal liver and bone marrow – Basis for humoral (antibody) immunity. Antigen docks on B-Cell, plasma cells stimulated to form Immunoglobulin. Basis for humoral immune memory. – B cells also act as APCs to help activate helper T-cells secrete the cytokines necessary for B-cell maturation

• T-Lymphocytes –From common stem cell, mature in Thymus –Basis for cell mediated immunity –Helper-T or regulatory T has antigen dock to it, creates Cytokines to stimulate suppressor and Cytotoxic – T cell activity. –Effector group includes CD8 and suppressor T- cells

Activation of endogenous proteins (mainly enzyme precursors) in case of immunologic need. Two pathways: – Classical: activated by antigen – antibody (AG/AB) reaction – Alternate: goes ‘around’ the AG/AB reaction, activates the compliment cascade in the middle (at the C-3 locus) without the Ag / Ab reaction. • Large polysaccharide in the cell membranes of some pathogens stimulate this reaction. • Less effective than Classical pathway

Alternate Pathway Starts here: (Faster / weaker response)

(c) PS Anderson - www.ConsultDrA.com 2020 43 Really got it bad for cytokine definitions? • They change with some regularity

• This is the most awesome resource I’ve seen for the cytokines they research: https://www.sinobiological.com/resource/cytokines/ cytokine-function

• Any of a group of proteins produced by cells in the body in response to an attack by a virus. – A cell infected by a virus releases minute amounts of interferons, which attach themselves to neighboring cells, prompting them to start producing their own protective antiviral enzymes. – The result is impairment of the growth and replication of the attacking virus. Interferon has also been shown to have some antitumor properties. • Alpha made by leukocytes: – Inhibits cell (Tumor) proliferation, enhances NK growth. • Beta made by fibroblasts: • Gamma made mainly by T-cells: – Activates NK, Killer-T cells – Activates Macrophages; Gamma is one of the most effective mediators of phagocytic activity in macrophages The Columbia Encyclopedia. Copyright © 2001-08 Columbia University Press. All rights reserved.

Mechanism • TNF acts via the TNF Receptor (TNF-R) and is part of the extrinsic pathway for triggering apoptosis. TNF-R is associated with procaspases through adapter proteins (FADD, TRADD, etc.) that can cleave other inactive procaspases and trigger the caspase cascade, irreversibly committing the cell to apoptosis. • TNF interacts with tumor cells to trigger cytolysis or cell death. • TNF interact with receptors on endothelial cells, which leads to increased vascular permeability allowing leukocytes access to the site of infection. This is a type of localized inflammatory response, although systemic release may lead to septic shock and death. Types • TNF-alpha is the most well-known member of this class, and sometimes referred to when the term "tumor necrosis factor" is used. • TNF-beta is a cytokine that is induced by interleukin 10

(c) PS Anderson - www.ConsultDrA.com 2020 46 Interleukins • Il-1: initiate responses- Secreted by Macrophages and Monocytes. – Fever, and T-cell proliferation • Il-2: promote cellular immunity- Secreted by CD-4 cells. –T-cell growth, B-cell activation. • Il-4: promote humoral immunity- Secreted by CD-4 cells. –B&T growth factor. MHC expression on B cells, and promotes production of IgG, IgE

• Il-6: from TH cells and BCL-6 promoted lines, pro- inflammatory –Produce TH lines that signal B-cell (Ab immunity) • Il-5: promote humoral immunity-Secreted by CD4 cells. –B-cell and eosinophil growth. • Il-10: promote humoral immunity-secreted by T-cells. –Regulates immune response class. • Il-11: Fibroblast secretion. –Megakaryocyte potentiator. Stimulates IgG.

(c) PS Anderson - www.ConsultDrA.com 2020 48 Il-37?????????????? (Also see webinar “Chronic Illness – Managing Comorbidity)

(c) PS Anderson - www.ConsultDrA.com 2020 49 Varvara G, Tettamanti L, Gallenga CE, et al. Stimulated mast cells release inflammatory cytokines: potential suppression and therapeutical aspects. J Biol Regul Homeost Agents. 2018;32(6):1355–1360. IL-37 is a member of the IL-1 family with anti-inflammatory activity through inhibition of pro-inflammatory cytokines. IL-37 particularly suppresses IL-1- mediated innate inflammatory response, but also acts on the acquired immune response. IL-37 is activated by pro-inflammatory agents and cytokines, playing a protective role against inflammation. This cytokine is a natural regulator of immunity and is a therapeutic promise against inflammatory diseases. Since IL- 1 is produced by and activates MCs to release IL-33 and TNF, here we hypothesize that MCs can be inhibited by IL-37 and therefore reduce their pro-inflammatory activity. However, the maturation, transport and secretion of IL-37 remain to be clarified.

(c) PS Anderson - www.ConsultDrA.com 2020 50 https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.spandidos-publications.com%2Fol %2F15%2F4%2F4711&psig=AOvVaw1VWWfLz1ptGK5pWULGw9Mf&ust=1587598134121000&source=i mages&cd=vfe&ved=0CAIQjRxqFwoTCND7yI3W-ugCFQAAAAAdAAAAABAD(c) PS Anderson - www.ConsultDrA.com 2020 51 Can we upregulate Il-37?

• “Typical” up stream agents: – ReDox support – Omega and Phospholipid therapies – Neurosteroids – Curcumin – Boswellia – Ginger…

• Or direct up regulation:

(c) PS Anderson - www.ConsultDrA.com 2020 52 https://doi.org/10.1155/2017/9148523 Tripterygium wilfordii Glycosides Upregulate the New Anti- Inflammatory Cytokine IL-37 through ERK1/2 and p38 MAPK Signal Pathways As a Chinese traditional patent medicine, Tripterygium wilfordii glycosides (TWG) have been approved by the China State Food and Drug Administration (Z32021007) for autoimmune and inflammatory diseases. Application of TWG leads to significant decrease of the inflammatory cytokines, such as IL-6, IL-1β, and TNF-α. However, little is known whether TWG could regulate the anti-inflammatory cytokines and what the mechanism is. Here, we found that TWG could induce the upregulation of IL-37 which is a new anti-inflammatory cytokine. Furthermore, the inhibitors of ERK1/2 and/or p38 MAPK pathways suppressed IL- 37 expression induced by TWG, indicating that the two pathways took part in this process. In conclusion, TWG could upregulate the anti-inflammatory cytokine IL-37 and ERK1/2 and p38 MAPK signal pathways were involved in the upregulation of IL-37 induced by TWG. The results showed that TWG had a potent activity on promoting the expression of IL-37, a new anti-inflammatory cytokine, which help further understanding the anti- inflammatory mechanism for the clinical application of TWG in therapy of diseases.

• Western single herb extracts are 10:1 to 20:1 • Safe doses are reported at 200 – 500 mg total per day • A loading dose (AFTER tolerance is judged) can be given at double that in most people. – Most common AE is GI upset (By taking the herb after meals or with antacids or vitamin B6 the chances of gastrointestinal upset can be reduced.) – Overdose AE’s: fever, bone marrow suppression, and convulsion (Very rare).

• Nephropathy studies used: – 1 to 2 mg / Kg / Day https://www.sciencedirect.com/topics/medicine-and-den tistry/tripterygium-wilfordii • 120 mg a day given as 40 mg TID is reported: http://www.itmonline.org/arts/triptery.htm • I recommend a taper up with food (200 mg BID to start) and then titrate to effect then decrease to lowest dose effect once therapeutic dose is achieved.

(c) PS Anderson - www.ConsultDrA.com 2020 55 An example single herb product NO AFFIL: https://www.thundergodrootextract.com/pages/contact- us Also available as a powder.

• Antigen recognition – Antigenicity- ability to stimulate an immune resp0onse to produce antibodies- factors include- molecule size, foreignness, structural complexity, amount of different epitopes, dosage exposure, entrance route into the body, and its timing of exposure – Major histocompatability complexes (MHC) • MHC-1: presents viral antigen to CD8 T Lymphocytes, play a major role in killing virally infected cells and cancer cells • MHC-2: docking protein on Macrophage which hooks a CD4-Thelper cell to the Macrophage. – Haptens • Incomplete antigen • Unable to stimulate immune response on its own • Will react with other proteins, therefore making them antigenic. • Many Haptens have highly reactive moieties that create their “completion”

(c) PS Anderson - www.ConsultDrA.com 2020 58 (c) PS Anderson - www.ConsultDrA.com 2020 59 (c) PS Anderson - www.ConsultDrA.com 2020 60 (c) PS Anderson - www.ConsultDrA.com 2020 61 (c) PS Anderson - www.ConsultDrA.com 2020 62 Immune Reactions

• Cell mediated immunity (T-cell mediated)

– Primary response • Antigen presentation stimulates T-cell formation • Activated T-cells (instead of the Ig’s in humoral immunity) are released to go directly to the site of antigen.

– Secondary (memory) response • As the primary response goes on, cloned cells of the specific T-cells are made and stored in the lymphatic and reticuloendothelial systems. • These then are available for later use.

• Humoral immunity (B-cell mediated) (know categories)

– Primary response • Interleukins, Prostaglandins, TNF, and interferon start • Adherence proteins (that activate compliment) are released, and leukocytes migrate.

– Secondary (memory) response • Memory B-cells respond, Ig’s produced. • IgM still occurs but the IgG production is immediate and in a larger quantity than in the primary response • Compliment also activated • Specific to the general disorder

• Ig-A: “Secretory” – Primarily the secretory form is the useful kind. (found in tears, saliva,mucus…) Prevents bacteria, viruses, and toxin from attaching to mucosal linings.

• Ig-E: “Allergy” – Type-1 immediate hypersensitivity (allergy) reactions. Parasite infection.

• Ig-M: “First Responder”. – Elevated in acute infection. Basis for ABO-blood type antigen / transfusion reaction.

• Ig-G: “Long Term” – Most common type. Focuses NK cells to their targets. Used in passive immunization (gamma-globulin injection).

(c) PS Anderson - www.ConsultDrA.com 2020 67 (c) PS Anderson - www.ConsultDrA.com 2020 68 (c) PS Anderson - www.ConsultDrA.com 2020 69 (c) PS Anderson - www.ConsultDrA.com 2020 © 70 healthjade.com Mucosal IgA Immunity

(c) PS Anderson - www.ConsultDrA.com 2020 71 (c) PS Anderson - www.ConsultDrA.com 2020 72 IgA: Respiratory (example of shift in COPD) erj.ersjournal s.com/ content/erj/ 45/4/980/F8

(c) PS Anderson - www.ConsultDrA.com 2020 73 Immunity to the respiratory pathogen Bordetella pertussis - Mucosal Immunology ©Nature

H. pylori IgG is the type of antibodies, forming after the declension of its IgM antibody titer. Also, it is the predominant form of serum antibodies. And, the main function of H. pylori IgG is to prevent the invading of pathogens. In diagnostics, it helps to diagnose the diseases; its higher levels indicate chronic infection. On the other hand, H. pylori IgA is another type of antibodies, occurring after a few weeks from the infection. Specifically, it occurs in the mucosal areas, preventing the colonization of the pathogen. Also, it helps to diagnose chronic active gastritis. Therefore, the main difference between H. pylori IgG and IgA is their role in the infection.

(c) PS Anderson - www.ConsultDrA.com 2020 75 Secretory antibody (nasal and gut IgA) and serum antibody (serum IgG, IgM and IgA) in response to killed polio vaccine (left) administered by intramuscular injection and to live attenuated polio vaccine (right) administered orally [Microbiologybook.org]

• Ig-A: “Secretory” – Primarily the secretory form is the useful kind. (found in tears, saliva,mucus…) Prevents bacteria, viruses, and toxin from attaching to mucosal linings.

• Ig-E: “Allergy” – Type-1 immediate hypersensitivity (allergy) reactions. Parasite infection.

• Ig-M: “First Responder”. – Elevated in acute infection. Basis for ABO-blood type antigen / transfusion reaction.

• Ig-G: “Long Term” – Most common type. Focuses NK cells to their targets. Used in passive immunization (gamma-globulin injection).

• High risk – High exposure to active COVID cases • PCR Tested positive on “Day-1” • No symptoms at all • Retested PCR and ran a Vibrant America Ig: G - M - A COVID-19 panel

(Case provided by Interactive Health Clinic, Lynwood, WA)

• Hypersensitivity –Type-I: IgE mediated. Anaphylaxis. –Type-II: Antibody mediated. • i.e. Goodpasture’s syndrome, and the Glomerular antibody reaction

• Hypersensitivity –Type-III: Immune complex mediated. • Ag/Ab complexes activate compliment. • i.e. serum sickness –Type-IV: cell mediated (T-cell) hypersensitivity. • Delayed and cytotoxic types. • i.e. skin test for tuberculosis immunity.

• Autoimmune – Humoral (type 1-2-3 above) • myasthenia gravis • Graves disease • immune thrombocytopenic purpura • pemphigus vulgaris • pemphigus foliaceous • neonatal lupus – Cell-mediated (type 4 above) • Hashimoto thyroiditis (Identified at Johns Hopkins, 1928)

• Serum tests. Serum must be separated from clot / SST Gel within 1 hour! – Pipette serum into a plastic transport tube – Excessive exposure to the gel in the SST will bind antibodies, causing false negative tests. • Used for allergy testing, Autoimmune testing, Exposure • Ig (Immunoglobulin) Types: – IgG: Long term exposure, Delayed reactions (ie. Food allergy). • IgG lasts a long time, and is a marker of EXPOSURE, not successful treatment. – IgM: Acute phase reactions. Indicates recent infection or re-exposure. – IgA: Secretory Ig. • Shows mucosal response and is a good marker of successful treatment. • Can be measured in the serum, stool and saliva – IgE: Anaphylaxis. (Type-1 Reaction). • Total IgE in serum is a test for general allergic level in the patient • Traditionally the marker used for food and Inhalant allergy, although IgG is more helpful with most food reactions.

• High IgG, Low IgM or IgA – Probable past infection / exposure. Inactive or cured. – In food allergy testing IgG is always considered active, but delayed response allergy. • Low IgG, High IgM – New infection / Exposure • High IgG, High IgM – Reactivated infection / Exposure • High IgG, Low IgM, High IgA – Current immune response (mucosal) that is past the initial IgM response window. (On going problem).

• Selective Ig-excess: • Ig A excess common in acute and chronic smoldering infections • Ig M excess common in acute and chronic smoldering infections • Ig E Elevation (Classic “Type-1” Anaphylaxis) • Common in IBD – Parasites / Helminths – significant dysbiosis

• Generally resolve with acute / chronic immune treatment

• Selective Ig-deficiency:

– All potentially can happen and are more common in these cases

• IgG specific selective deficiency:

– Low levels (functional) common

– Must follow – May respond to IgG Tx.

• Screening: – IgG Subclasses: IgG1,2,3,4: Test Number: 209601

The IgG in the bloodstream is 60-70% IgG1, 20-30% IgG2, 5-8% IgG3 and 1-3% IgG4. The amount of the different IgG subclasses present in the bloodstream varies with age. For example, IgG1 and IgG3 reach normal adult levels by 5-7 years of age while IgG2 and IgG4 levels rise more slowly, reaching adult levels at about 10 years of age. In young children, the ability to make IgG2 antibodies to the polysaccharide coatings of bacteria develops more slowly than the ability to make antibodies to proteins. IgG1: IgG1 comprises 60 to 65% of the total main subclass IgG, and is predominantly responsible for the thymus-mediated immune response against proteins and polypeptide antigens. IgG1 binds to the Fc-receptor of phagocytic cells and can activate the complement cascade via binding to C1 complex. IgG1 immune response can already be measured in newborns and reaches its typical concentration in infancy. A deficiency in IgG1 isotype is typically a sign of a hypogammaglobulinemia.

IgG2: IgG2, the second largest of IgG isotypes, comprises 20 to 25% of the main subclass and is the prevalent immune response against carbohydrate/polysaccharide antigens. “Adult” concentrations are usually reached by 6 or 7 years old. Among all IgG isotype deficiencies, a deficiency in IgG2 is the most common and is associated with recurring airway/respiratory infections in infants. IgG3: IgG3 comprises around 5 to 10% of total IgG and plays a major role in the immune responses against protein or polypeptide antigens. The affinity of IgG3 can be higher than that of IgG1. IgG4: Comprising usually less than 4% of total IgG, IgG4 does not bind to polysaccharides. In the past, testing for IgG4 has been associated with food allergies, and recent studies have shown that elevated serum levels of IgG4 are found in patients suffering from sclerosing pancreatitis, cholangitis and interstitial pneumonia caused by infiltrating IgG4 positive plasma cells. The precise role of IgG4 is still mostly unknown.

• Mre11, Rad50, and Nbs1 form an evolutionarily conserved protein complex (Mre11-Rad50-Nbs1, MRN) that has been proposed to function as a DNA damage sensor. Hypomorphic mutations in Mre11 and Nbs1 result in the human … • Here, we use Cre-loxP-mediated recombination to restrict Nbs1 deletion to B lymphocytes. We find that disruption of Nbs1 results in the accumulation of high levels of spontaneous DNA damage… • Moreover, we show that Ig class-switch recombination (CSR) is diminished in Nbs1-deficient B cells. The CSR defect is B cell-intrinsic, independent of switch- region transcription, and a consequence of inefficient recombination at the DNA level. Our findings reveal that Nbs1 is critical for efficient Ig CSR and maintenance of the integrity of chromosomal structure and number. PMID: 15668392

• INTRODUCTION: Chemokines are regulated by a family of 'atypical' chemokine receptors, D6, DARC and CCX-CKR, each of which efficiently internalizes its cognate chemokine ligands. Development of monoclonal antibodies (MAbs) that would recognize CCX-CKR on the cell surface will be helpful to identify primary CCX-CKR-expressing cell types and analyze the fate of CCX-CKR after ligand binding to the receptor. • RESULTS: A panel of MAbs reacting with CCX-CKR expressed on the cell surface was prepared. The panel was a small one, consisting of only ten MAbs, but was rich in terms of diversity of the Ig isotypes and of the epitopes. Epitope analyses revealed that all the 10 MAbs recognized at least three different, although very close, peptide structures of the N-terminal domain. Three MAbs, namely, 2F11, 13E11 and 14F10, were selected to represent the panel. All of the MAbs were applicable for flow cytometry and immunoflurescent assays and immunoprecipitation. The reactivity of the 2F11 MAb was also confirmed by western blotting. Endogenous expression of CCX-CKR on human hepatocytes and hepatic tumor cell lines was demonstrated using the 13E11 MAb. Interestingly, binding of the 13E11 MAb with B300-19 cells expressing CCX-CKR resulted in induction of CCX-CKR internalization. PMID: 21184834

• IgE has long been known as a therapeutic target for allergic disease, but the difficulty has been in selecting agents that don't trigger cross linkage of IgE when bound to its high affinity receptor (FceR1) on mast cells and basophils. • By “designing” a monoclonal antibody (mAb) which targets that part of IgE that binds to that binds to the a-chain of FceR1, the allergic cascade can be effectively interrupted and diseases such as asthma greatly improved, providing a substantial part of their phenotype engages IgE. Holgate World Allergy Organization Journal 2014, 7:17

• IL-13 are able to induce an immunoglobulin isotype switch to IgE in B cells. A major question is to what extent these cytokines contribute to the production of IgE in allergic patients. To address this question we used an in vitro culture system in which the production of IgE is dependent on endogenously produced IL-4 and IL-13. • Our results indicate that, at least in vitro, IgE production in allergic asthma patients is more dependent on IL-13 than in non-atopics, due to enhanced IL- 13 production and to enhanced IgE production in response to IL-13. Van Der Pouw Kraan TCTM, Van Der Zee JS, Boeije LCM, DE Groot ER, Stapel SO, Aarden LA. The role of IL-13 in IgE synthesis by allergic asthma patients. Clinical and Experimental Immunology. 1998;111(1):129-135. doi:10.1046/j.1365- 2249.1998.00471.x.

• Also known as: CD32; FCG2; FcGR; CD32A; CDw32; FCGR2; IGFR2; FCGR2A1 • Summary: This gene encodes one member of a family of immunoglobulin Fc receptor genes found on the surface of many immune response cells. The protein encoded by this gene is a cell surface receptor found on phagocytic cells such as macrophages and neutrophils, and is involved in the process of phagocytosis and clearing of immune complexes. Alternative splicing results in multiple transcript variants. [provided by RefSeq, Oct 2008 - NLM]

• Tumor necrosis factor (TNF) receptor superfamily (TNFRSF), agonistic antibodies have been used to stimulate TNFRSF receptors in vitro and in vivo. TNFRSF receptor-specific antibodies of the IgM subclass and secondary cross-linked or aggregation prone dimeric antibodies typically display superior agonistic activity compared with dimeric antibodies…. Cell Death and Differentiation (2015) 22, 1727–1741; doi:10.1038/cdd.2015.109; published online 21 August 2015 • TNFRSF13B/TACI defects have been associated with CVID pathogenesis and/or phenotype, especially the development of benign lymphoproliferation and autoimmunity. Our purpose was to investigate the role … Both mutations identified in TH patients have been assessed as deleterious for protein function, while the patient with the R202H mutation and sarcoidosis exhibited also sIgG4D. Our study further supports the notion that… but may be also found frequently in distinct clinical phenotypes, including benign lymphoproliferation and IgG subclass deficiencies. Speletas M, Salzer U, Florou Z, et al. Heterozygous Alterations of TNFRSF13B/TACI in Tonsillar Hypertrophy and Sarcoidosis. Clinical and Developmental Immunology. 2013;2013:532437. doi:10.1155/2013/532437.

• We carried out a genome-wide association study of IgA nephropathy, a major cause of kidney failure worldwide. We studied 1,194 cases … as well as a common deletion of CFHR1 and CFHR3 at chromosome 1q32 and a locus at chromosome 22q12 that each surpassed genome-wide significance. • These five loci explain 4–7% of the disease variance and up to a tenfold variation in inter individual risk. Many of the alleles that protect against IgA nephropathy impart increased risk for other autoimmune or infectious diseases, and IgA nephropathy • Nature Genetics 43, 321–327 (2011) doi:10.1038/ng.787

• To understand the genetic predisposition to selective immunoglobulin A deficiency (IgAD), we performed a genome-wide association study in 430 affected individuals (cases) from Sweden and Iceland and 1,090 ethnically matched controls, and we performed replication studies in two independent European cohorts. In addition to the known association of HLA with IgAD, we identified association with a nonsynonymous variant in IFIH1 (rs1990760G>A, P = 7.3 x 10(-10)) which was previously associated with type 1 diabetes and systemic lupus erythematosus. Variants in CLEC16A, another known autoimmunity locus, showed suggestive evidence for association (rs6498142C>G, P = 1.8 x 10(-7)), and 29 additional loci were identified with P < 5 x 10(-5). A survey in IgAD of 118 validated non-HLA autoimmunity loci indicated a significant enrichment for association with autoimmunity loci as compared to non-autoimmunity loci (P = 9.0 x 10(-4)) or random SNPs across the genome (P < 0.0001). These findings support the hypothesis that autoimmune mechanisms may contribute to the pathogenesis of IgAD. PMID: 20694011

• This protein and TRAF2 form a heterodimeric complex, which is required for TNF-alpha-mediated activation of MAPK8/JNK and NF-kappaB. The protein complex formed by this protein and TRAF2 also interacts with inhibitor-of- apoptosis proteins (IAPs), and thus mediates the anti-apoptotic signals from TNF receptors. The expression of this protein can be induced by Epstein- Barr virus (EBV). EBV infection membrane protein 1 (LMP1) is found to interact with this and other TRAF proteins; this interaction is thought to link LMP1-mediated B lymphocyte transformation to the signal transduction from TNFR family receptors. [NLM] • Also related to IgA Nephropathy etc…

• Related to IgA: – Nephropathy – Deficiency – Crosstalk

• Colostrum: – Crooks CV, Wall CR, Cross ML, Rutherfurd-Markwick KJ. The effect of bovine colostrum supplementation on salivary IgA in distance runners. Int J Sport Nutr Exerc Metab. 2006 Feb;16(1):47-64. PMID:16676703

• Sacro b.: • Amir Qamar, et.al. Saccharomyces boulardii Stimulates Intestinal Immunoglobulin A Immune Response to Clostridium difficile Toxin A in Mice. Infect Immun. 2001 Apr; 69(4): 2762–2765. doi: 10.1128/IAI.69.4.2762-2765.2001. PMCID: PMC98222 • Zanello G, et.al. Saccharomyces boulardii effects on gastrointestinal diseases Curr. Issues Mol. Biol. 11: 47-58.

• Mushrooms: – van Nevel CJ1, Decuypere JA, Dierick N, Molly K. The influence of Lentinus edodes (Shiitake mushroom) preparations on bacteriological and morphological aspects of the small intestine in piglets. Arch Tierernahr. 2003 Dec;57(6):399-412. PMID: 14982320 • Thymus: – Lin CY, Hsu HC, Chen CL, Shen EY. Treatment of combined immunodeficiency with thymic extract (Thymostimulin). Ann Allergy. 1987 May;58(5):379-84. PMID: 3578932

• All the above IgA things • Methylation and Marrow Support • Mitochondrial Support

• Immune Balancing

(c) PS Anderson - www.ConsultDrA.com 2020 110 Excerpt from DrA-Academy Emergency Medicine for the Physician Office Course

Endotoxin Reactions

Dr. Anderson

• Endotoxin is a biological toxin that is part of the outer membrane of some types of gram negative bacteria. • Endotoxin causes a powerful inflammatory reaction in humans, especially at high doses, when it causes fever, flu-like symptoms, cough, headache and respiratory distress. • Endotoxin in the indoor air is suspected of playing a significant role in "sick building syndrome." They are increased in situations where there is significant water damage or dampness. Stagnant water and sewage can contain very high levels of endotoxin and can be a source of high exposure. Adapted from: http://www.nrdc.org/health/effects/katrinadata/endotoxin.asp

(c) PS Anderson - www.ConsultDrA.com 2020 112 http://www.biostrategics.com/kpmgendo.pdf(c) PS Anderson - www.ConsultDrA.com 2020 113 Endotoxin Reaction

• Many Sn/Sx are possible (see above) – Onset can be rapid • A classic case report [PMID: 6829590] listed the most common signs and symptoms in one group: – Chills (75 percent) – Nausea and/or vomiting (30 percent) – Fever (90 percent) – Mean times of onset after starting infusion of:

• 1.1, 1.6, and 3.6 hours, respectively.

Watch and Wait

Support

• If truly an endotoxin reaction Sn/Sx and outcome will be self limited EXCEPT IN FRAIL AND DEPLETED PATIENTS.

• Supportive therapy: –Hydration –Anti-nausea medications •Oral anti-nausea meds (Part-2) •IV anti-nausea meds (Part-2)

• Supportive therapy: – Low dose steroids • Oral: – Prednisone 30 mg / 20 mg / 10 mg 3 day taper • IV: – (IV or IM) Dexamethasone @ 5 mg – (IV) Solu-Cortef (Hydrocortisone) @ 100 mg – (IV) Solu-Medrol (Prednisone) @ 20 mg

(c) PS Anderson - www.ConsultDrA.com 2020 117 Most common causes of endotoxin reactions in the clinical setting: According to UCLA Pharmacology #1 is amino Acid sterile product, then B Vitamins. In office IVNT I see it due to SDV being used for MDV, PolyMVA used MDV or improperly compounded, Amino Acids, B Vitamins. (c) PS Anderson - www.ConsultDrA.com 2020 118 Immunology of Vitamin C

(c) PS Anderson - www.ConsultDrA.com 2020 120 (c) PS Anderson - www.ConsultDrA.com 2020 121 (c) PS Anderson - www.ConsultDrA.com 2020 122 (c) PS Anderson - www.ConsultDrA.com 2020 123 One Example Wormwood Compounds and Immunology

• See the above references webinars and papers • See the multiple webinars where immune reacting, inflammatory modulating and other MOA of herbs are discussed. • Wormwood is simply a unique set of constituents that help show an immunological point.

(c) PS Anderson - www.ConsultDrA.com 2020 125 Maria P. Crespo-Ortiz and Ming Q.Wei. Antitumor Activity of Artemisinin and Its Derivatives: From aWell-Known Antimalarial Agent to a Potential Anticancer Drug .Journal of Biomedicine and Biotechnology. Volume 2012, Article ID 247597, 18 pages. doi:10.1155/2012/247597

FAMOU S MOA

(c) PS Anderson - www.ConsultDrA.com 2020 126 (c) PS Anderson - www.ConsultDrA.com 2020 127 (c) PS Anderson - www.ConsultDrA.com 2020 128 © ScienceDirect

(c) PS Anderson - www.ConsultDrA.com 2020 134 NOTE: “ASC” here is NOT Ascorbate: ASC (apoptosis-associated speck-like protein with a caspase recruitment domain) ASC oligomers induce the recruitment of caspase-1

NEXT 3 SLIDES Tay, M.Z., Poh, C.M., Rénia, L. et al. The trinity of COVID-19: immunity, inflammation and intervention. Nat Rev Immunol (2020). https://doi.org/10.1038/s41577-020- 0311-8

(c) PS Anderson - www.ConsultDrA.com 2020 135 (c) PS Anderson - www.ConsultDrA.com 2020 136 (c) PS Anderson - www.ConsultDrA.com 2020 137 https://www.townsendletter.com/article/online-covid -19-ards-cell-free-hemoglobin-ascorbic-acid-connect ion/

Moens B, Decanine D, Menezes SM, Khouri R, Silva-Santos G, et al. (2012) Ascorbic Acid Has Superior Ex Vivo Antiproliferative, Cell Death-Inducing and Immunomodulatory Effects over IFN-a in HTLV-1-Associated Myelopathy. PLoS Negl Trop Dis 6(7): e1729. doi:10.1371/journal.pntd.0001729

(c) PS Anderson - www.ConsultDrA.com 2020 140 (c) PS Anderson - www.ConsultDrA.com 2020 141 Ascorbate Concentration Methods

Ascorbic Acid (AA) tested in vitro at concentrations of (10, 50 or 100 µg/ml) In this paper they identify concentrations as the following: • Low-dose AA (10 µg/ml) • Intermediate-dose AA (50 µg/ml) • High-dose AA (100 µg/ml)

(c) PS Anderson - www.ConsultDrA.com 2020 142 Ascorbate Concentrations used in this study converted to mg/dL – How does this relate to “HDIVC” plasma post- treatment levels?

• Low-dose AA (10 µg/ml) = 1 mg/dL • Intermediate-dose AA (50 µg/ml) = 5 mg/dL • High-dose AA (100 µg/ml) = 10 mg/dL HDIVC @ 25-100Grams = Human ASC Plasma concentrations of 300 to 400 mg/dl = ASC [17.04 - 22.7 mMol/L] exceed the 10 mM oxidative threshold originally published* and should therefore create a stead state of H2O2 production in the extracellular space for an extended period. *Verrax J, Calderon PB. The controversial place of vitamin C in cancer treatment. Biochemical Pharmacology 76 (2008) 1644–1652

IL-6 • High-dose AA significantly reduced IL-6 secretion with 37% in comparison to untreated cells • IFN-α significantly increased IL-6 secretion • Intermediate-dose and low-dose AA exerted no effect on IL-6 levels. IL-10 • Neither high-, intermediate- or low-dose AA, nor IFN-α exerted an effect on IL-10 levels

AA treatment dose-dependently reduced p19 levels (which correlate to HTLV levels). • Maximum inhibition of p19 secretion was observed for high-dose AA with 41% reduction for MT-2 and 70% reduction for MT-4 cells, in comparison to untreated cells. • IFN-α treatment reduced p19 concentration by 31% for MT-2 and by 20% for MT-4 cells, although without reaching statistical significance in MT-4 cells.

HTLV is a (?) viri? ***It contains two copies of a single-stranded RNA virus

• Gene-expression profiling of MT-2 revealed 142 genes significantly regulated by high-dose AA, of which 48 were down- and 94 were up-regulated.

• Intermediate-dose AA significantly regulated 17 genes, of which 15 were down- and 2 were up-regulated. • Low-dose AA significantly regulated 12 genes, of which 9 were down- and 3 were up-regulated.

• In comparison to high-dose AA, five common regulated genes were identified for intermediate-dose AA, including microRNA 155. • For low-dose AA, only transmembrane channel-like 7 was common with high- dose AA-regulated genes. • Moreover, the number of genes regulated by AA treatment was proportional with the used doses, confirming a dose-dependent effect. • In parallel, gene-expression profiling of MT-2 revealed 93 genes significantly regulated by IFN-α, of which 3 were down- and 90 were up-regulated.

(c) PS Anderson - www.ConsultDrA.com 2020 147 microRNA 155 is Downregulated by Ascorbate Upregulation of microRNA 155 is strongly correlated with oncogenesis: • doi: 10.1038/onc.2012.636 • doi: 10.1158/1055-9965.EPI-12-0173 • doi: 10.3892/ijmm.2013.1348 • doi: 10.18632/oncotarget.3273 A recent review on the topic: https://www.consultdranderson.com/brain-fire-understanding-leaky-blood-brain- barrier-chronic-neuro-inflammation-potential-connection-cancer-protection-treat ment/

(c) PS Anderson - www.ConsultDrA.com 2020 148 (c) PS Anderson - www.ConsultDrA.com 2020 149 High Dose Ascorbic Acid and Genes:

Moreover, as IFN-α has a higher cost price and more severe side effects in comparison to high-dose AA treatment, the therapeutic potential of high- dose AA should be further explored, in parallel with widely used treatments such as corticosteroids and IFN-α, in future clinical studies with a biomarker discovery design. Considering the differential and effects of AA and IFN-α, as demonstrated in this study, their modest effectiveness might be increased if host or viral biomarkers are identified that reliably predict treatment outcome.

(c) PS Anderson - www.ConsultDrA.com 2020 152 Interferon-α2b Treatment for COVID-19. Frontiers in Immunology (2020) DOI=10.3389/fimmu.2020.01061 In this study, researchers examined the course of COVID-19 disease progression in patients with confirmed infection admitted to Union Hospital, Tongii Medical College, in Wuhan between Jan. 16 and Feb. 20. All patients had moderate symptoms, meaning none required intensive care or oxygen supplementation or intubation. Patients in the study were treated either with interferon-alpha-2b, the antiviral arbidol or a combination of the two. The researchers found that those who received interferon-alpha-2b as part of their treatment achieved undetectable levels of SARS-CoV-2 up to seven days faster than those who didn't receive the drug. In addition, treatment with interferon-alpha-2b, either alone or in combination with arbidol, also cleared the virus faster than arbidol alone. Also, interferon-alpha-2 treatment "significantly" reduced levels of interleukin-6 and C-reactive protein, two inflammatory proteins found in the human body that become elevated in some with COVID-19. [Reported May 2020 UPI.com online]

(c) PS Anderson - www.ConsultDrA.com 2020 153 Interferon-α2b Treatment for COVID-19. Frontiers in Immunology (2020) DOI=10.3389/fimmu.2020.01061

Fish and her colleagues, however, emphasized that the findings need to be confirmed by a larger, randomized, controlled trial -- the gold standard for evaluating the safety and efficacy of a treatment -- before it can be considered for widespread use. "Rather then developing a virus-specific antiviral for each new virus outbreak, I would argue that we should consider interferons as the 'first responders' in terms of treatment," Fish said. [Reported May 2020 UPI.com online]

(c) PS Anderson - www.ConsultDrA.com 2020 155 What policy makers need to know about COVID-19 protective immunity Currentwww.thelancet discussion,.com Published for example, online April addresses 27, 2020 https://doi.org/10.1016/S0140- the notion that scaled 6736(20)30985-5 1 up antibody testing will determine who is immune, thus giving an indication of the extent of herd immunity and confirming who could re-enter the workforce. There are questions to be addressed about the accuracy of tests and practicalities of implementation of laboratory-based versus home-use assays.5 For any country contemplating these issues, another crucial question is how solid is the assumption that antibodies to SARS-CoV-2 spike protein equate to functional protection? Furthermore, if presence of these antibodies is protective, how can it be decided what proportion of the population requires these antibodies to mitigate subsequent(c) PS Anderson - www.ConsultDrA.com waves of 2020 cases of COVID-19? 156 Lancet: 04-27-2020

• Caution is needed because total measurable antibody is not precisely the same as protective, virus-neutralizing antibody. Furthermore, studies in COVID-19 show that 10–20% of symptomatically infected people have little or no detectable antibody.8 In some cases of COVID-19, low virus-binding antibody titres might correlate with lethal or near-lethal infection, or with having had a mild infection with little antigenic stimulation. • The route to certainty on the degree and nature of the immunity required for protection will require evidence from formal proofs using approaches such as titrated transfers of antibodies and T lymphocytes to define protection in non- human primate models, as used, for example, in studies of Ebola virus.9

• A study of survivors of SARS showed that about 90% had functional, virus-neutralising antibodies and around 50% had strong T-lymphocyte responses.10 These observations bolster confidence in a simple view that most survivors of severe COVID- 19 would be expected to have protective antibodies. • A caveat is that most studies, either of SARS survivors or of COVID-19 patients, have focused on people who were hospitalised and had severe, symptomatic disease. Similar data are urgently needed for individuals with SARS-CoV-2 infection who have not been hospitalised.

• How long is immunity to COVID-19 likely to last? – The best estimate comes from the closely related coronaviruses and suggests that, in people who had an antibody response, immunity might wane, but is detectable beyond 1 year after hospitalisation.10–12 • Obviously, longitudinal studies with a duration of just over 1 year are of little reassurance given the possibility that there could be another wave of COVID- 19 cases in 3 or 4 years. • Specific T-lymphocyte immunity against Middle East respiratory syndrome coronavirus, however, can be detectable for 4 years, considerably longer than antibody responses.13

(c) PS Anderson - www.ConsultDrA.com 2020 160 Wadhwa A, Aljabbari A, Lokras A, Foged C, Thakur A. Opportunities and Challenges in the Delivery of mRNA-based Vaccines. Pharmaceutics. 2020;12(2):102. Published 2020 Jan 28. doi:10.3390/pharmaceutics12020102 In the past few years, there has been increasing focus on the use of messenger RNA (mRNA) as a new therapeutic modality. Current clinical efforts encompassing mRNA-based drugs are directed toward infectious disease vaccines, cancer immunotherapies, therapeutic protein replacement therapies, and treatment of genetic diseases.

(c) PS Anderson - www.ConsultDrA.com 2020 161 Wadhwa A, Aljabbari A, Lokras A, Foged C, Thakur A. Opportunities and Challenges in the Delivery of mRNA-based Vaccines. Pharmaceutics. 2020;12(2):102. Published 2020 Jan 28. doi:10.3390/pharmaceutics12020102

However, challenges that impede the successful translation of these molecules into drugs are that (i) mRNA is a very large molecule, (ii) it is intrinsically unstable and prone to degradation by nucleases, and (iii) it activates the immune system. Although some of these challenges have been partially solved by means of chemical modification of the mRNA, intracellular delivery of mRNA still represents a major hurdle. The clinical translation of mRNA-based therapeutics requires delivery technologies that can ensure stabilization of mRNA under physiological conditions.

Mechanism of action of mRNA vaccines. 1. The mRNA is in vitro transcribed (IVT) from a DNA template in a cell-free system. 2. IVT mRNA is subsequently transfected into dendritic cells (DCs) via (3) endocytosis. 4. Entrapped mRNA undergoes endosomal escape and is released into the cytosol. 5. Using the translational machinery of host cells (ribosomes), the mRNA is translated into antigenic proteins. The translated antigenic protein undergoes post-translational modification and can act in the cell where it is generated. 6. Alternatively, the protein is secreted from the host cell. 7. Antigen protein is degraded by the proteasome in the cytoplasm. The generated antigenic peptide epitopes are transported into the endoplasmic reticulum and loaded onto major histocompatibility complex (MHC) class I molecules (MHC I). 8. The loaded MHC I-peptide epitope complexes are presented on the surface of cells, eventually leading to the induction of antigen-specific CD8+ T cell responses after T-cell receptor recognition and appropriate co-stimulation. 9. Exogenous proteins are taken up DCs. 10. They are degraded in endosomes and presented via the MHC II pathway. Moreover, to obtain cognate T-cell help in antigen-presenting cells, the protein should be routed through the MHC II pathway. 11. The generated antigenic peptide epitopes are subsequently loaded onto MHC II molecules. 12. The loaded MHC II-peptide epitope complexes are presented on the surface of cells, leading to the induction of the antigen-specific CD4+ T cell responses. Exogenous antigens can also be processed and loaded onto MHC class I molecules via a mechanism known as cross-presentation (not shown in the figure).

(c) PS Anderson - www.ConsultDrA.com 2020 164 In: STAT, an online publication of Boston Globe Media that covers health, medicine, and scientific discovery. (05-2020)

• Moderna is developing the vaccine in conjunction with the NIAID’s Vaccine Research Center. “These interim Phase 1 data, while early, demonstrate that vaccination with mRNA-1273 elicits an immune response of the magnitude caused by natural infection starting with a dose as low as 25 μg,” said Tal Zaks, Moderna’s chief medical officer. • “I think 25 [micrograms] gets us there, but you always want to have somewhat of a margin,” Zaks told STAT in an interview. • “The sense is at the end of the day we’re going to narrow it down on somewhere between 25 and 100,” he said. “It’s going to be really hard math for us.”

(c) PS Anderson - www.ConsultDrA.com 2020 166 Next Webinars All are Tuesday PM – 5:30 – 7:00 PM Pacific Time NOTE – All are third Tuesday of the month unless noted “*” *Bonus 06-02-2020 (Controversies in integrative and naturopathic oncology) 06-16-2020 07-21-2020 08-18-2020 09-15-2018

TAB – DrA’s IV Monographs: WWW.ConsultDrA.com Tell your friends we have lots of free content… ======And Some changes in subscription benefits

New “MasterClass” Series at DrA-Academy.com Emergency Medicine for the Medical Office 4.5 Total AANP CME of which 2.0 are Pharmacology --- And More Series to Come (Medical Laser, HBOT, etc.)

DATE CHANGE August 21, 22 & 23(Friday through Sunday)

Advanced Applications in Chronic Digestive Disorders

(c) PS Anderson - www.ConsultDrA.com 2020 171 Daily Focus Areas: aampscottsdale.com FRIDAY: GI Assessment and Treatment in the Chronically Ill Patient • From signs and symptoms to testing and diagnosis – Latest Updates and Best Practices • Infectious Diseases • Autoimmune Diseases • Other Inflammatory Syndromes • Cancers SATURDAY: SIBO – SIFO and Dysbiotic Overgrowth Syndromes • Making sense of SIBO-SIFO: How do I reliably assess and treat a patient? • When to think of “Overgrowth” in a chronic case • Diet Changes and Therapies • Prescription and Natural Therapy Strategies • End the day feeling updated and confident in managing overgrowth syndromes SUNDAY: Allergy – Sensitivity – GI Repair • MCAS – POTS: Latest concepts in assessment and treatment • Food Allergy and Sensitivity: What’s the latest science and their clinical implications • GI Repair: Best practices during and after intensive GI therapies

MOLD, ALLERGY, RESPIRATORY DISEASE AND THEIR SYSTEMIC EFFECTS: THE IMMUNOLOGY AND TREATMENT OF MYCOTOXIN AND IMMUNO-REGULATORY ILLNESS.

TOPICAL AREAS: • MOLD & MYCOTOXIN / BIOTOXIN ILLNESS • CIRS • MAST CELL DISORDERS • ALLERGY: RESPIRATORY & Systemic • INFECTIOUS COMPLICATIONS • OTHER RELATED CLINICAL SYNDROMES

• Paul Anderson • Mary Beth Ackerley MD, MD(H), ABIHM • Jill Crista, ND • Kellyn Milani, ND • Lauren Tessier, ND