How and when to intervene to prevent multiple

sclerosis; targeting the environment?

Professor Gavin Giovannoni Professor of Clinical Neurology & Chair of Neurology

Blizard Institute, Barts and The London School of Medicine and Dentistry, London

Multiple sclerosis is a complex disease

Genes 1. HLA 2. Etc.

Epigenetics

1. Month of birth 2. Maternal parent-

of origin effect 3. Dizygotic vs.

sibling concordance rates

4. vD, EBV & smoking

Environment

1. EBV 2. vD 3. Smoking

Chance

EBV

99.2% vs. 90.2%

.

Ascherio et al, 2000

Sero-positivity among MS patients compared with controls by study

Infectious mononucleosis

Handel et al. 2010.

Small OR

Odds ratio of MS in subjects seronegative for EBV

Ascherio et al, 2007

Distribution of MS in England

Ramagopalan et al., JNNP 2011.

Distribution of IM in England

Ramagopalan et al., JNNP 2011.

Correlation Between Distribution of IM and MS in England

Females- Pearson R= 0.70, p=0.000025

Males- Pearson R= 0.55, p=0.003

Correlations don’t imply causation Ramagopalan et al., JNNP 2011.

Primary infection with the EBV and risk of MS

• Nested case-control study including from over 8 million military personnel with serum stored in the Department of Defense Serum Repository.

Levin et al. Ann Neurol 2010.

MS

Controls N = 610

N = 305 10/305 (3.3%) EBV –ve

32/610 (5.2%) EBV –ve 10/28 (35.7%) EBV –ve

10/10 (100%) EBV –ve

• MS risk is extremely low among individuals not infected with EBV, but it increases sharply in the same individuals following EBV infection.

The ugly fact

“The great tragedy of Science; the slaying of a beautiful hypothesis by an ugly fact.” Thomas Henry Huxley

Viral serologies in children with MS

Banwell et al. Lancet Neurology, Sept. 2007

?

The risk of developing MS in individuals seronegative for EBV: a meta-analysis

Pakpoor et al., MSJ 2012

EBV antibody titres: anti-EBNA1

.

Levin et al, 2005

EBV & Disease Activity

Farrell et al. Neurology 2009

EBNA-1

NOT VCA or EA

International CIS study: EBNA-1 IgG and conversion to CDMS*

Cox univariate HR 95% CI P value

EBNA-1 nOD 1.01 0.996-1.029 0.137

* similar results in OCB+ve and MRI T2 +ve patients only

Median Survival (days) Log-rank p

< Median 1247

0.216 > Median 1032

Dr Jens Khule, ECTRIMS 2013

N Engl J Med 2008;358:676-88.

The Reduction in Gd-Enhancing T1 Lesions

by OCR Is Maintained Through 144 Weeks

Primary endpoint:

OCR vs placebo1

Weeks

* *

1. Kappos L, et al. Lancet. 2011;378(9805):1779–87; 2. Kappos L, et al. Abstract presented (P362) ECTRIMS 2012 , October 12

OCR 600 mg arm (n=55)

OCR 1000 mg arm (n=55)

Placebo (n=54)

IFN-β1a (n=54)

- ‘Core Study' (0–96 weeks)

- ‘Follow-Up' (97–144 weeks)a

*p<0.0001 for both OCR doses vs placebo, N (for primary analysis): Placebo=54, OCR 600 mg=51, OCR 1000 mg=52, IFN-β1a=522

aPatients who withdrew during earlier treatment cycles were also included in the follow-up periods

Patients with baseline MRI

vD

Compston & Coles, Lancet 2008.

Epidemiology: worldwide distribution & migration studies

Latitude & link with vD & UVB

1Jablonski NG, Chaplin G. J Hum Evol 2000;39:57–106. 2Chaplin G. Am J Phys Anthropol 2004;125:292–302.

45

55

70

47 76

71 78

51 53 51

59

77

62

88

103

98 100

84

82

93

87

95

MS Prevalence by Department Against UVMED Minimum

3–4

4–6

6–7

Department UVMed MIN

7–9

10–11

11–13

14–16

Relationship of MS Prevalence to Ultraviolet exposure

Ramagopalan et al, 2011

Prevalence of MS in Norway

• Prevalence data for counties in Norway (/105):

A Finnmark1 (2003) >83

B Troms1 (2003) >104

C Nordland (1999) 106

D Nord Trøndelag (1999) 164

E Oppland (2002) 190

F Hordaland (2003) 151

G Oslo (2005) 154

• In Norway, MS prevalence does not rise with increasing latitude, unlike other northern European countries and the USA

• As expected, measured UV radiation levels decrease with increasing latitude

1Kampman MT et al. J Neurol 2007;254:471–477.

A

B

C

D

E

F G

Fish consumption?

Kampman et al, 2007

A study of childhood environmental factors in Norway

Odds ratio for MS and summer outdoor activities

Kampman MT et al. J Neurol 2007;254:471–477.

Unadjusted odds ratio P- value Adjusted odds ratio* P- value

Summer outdoor activities

OR† 95% CI OR† 95% CI

Age 16–20 0.54 0.38–0.75 0.001 0.55 0.39–0.78 0.001

Age 11–15 0.70 0.52–0.96 0.025 0.74 0.54–1.01 0.055

Age 6–10 0.69 0.51–0.93 0.013 0.71 0.52–0.96 0.025

The regression analysis included 111 patients and 246 controls with complete data for all variables. *Adjusted for use of cod-liver oil supplementation and meals of boiled or fried fish. †Odds ratio per one unit change in summer outdoor activities.

Can serum levels of 25(OH)D3 predict MS risk?

• Nested case-control study including from over 7 million military personnel with serum stored in the Department of Defense Serum Repository.

MS

Controls N = 296

N = 148 25-OH vD3

25-OH vD3

quintiles

• RR of MS significantly decreased with increasing levels of 25-OH-vD

• OR for a 50-nmol/L increase in 25-OH-vD was 0.59 (95%CI = 0.36-0.97)

• RR lowest quintile (<63.3 nmol/L) as the reference, the ORs for each subsequent quintile were 0.57, 0.57, 0.74, and 0.38 (P = .02 for trend across quintiles)

• OR for the highest quintile, corresponding to 25-hydroxyvitamin D levels higher than 99.1 nmol/L, was significantly different from 1.00 (OR = 0.38; 95%CI = 0.19-0.75; P = .006)

Munger KL et al. JAMA 2006;296:2832–2838.

Can vD supplements prevent MS?

• Nurses' Health Study

• NHS I - 92,253 women followed from 1980 to 2000

• NHS II - 95,310 women followed from 1991 to 2001

• Diet assessed at baseline & every 4 years thereafter

Munger KL et al. Neurology. 2004 Jan 13;62(1):60-5.

Results:

• RR highest quintile of total vitamin D intake to the lowest quintile was 0.67 (95% CI = 0.40 to 1.12; p for trend = 0.03)

• RR comparing women with intake of >or=400 IU/day with women with no supplemental vitamin D intake was 0.59 (95% CI = 0.38 to 0.91; p for trend = 0.006)

MS N = 173

1st 2nd 3rd 4th 5th

What dose of vD?

Veith Am J Clin Nutr 1999;69:842–56.

Level of vD supplementation

Veith Am J Clin Nutr 1999;69:842–56.

Level of vD supplementation

Cultural changes

Genetics of MS: the rate of MS in females is increasing

1Orton SM et al. Lancet Neurol 2006;5:932–936.

0.06

0.065

0.07

0.075

0.08

0.085

0.09

0.095

0.1

0.105

1996 1998 2000 2002 2004 2006 2008 2010

L/in

div

idu

al

Ramagopalan & Giovannoni, submitted.

Sunscreen sales per capita in the USA (1997-2008)

Smoking

Smoking is a risk factor for multiple sclerosis

Handel et al. PLoS One. 2011 Jan 13;6(1):e16149.

Prevalence of Smoking in England

Source: Office of National Statistics

When to supplement?

Month of Birth

1Willer CJ et al. BMJ 2005;330:120–125.

Compston & Coles, Lancet 2008.

MS Familial Risk

Parent-of-origin effects

Ebers et al. Lancet. 2004;363(9423):1773–1774.

Analogy

Japanese macaque encephalomyelitis: spontaneous MS–like disease in a nonhuman primate

Axthelm et al. Ann Neurol 2011.

Prevention strategies

A causal cascade for multiple sclerosis?

.

Ramagopalan et al, 2010

vD supplementation

Smoking prevention

EBV vaccination IM prevention and treatment EBV therapies

Causation theory

Sir Bradford-Hill: Criteria for Causation

Bradford-Hill A. The environment and disease: association or causation? Proc Royal Soc Med 1966; 58:295.

1. CONSISTENCY AND UNBIASEDNESS OF FINDINGS

2. STRENGTH OF ASSOCIATION

3. TEMPORAL SEQUENCE

4. BIOLOGICAL GRADIENT (DOSE-RESPONSE RELATIONSHIP)

5. SPECIFICITY

6. COHERENCE WITH BIOLOGICAL BACKGROUND AND PREVIOUS KNOWLEDGE

7. BIOLOGICAL PLAUSABILITY

8. REASONING BY ANALOGY

9. EXPERIMENTAL EVIDENCE

Sir Bradford-Hill: Criteria for Causation Is EBV the cause of MS?

Bradford-Hill A. The environment and disease: association or causation? Proc Royal Soc Med 1966; 58:295.

1. CONSISTENCY AND UNBIASEDNESS OF FINDINGS - Yes (not 100%)

2. STRENGTH OF ASSOCIATION – ? / Yes (RR ~ 2 to 3)

3. TEMPORAL SEQUENCE - Yes

4. BIOLOGICAL GRADIENT (DOSE-RESPONSE RELATIONSHIP) - ? (not relevant to infections)

5. SPECIFICITY – No (not 100% other putative autoimmune diseases also associated with EBV)

6. COHERENCE WITH BIOLOGICAL BACKGROUND AND PREVIOUS KNOWLEDGE - Yes

7. BIOLOGICAL PLAUSABILITY - Yes

8. REASONING BY ANALOGY - Yes

9. EXPERIMENTAL EVIDENCE - ?

VS.

Conclusions • Genetics

• Increased familial risk proportional to degree of relatedness

• The effect of the HLA dwarfs that of any other region (at least 6 loci)

• 102 imputed genes, of modest effect, now have convincing evidence for involvement in MS

• Genetics support an immunological basis to the aetiology of MS

• Epigenetics • Month of birth effect

• Dizygotic twin vs. sibling concordance rate

• Parent of orgin effect

• vD, EBV and smoking biology

• Environment • vD; latitude, migration, outdoor activity, Vd levels, fish consumption, etc.

? epigenetic / immunological mechanisms

• EBV ? Cause; ? biological mechanisms

• Smoking ? Post-translational modification of putative autoantigens

• Is MS a preventable disease? YES!!!!

Acknowledgements

• Ute Meier

• Monica Marta

• Sreeram Ramagopalan

• Ruth Dobson

• George Ebers

• Jo Topping

• Georgina Burrow

• Julian Gold

• Rachel Farrell

• Cosimo Maggiore

• Jaap Middeldorp

• Sandra Amor

• Dorothy Crawford

• Karen McCauley

• Adam Handel

• Giulio DeSanto

• Hadi Amir-Maghzi

• Chris Hawkes

• Klaus Schmierer

• David Baker

• Jens Kuhle

• Arie Gafson

• Julia Pakpoor