Review - The Human Virome (Composition and Interaction) PDF

Reviews The human virome: assembly, composition and host interactions Guanxiang Liang ✉ and Frederic D. Bushman ✉ Abstract | The human body hosts v...

Reviews The human virome: assembly, composition and host interactions Guanxiang Liang ✉ and Frederic D. Bushman ✉ Abstract | The human body hosts vast microbial communities, termed the microbiome. Less well known is the fact that the human body also hosts vast numbers of different viruses, collectively termed the ‘virome’. Viruses are believed to be the most abundant and diverse biological entities on our planet, with an estimated 1031 particles on Earth. The human virome is similarly vast and complex, consisting of approximately 1013 particles per human individual, with great heterogeneity. In recent years, studies of the human virome using metagenomic sequencing and other methods have clarified aspects of human virome diversity at different body sites, the relationships to disease states and mechanisms of establishment of the human virome during early life. Despite increasing focus, it remains the case that the majority of sequence data in a typical virome study remain unidentified, highlighting the extent of unexplored viral ‘dark matter’. Nevertheless, it is now clear that viral community states can be associated with adverse outcomes for the human host, whereas other states are characteristic of health. In this Review, we provide an overview of research on the human virome and highlight outstanding recent studies that explore the assembly, composition and dynamics of the human virome as well as host–virome interactions in health and disease. We are becoming accustomed to the idea that emphasizing how little of this diversity had been stud­ healthy humans are colonized by a rich diversity of ied previously. Since then, similar methods have been microorganisms — the microbiome. However, less applied in many studies of virome populations, providing well known is that healthy humans are also colonized a rich picture of the associations of the human virome by a remarkable diversity of viruses — the virome. The with health and disease, and continuing to emphasize human virome comprises bacteriophages (phages) that the expanse of viral dark matter (reviewed in refs9,10). infect bacteria, viruses that infect other cellular micro­ The discovery of so much dark matter is not sur­ organisms such as archaea, viruses that infect human prising, given that seawater has ~107 virus-like particles cells and viruses present as transients in food1–7. (VLPs) per millilitre and faeces ~109 VLPs per gram. Centuries of medical research have linked infec­ In these studies, particles that look like viral particles tion by specific viruses with characteristic disease are not commonly verified as replication competent; states; however, the nature and importance of whole thus, the term VLP is used to reflect the fact that we are viral popu­lations were mostly not appreciated until the uncertain that these particles are replication-competent development of advanced DNA sequencing methods viruses, although for many it seems likely. These vast that could report the structures of whole communities. populations, inferred to be mostly unstudied phages, Untargeted sequencing of purified viral samples, termed are extremely diverse in the number of types as well as ‘shotgun sequencing’, was first applied to environmental overall numbers of particles. Furthermore, in a few cases, viral populations in 2002 by Breitbart et al. Viral par­ viral lineages have been shown to evolve rapidly, also con­ ticles were prepared from seawater, and then shotgun tributing to the observed rich sequence variation4. The Department of Microbiology, metagenomic sequencing was employed to character­ National Center for Biotechnology Information (NCBI) Perelman School of Medicine, ize the viral communities present8, revealing highly Genomes database contains only 10,462 complete viral University of Pennsylvania, abundant and diverse phage genomes, as well as a large genome sequences (as of February 2021), a tiny fraction Philadelphia, PA, USA. proportion of viral ‘dark matter’ (that is, sequences of the global diversity. Thus, studying the virome is excit­ ✉e-mail: liangguanxiang@ that looked like nothing in available databases). The ing for the extent of the novelty in every experiment, but gmail.com; bushman@ pennmedicine.upenn.edu next year, the same research group carried out the first also daunting for the analytical challenges. https://doi.org/10.1038/ study of whole viral communities from human faeces1, Viral populations vary greatly across the human body. s41579-021-00536-5 again revealing rich and diverse viral populations, and The human gut contains the most abundant populations, 514 | August 2021 | volume 19 www.nature.com/nrmicro 0123456789();:  Reviews Table 1 | Examples of viral population alterations in human disorders Most studies have only reported associations of the virome and diseases — thus, more work is needed to Human disease Sample Major virome alteration Ref. understand the directions of causal relationships. Severe acute Faeces Reduced viral diversity 102 In this Review, we provide an overview of research on malnutrition the human virome, focusing both on secure conclusions Crohn’s disease and Faeces Increased Caudovirales richness 14 and on areas where additional work would be helpful. We ulcerative colitis first discuss the virome at different body sites in healthy Crohn’s disease Faeces and Moderate alterations 152 humans. Next, we summarize nascent work on the origin biopsies of these populations, that is, the initial assembly of the AIDS Faeces Increased enteric adenoviruses 30 human virome in neonates and infants after delivery. Type 1 diabetes Faeces Reduced viral diversity 16 We then summarize data on interactions between the Hypertension Faeces Erwinia phage ΦEaH2 and Lactococcus 18 host and the virome, including links to disease states. phage 1706 may be associated with hypertension Human virome diversity Type 2 diabetes Faeces Increased putative phage scaffolds 153 The number of bacterial cells associated with the human DOCK8 deficiency Skin swabs Increased skin virome, especially human 71 body is estimated to be roughly the same as the num­ papillomavirus ber of human cells, ~1013 in total20. One estimate sug­ Colorectal cancer Faeces Increased viral diversity 19 gests that each gram of metazoan tissue is associated, Crohn’s disease and Faeces Increased Caudovirales abundance 11 on average, with 3 × 109 bacteria21, and the complexity ulcerative colitis of these communities increases with body size22. VLP Type 1 diabetes Faeces Increased picobirnaviruses and 17 counts in humans reveal that the ratios between viruses during pregnancy tobamoviruses and bacteria range from roughly 0.1 to 10, suggesting Bacterial vaginosis Vaginal Viral population structures correlated with 74 that the total number of viruses in the human body is swabs bacterial vaginosis of a similar order to the number of bacterial and human Early-diagnosed Gut Increased Hepadnaviridae and Hepeviridae; 154 cells (reviewed in ref.10). Crohn’s disease and biopsies reduced Polydnaviridae, Tymoviridae and Viruses that are found in humans can be categorized ulcerative colitis Virgaviridae by various features. Viral genomes can be either RNA or Coeliac disease Faeces Increased enteroviruses 145 DNA, and either double-stranded or single-stranded. autoimmunity Genome sizes can be as low as a few kilobases or as large Crohn’s disease Faeces The virulent phages are replaced with 13 as hundreds of kilobases. All viruses have a protein shell temperate phages (or capsid) surrounding the genome; viruses can also be Ulcerative colitis Gut Increased Caudovirales, phage and 15 enclosed in one or more lipid membranes. Viral parti­ biopsies bacteria virulence functions, and loss cles can be classified according to their morphology — of viral–bacterial correlations spherical (usually icosahedral), filamentous, bullet-shaped, HIV viraemia Seminal Increased human cytomegalovirus 75 pleomorphic or, for phages, tailed. fluid Most constituents of the human virome are inferred Very early-onset Faeces Increased ratio of Caudovirales to 12 to be phages. This is an inference because, in most inflammatory bowel Microviridae cases, the majority of sequences uncovered in a virome disease metagenomic sequencing experiment do not align Haematopoietic Faeces Increased picobirnaviruses 155 with any information present in existing databases stem cell (Box 1), so it is unknown whether they are phages or transplantation some other virus types. The major taxa of phages are typically Caudovirales (tailed phages) and Microviridae and these have been the most studied. This site is rich (icosahedral non-tailed phages) of the group including in cells of both the human gut and prokaryotic micro­ phage ΦX174. Phages can have multiple relationships biota, providing a rich variety of hosts for viral growth. with their bacterial hosts, which constrain ideas about Most other sites have sparser microbiota, at least in virome dynamics (Fig. 1). Lytic phages inject their nucleic healthy individuals, and so sparser viral populations as acid into cells, leading to the synthesis of new viral com­ well; however, recent work has defined rich viral popu­ ponents, the assembly of particles and the lysis of host lations at many locations throughout the human body. cells, thus releasing progeny phages. Another mode of A high degree of inter-individual variation is seen in replication, carried out by temperate phages, can spare the human virome, paralleling findings from bacterial the host initially. Phages inject DNA into cells, after and fungal communities, raising questions of to what which the DNA can then become integrated into the host extent inter-individual differences in phenotypes are cell chromosome, forming a prophage. Prophages are attributable to differences in the virome (Table 1). maintained in a quiescent state by repressor proteins23. Recent studies have uncovered numerous factors that However, should conditions become unfavourable in show associations with virome structure in addition to the host cell — for example, by damage to DNA — phage anatomical location, such as diet, age and geographic DNA can become excised from the cellular chromosome location of the individual sampled. Disease is another leading to lytic growth, resulting in cell lysis and the Temperate phages Phages that are able to grow prominent influence, with emerging studies suggesting production of viral progeny. Phages can also have other via both lytic and lysogenic associations between virome structure and inflammatory relationships with their hosts — one is pseudolysogeny, replication pathways. bowel disease, diabetes, hypertension and cancer11–19. in which phage genomes persist as episomes without NAtuRe RevIews | MicRobiology volume 19 | August 2021 | 515 0123456789();: Reviews integration. In another mode, phages can bud out of sequencing studies have unveiled some new lineages of infected cells, sparing the host cell from lysis and death. human viruses that appear to be such commensals. For Viruses that infect human cells are also an impor­ example, the Anelloviridae are a family of non-enveloped, tant part of the human virome. Some may cause acute single-stranded DNA viruses with quite small circular infections, and others may establish long-term latency. genomes (2–4 kb), including torque teno virus, torque teno Some viruses engage in benign colonization and can­ mini virus and torque teno midi virus24–26. The genomes not be associated with any particular disease, appearing of viruses in this family encode what appears to be a single to be long-term ‘passengers’ or ‘commensals’. Virome large protein, although gene expression has not been Box 1 | Methods for studying the virome and the ‘dark matter’ Isolating virus-like particles (VLPs) from samples of interest is the first developing stand-alone virome-derived contig databases that can be step of a virome study. Focusing on VLPs avoids wasting resources on updated regularly, such as the Gut Virome Database (GVD)133, which sequencing of non-viral nucleic acids. Filtration is a typical first step to are useful for updating new discoveries and establishing standards for purify VLPs, taking advantage of the fact that viruses are smaller than annotating the dark matter. cells. Commonly used filter pore sizes include 0.2 μm and 0.45 μm. RNA viruses of the human virome have generally been less studied. RNA Filtering VLPs using 0.2-μm filters may lose large viruses158, whereas appears to be less stable in samples typically used for metagenomics, so 0.45-μm filters may fail to retain some bacteria, as rare bacteria are the RNA viruses may be undersampled for technical reasons. Many studies 32,000 species were predicted to be phages, which Vfam Database 182 is 12-fold higher than the phage number in the RefSeq database133. Sunbeam Analysis pipeline 183 Thus, metagenomic sequencing boosts the discovery of novel viral genomes enormously. The vast majority of these probable viruses have yet to be Cenote-Taker Analysis pipeline 184 grown in cell culture, classically a key step in establishing viral taxa, VirusSeeker Analysis pipeline 185 but today viral lineages are commonly specified as sequences before PHACT Phage life cycle classification 186 successful culture. As a consequence, for many members of the virome, it is not known what organisms serve as hosts for replication. The field is PHASTER Prophage prediction 187 516 | August 2021 | volume 19 www.nature.com/nrmicro 0123456789();:  Reviews Viral contigs well studied because representative Anelloviridae have Another recent study tracked the gut virome of 10 indi­ Contiguous sequences not yet been grown in pure culture. Anelloviridae are viduals and found that >90% of recognizable viral contigs assembled from overlapping extremely diverse and can be found in many human persisted in each individual over 1 year39. Studies on the sequence reads, which are then body sites in a large fraction of all humans examined. oral virome revealed similar stability40,41. As discussed annotated as whole or partial viral genomes. No specific pathogenic effects have been linked to below, destabilization of the virome is often associated Anelloviridae so far (reviewed in refs27,28). Greater with disease states. abundance of Anelloviridae has been found in indi­ viduals who are immunocompromised, including the Virome of different body sites recipients of lung transplants, individuals who are HIV Numerous recent studies have characterized the human positive and individuals on immuno­suppressive medi­ virome at different body sites, revealing rich populations cations owing to inflammatory bowel disease, indicat­ at numerous locations (Fig. 2). Phages are distributed ing that Anelloviridae are normally under host immune widely across the human body, and different anatomical control12,14,29–31. The newly discovered Redondoviridae sites may have quite different phage composition due to are another family of small circular DNA viruses that the presence of different host bacteria. The distribution appear to be widespread commensals commonly found of eukaryotic viruses also differs at different body sites. in the respiratory tract32–34. Some notable site-specific features are summarized below. High inter-individual variation in the human virome has been reported in many studies (reviewed Gastrointestinal tract. The gastrointestinal tract is com­ in refs9,10,35–38). However, within a healthy adult, the monly the most abundant site of viral colonization, virome is usually relatively stable over time, paralleling reaching ~109 VLPs per gram of intestinal contents. stability in the cellular microbiome. For example, one Analysis of virome sequence data suggests that phages study found that ~80% of viral contigs present persisted are the most abundant identifiable members of this over a span of 2.5 years in the gut of one individual6. population (reviewed in refs9,10,35–38). Visualization of Bacterial genome No replication or integration Pseudolysogeny Phage proteins Phage genome Induction Budding Lytic growth Lysogeny Fig. 1 | Phage replication cycles. Phages can engage in four types of interactions with their hosts. In lytic growth, phages infect cells, produce viral macromolecules, assemble new particles and lyse host cells, thereby liberating new viral particles. In lysogenic growth, phages inject their genomes into cells, and the genomes then become integrated into the bacterial cellular chromosome. The prophage is maintained in a quiescent state until detection of a suitable induction signal, after which the phage genome becomes excised and goes on to direct lytic growth. Pseudolysogeny is a loose interaction between the phage and the host in which the phage genome is present in the bacterial cell but not actively directing lytic growth156. Lastly, some phages such as the filamentous phages (Inoviridae) can infect cells and preserve the infected cell while producing new phage progeny by budding. NAtuRe RevIews | MicRobiology volume 19 | August 2021 | 517 0123456789();: Reviews Oral cavity Nervous system Eukaryotic viruses Phages Eukaryotic viruses Phages Blood Herpesviridae Siphoviridae Herpesviridae Siphoviridae Eukaryotic viruses Phages Redondoviridae Podoviridae Podoviridae Anelloviridae Siphoviridae Anelloviridae Myoviridae Myoviridae Herpesviridae Podoviridae Papillomaviridae ~104 VLPs per millilitre of cerebrospinal fluid Picornaviridae Myoviridae ~108 VLPs per millilitre of saliva Microviridae Inoviridae Lung ~108 VLPs per millilitre of saliva Eukaryotic viruses Phages Anelloviridae Siphoviridae Skin Redondoviridae Podoviridae Adenoviridae Myoviridae Eukaryotic viruses Phages Herpesviridae Microviridae Adenoviridae Siphoviridae Papillomaviridae Inoviridae Anelloviridae Podoviridae Circoviridae Myoviridae Herpesviridae Gastrointestinal tract Papillomaviridae Eukaryotic viruses Phages Polyomaviridae Anelloviridae Siphoviridae Adenoviridae Podoviridae Urinary system Caliciviridae Myoviridae Picornaviridae Microviridae Eukaryotic viruses Phages Herpesviridae Inoviridae Papillomaviridae Siphoviridae Circoviridae Polyomaviridae Podoviridae Virgaviridae Herpesviridae Myoviridae ~109 VLPs per gram of faeces ~107 VLPs per millilitre of urine Vagina Semen Eukaryotic viruses Phages Eukaryotic viruses Phages Anelloviridae Siphoviridae Anelloviridae Unknown Herpesviridae Podoviridae Papillomaviridae Myoviridae Herpesviridae Microviridae Fig. 2 | The human virome at different body sites. Summary of viruses found at each human body site. Viral types are summarized from published virome surveys2,9,10,29,32–38,40–48,53–74,76–78; those known at each body site are likely to increase as more human populations are surveyed and more viral types are discovered. In a few cases, viral lineages were excluded from the analysis because they likely represent contaminants or misattributions. These exclusions include mimivirus, phycodnavirus, marseillevirus, flaviviruses and poxviruses in blood, and baculovirus in the vagina. VLP, virus-like particle. stool VLPs using electron microscopy reveals that the The healthy human gut usually contains relatively majority of the phages belong to the order Caudovirales low pro­portions of eukaryotic viruses. DNA viral lin­ (tailed phages; reviewed in ref. 10). Metagenomic eages occa­s ionally detected include Anelloviridae, sequencing of the human gut virome also indicated that Geminiviridae, Herpesviridae, Nanoviridae, Papilloma­ Caudovirales is commonly predominant, along with the viridae, Parvoviridae, Polyomaviridae, Adenoviridae spherical Microviridae (reviewed in refs9,10,35–38). and Circoviridae (reviewed in ref.48). The most com­ It has been suggested that the most prevalent phage monly detected RNA viruses include Caliciviridae, lineage in the human gut is often crAssphage (cross- Picornaviridae, Reoviridae and some plant viruses that assembly phage; members of the Caudovirales), specifi­ appear to originate in food, such as Virgaviridae2,12,49,50. cally the short-tailed podoviruses, which infect bacteria A notable pattern in viruses of the gut is that most res­ of the phylum Bacteriodetes, common members of the idents, including both phages and human viruses, are not gut microbiota42–46. crAssphages are commonly found enveloped. This makes sense — lipid envelopes are in greater than 50% of human gut content samples unlikely to survive the detergent effects of bile salts, and show a global distribution42–44. The abundance of dehydration in the large intestine and the conditions of crAssphages can be up to 90% of a human gut viral the environment outside the gut required for transmis­ community42. Recently, the crAssphage ΦCrAss001 has sion via the faecal–oral route. A recent statistical analy­ been shown to infect Bacteroides intestinalis46, specify­ sis showed a significant association between faecal–oral ing one host species experimentally. Genomic analysis transmission and the absence of a lipid envelope51. It will shows that phage genes important for lysogeny are rare be of interest to investigate virus structure–­transmission or absent in crAssphage genomes45,46, and a lytic mode relationships in more detail and at additional human of replication has been suggested by infection studies body sites. in vitro46. However, curiously, proliferation of crAss­ Surprisingly, coronaviruses are an exception; despite phages does not appear to reduce the growth rate of their possessing a lipid envelope, many coronaviruses are host cells in vitro46. One explanation is that crAssphages known to be transmitted via the faecal–oral route51. replicate via pseudolysogeny, in which the phage genome For severe acute respiratory syndrome coronavirus 2 persists in a quiescent state as an episome (reviewed in (SARS-CoV-2), viral RNA has been widely reported in ref.47), only rarely lysing the host cell. faeces, although the infectious potential of these viruses 518 | August 2021 | volume 19 www.nature.com/nrmicro 0123456789();:  Reviews Multiple displacement is uncertain52. One possible explanation is that corona­ Blood. Viruses of blood have been studied closely, to amplification viruses such as SARS-CoV-2 can replicate in host cells understand human health and also to assess the safety A whole-genome amplification of the lower gastrointestinal tract, so they do not need of donor blood supplies. A pioneering study found method, which starts by to traverse the entire gastrointestinal tract in order to viral particles in blood using electron microscopy and binding random primers to the template DNA and appear in faeces; another possibility is that corona­virus identified genomic sequences related to several eukar­ is then followed by strand particles are relatively stable for enveloped viruses. yotic viruses, including Anelloviridae63. Other recent displacement DNA synthesis It will be useful to investigate these questions and clar­ studies have reported Herpesviridae, Marseilleviridae, performed by DNA ify the infectivity of coronaviruses in faecal material Mimiviridae, Phycodnaviridae and Picornaviridae fam­ polymerase, usually systematically. ilies, with proportions varying with the geographical Φ29 DNA polymerase. site sampled64,65. Some of these findings illustrate the Primary immunodeficiencies Oral cavity. The human oral cavity contains diverse challenges of virome studies, where samples with low A group of rare immune viral communities as well as complex microbial popu­ levels of authentic viruses may be prone to contamina­ disorders caused by genetic lations. To date, saliva samples have been the primary tion (Box 1). It is important to note that Marseilleviridae, defects. source of material to characterize the oral virome40,53, Mimiviridae and Phycodnaviridae are not known to rep­ revealing abundant viral populations. Additional oral licate in human cells, and may represent environmental microenvironments, such as dental plaque54, have also contamination. Phages belonging to the Myoviridae, been studied, revealing high diversity in these environ­ Siphoviridae, Podoviridae, Microviridae and Inoviridae ments as well. Staining of particles with a fluorescent families have also been reported in blood, and, similarly, dye that binds DNA, followed by visualization under their origin is unclear (reviewed in refs48,66,67). Some of a fluorescent microscope, shows approximately 108 these studies did not perform viral particle enrichment VLPs per millilitre of saliva in healthy humans55. The prior to sequencing, so that prophage sequences inte­ most abundant taxon of phages in the oral virome is grated in bacterial genomes (rather than viral particles) the Caudovirales40,41,56. may have been identified. A recent study reported that Common eukaryotic viruses in the oral cavity of phage particles may be transported across gut epithe­ healthy adults include Herpesviridae, Papillomaviridae, lial cell layers by transcytosis, potentially reaching sys­ Anelloviridae and Redondoviridae32,57. Anelloviridae are temic circulation, with unknown consequences68. Thus, the most common, but, surprisingly, the newly discov­ much remains to be learnt about the blood virome of ered Redondoviridae32 is the second most common virus healthy individuals; however, it does seem likely that at family. However, it should be noted that prevalence meas­ least Anelloviridae are common in blood and so must ures are expected to be dependent on the sampling meth­ be expected to be present throughout the blood supply. ods used, and the multiple displacement amplification steps typically used to amplify virome samples likely favour Skin. Compared with other body sites, the skin has a amplification of small DNA circles, potentially boosting relatively low microbial biomass, which can, for some detection of Anelloviridae and Redondoviridae. Reports samples, make it difficult to distinguish the resident so far put the prevalence of Redondoviridae at 2–15% microbiome and virome from various forms of contam­ in different populations32–34. As with Anelloviridae, ination. Metagenomic analysis of skin swabs revealed the whether Redondoviridae can cause disease is unknown. presence of multiple eukaryotic virus families including Preliminary studies show increased levels of redondo­ Polyomaviridae, Papillomaviridae and Circoviridae69. viruses in humans with periodontitis, patients who are In a recent DNA virome study with VLP enrichment70, critically ill in a medical intensive care unit and indi­ ~95% of the viral sequences did not match a known viduals with severe respiratory diseases32,33, although to viral genome and of the reads that could be assigned, date there is no evidence that redondoviruses are con­ many were associated with Caudovirales. This study also tributing to the disease states. Thus, both anelloviruses reported that the skin of healthy individuals harboured and redondoviruses appear to be common commensal eukaryotic viruses including Adenoviridae, Anelloviridae, viruses that might be undetected if not for developments Circoviridae, Herpesviridae, Papillomaviridae and in viral metagenomic sequencing methods. Polyomaviridae70. A notable expansion of these eukary­ otic viruses was observed on the skin of individuals with Respiratory tract. Virome analyses have been performed primary immunodeficiencies, indicating the importance of on respiratory tract samples including sputum, naso­ immune surveillance in controlling viral colonization pharyngeal swabs and bronchoalveolar lavage, showing of the skin71. that the healthy human lung and respiratory tract can be populated by large viral communities29,58–62. Among Urogenital system. Urine samples from healthy humans human DNA viruses, Anelloviridae has been reported to have been reported to contain viruses in the region of be the most prevalent family of DNA viruses, followed 107 VLPs per millilitre72. Most of the identifiable viruses by Redondoviridae32. Additional eukaryotic viruses fre­ were phages; in addition, human papillomaviruses could quently detected include Adenoviridae, Herpesviridae be identified in >90% of subjects in some cohorts72,73. and Papillomaviridae29,58–62. Phages are commonly found, Virome analyses of healthy vaginal samples showed that including Caudovirales, Microviridae and Inoviridae29,58–62. the majority of identified viral sequences are derived from Phages, like most of the cellular microbiota, even when double-stranded DNA phages, with eukaryotic viruses found in the lung appear to be derived mainly from the contributing only 4% of total reads74. In seminal fluid, abundant bacterial populations in the mouth and upper Anelloviridae, Herpesviridae and multiple genotypes of respiratory tract. Papillomaviridae have been detected75. Thus, for these NAtuRe RevIews | MicRobiology volume 19 | August 2021 | 519 0123456789();: Reviews Meconium body sites we again see mixtures of viruses that replicate rubella virus, human cytomegalovirus, herpes simplex The first stool of a neonate. in human cells and viruses from the resident microbiota. viruses, HIV, Zika virus and human papillomavirus (reviewed in refs89–92). However, these are characteristic Nervous system. Little information is available on virome of disease states and not health. Virome populations are populations in the nervous system in healthy humans. robust in adults, so the question is when does the virome A recent study estimated the VLP number at ~104 per become established in healthy neonates. millilitre of cerebrospinal fluid, with phages predominant, including Myoviridae, Siphoviridae and Podoviridae76. The virome at delivery. An early study of virome colo­ Herpesviridae were also detectable76. The clinical con­ nization sampled meconium shortly after delivery, and sequences of infection by herpesviruses in the nervous failed to find VLPs using epifluorescent microscopy but system have been well studied. Herpes simplex viruses, did report ~108 VLPs per gram at 1 week of life, sug­ human cytomegalovirus and varicella zoster virus can gesting that the neonate lacked a virome at birth but establish latent infections in the central nervous sys­ was quickly colonized93. In a study of amniotic fluid, tem without symptoms77,78; these viruses can later be no evidence was found for the existence of a virome in reactivated and produce viral particles78. healthy pregnancies before delivery86. A later study of To summarize the virome over multiple human neonate stool samples, investigating both RNA and DNA body sites, the human gut contains the most abundant viromes, taken a median of 2.6 days after birth found viruses and has been the most frequently studied. Lower high diversity in the gut virome, consistent with rapid particle numbers are found at other body sites, but all colonization after delivery50. Another metagenomic seem to have detectable viral colonization. For sites with study using stool samples collected a median of 37 h after a resident microbiota, the viruses found are typically a birth again showed high viral diversity, supporting rapid mixture of viruses replicating in the local human cells and virome acquisition94. A more recent study of VLPs sam­ viruses infecting the local microbiota. The extent of circu­ pled a median of 17 h after birth reported that only 15% lation between sites is just starting to be assessed. Upper of samples were positive49. Thus, the picture that emerges respiratory microbiota likely contribute much of the is that neonates usually lack a detectable virome at birth, microbiome and virome to lower respiratory sites, at least but are rapidly colonized after rupture of membranes for the phage population. Small circular DNA viruses and delivery (Fig. 3). (Anelloviridae and Redondoviridae) are common in res­ piratory samples and can also be found in faecal samples, The first detectable viruses — a predominance of phages. although it is not known whether they appear in the gut Several studies have investigated the nature of the human because of replication in the gastrointestinal tract or swal­ virome in samples taken very early in life. Recognizable lowing of saliva. Anelloviridae but not Redondoviridae early colonizers were mainly phages of the Siphoviridae, appear in blood, indicating systemic circulation. Even Podoviridae and Myoviridae families. Another phage sites that are mostly cut off from normal microbial colo­ family, the Microviridae, are less abundant during early nization, such as cerebrospinal fluid, show low levels of life but rise in abundance with age49,50. Early bacterial viruses including phages. How much of this colonization colonizers commonly include Escherichia, Klebsiella, is due to true local viral replication, how much is due Enterococcus, Staphylococcus and Streptococcus species95,96, to systemic circulation of viruses and how much is due to and the phages of these bacteria are some of the most technical mishaps associated with reagent contamination common early virome members. remains to be fully clarified. At all of these sites, unanno­ A recent study investigated the production of the tated ‘dark matter’ sequences are prominent, emphasizing virome in gut samples of infants at 1 month of life and how much remains to be learnt. concluded that lytic phages were relatively rare49. Ongoing replication of lytic phages could not be detected in direct Establishment of the human virome infection assays; viral sequences were annotated pri­ Timing of the first microbial colonization. The timing marily as lysogenic phages and not lytic phages; and of virome establishment is linked to the question of Microviridae and crAssphages, which usually do not form establishment of the microbiome as a whole in human lysogens, were rare or absent during the first month in neonates and infants. Historically, the inability to culture infant guts. Instead, prophage induction was found to microorganisms from samples from healthy deliveries contribute most of the gut virome. Bacterial strains were has supported the idea that neonates are usually born isolated from infants’ stools, and many were found to sterile. Starting in 2014, several studies using metagen­ produce viral particles at high levels. The viruses that omic sequencing were carried out, leading to the pro­ were produced could be detected as prophage sequences posal of a microbiome in the placenta, amniotic fluid in the bacterial genome sequences. Sequences of the and even the fetus, implying that microbial colonization induced phages were also commonly found in the infant may start in utero79–83. However, multiple recent studies stool virome, and the abundance of each type of VLP have indicated that these detections of microorganisms in stool was positively correlated with the abundance of are likely to be false positives due to experimental con­ the host bacteria in the same sample. tamination, and that no placental microbiome is pres­ These experiments suggested a high rate of phage ent before rupture of membranes and delivery84–88. This induction in the infant gut, raising the question of what raises the question of when viral colonization takes place constitutes the inducing signal. DNA damage is the in human neonates. Vertical transmission of pathogenic most studied signal (reviewed in ref.97). In vitro stud­ viruses during pregnancy has been well documented for ies suggested that spontaneous induction rates may be 520 | August 2021 | volume 19 www.nature.com/nrmicro 0123456789();:  Reviews Month 0 Pioneering bacteria Month 1 Month 4 Phage induction Viruses of human cells Formula Breast milk Immune cells Maternal antibodies Human milk oligosaccharides Lactoferrin Mucin Monocyte Macrophage Lymphocyte No report Rubella virus Dengue virus Norovirus Rotavirus Poxvirus VZV HSV Rotavirus Norovirus RSV Parechovirus Influenza virus SARS-CoV Measles virus Bordetella pertussis Influenza virus Fig. 3 | Stepwise assembly of the paediatric virome. Healthy neonates are typically born lacking a gut virome or microbiome. Pioneering bacteria colonize the gut of the neonate, such that infants have a detectable microbiome by month 1 of life. These bacteria commonly harbour integrated prophages, which occasionally induce prophages, providing a first wave of viral particles in the gut. Later, by month 4, more viruses that infect human cells can be detected. Infection with these viruses, some of which can be pathogenic, is inhibited by breastfeeding. Breastfeeding can also alter the types of phages present by altering the proportions of bacteria in the infant gut, which consequently alters the proportions of their phages. The protective effects of breast milk can be conferred by maternal immune cells or various macromolecules. These include maternal antibodies, human milk oligosaccharides, lactoferrin, mucin and gangliosides. The viral groups targeted by each antiviral factor in human breast milk are shown. Supporting references include refs49,111,113–121,157. HSV, herpes simplex viruses; RSV, respiratory syncytial virus; SARS-CoV; severe acute respiratory syndrome coronavirus; VZV, varicella zoster virus. relatively low98,99. Bacterial metabolites, nutrients and The effect of the delivery mode has been reproduced bile salts have all been shown to induce prophages in in some, but not all, cohorts in other studies49. Studies some models100,101. Thus, the signals (if there are any) linking the birth mode and long-term health outcomes are unclear and an interesting topic for future studies. reported greater risk for various diseases, including asthma, obesity and diabetes, in children delivered by Later evolution of the paediatric virome. The paediat­ caesarean section, although the results are controver­ ric virome continues to mature with age. Lytic phages sial and research is ongoing104–108. It may be useful to appear to become more common later in life. For exam­ consider possible influences of the virome as well. ple, the crAssphages are mostly absent in the first month of life but become more prominent by month 4 (ref.49). Colonization of infants with viruses infecting human The gut virome also often undergoes a shift from cells. The viruses that replicate in human cells are also Caudovirales-dominated to Microviridae-dominated12,50,102. detected in metagenomic surveys of samples taken in Another question is the possible influence of the early life. Gastroenteritis is one of the leading causes of mode of delivery. A metagenomic analysis of faecal childhood mortality, resulting in more than two million virome samples from 20 infants at 1 year of age com­ deaths every year109, and viral pathogens are primary pared spontaneous vaginal delivery with caesarean sec­ causes (reviewed in ref.110), highlighting the impor­ tion and found that the birth mode resulted in distinctly tance of paediatric virome studies. Viruses that have different viral communities, with infants born by spon­ been reported to be associated with childhood diarrhoea taneous vaginal delivery having greater viral diversity103. include rotavirus, astrovirus, calicivirus, picornavirus, NAtuRe RevIews | MicRobiology volume 19 | August 2021 | 521 0123456789();: Reviews polyomavirus and adenovirus (reviewed in ref.110). Less and SARS-CoV (reviewed in refs111,113–121). The phage well known is the fact that these viruses are commonly population structure in infant stool can also be influ­ found in healthy infant guts in metagenomic studies49,50. enced by breastfeeding — specific bacteria are known Other common viruses in healthy infant guts include to increase in abundance with breastfeeding, and in a parvovirus and anellovirus49,50. recent report their phages were increased in abundance Thus, recent data suggest that healthy infants are colo­ as well49. Alterations of the viral population in infant nized in a stepwise fashion. In the first step, prophage stool samples owing to breastfeeding has been pro­ induction from pioneering bacteria provides an initial posed in another study, although the small sample size population. Later, lytic phages become more common, was a limitation94. Furthermore, it has been suggested and also viruses that replicate in human cells. that the infant virome may, in fact, be at least partially transmitted from the mother via breast milk122,123. Factors that shape the human virome Diet has also been reported to affect the virome in Numerous factors have been reported to influence the adults. For example, comparison of the virome struc­ human virome and, ultimately, affect health (Fig. 4), ture in adult subjects on two different controlled diets starting in infancy and extending throughout the life of showed that individuals on the same diet showed more the individual. similar viral compositions than those on different diets6. Diet. The infant virome, including both phages and Host genetics and immunity. Intense interest has focused eukaryotic viruses, can be affected by diet. Breastfeeding on the potential influence of human genetics on the is well established to reduce viral gastroenteritis and microbiome, raising the linked question of the role of infant mortality (reviewed in refs111,112). A recent meta­ human genetics in programming the virome. Several genomic virome study showed lower accumulation of studies of twins, comparing monozygotic and dizygotic animal cell viruses in guts of infants fed with breast twin pairs, have suggested an influence of human genet­ milk49 (Fig. 3). The protective effect was seen in cohorts ics on microbiome composition because the monozygotic from both the United States and Botswana49. Viruses twins showed more similarity124–126. By contrast, a recent affected included Adenoviridae, Picornaviridae and large-scale study of healthy adults (non-twins) reported Caliciviridae. Breast milk contains multiple compo­ little effect of genetics and emphasized environmental nents that protect children from intestinal infections, factors127. In studies of the infant virome, the gut virome such as maternal antibodies, oligosaccharides and compositions of co-twins were more similar than those lactoferrin (reviewed in ref.111). These antiviral com­ between unrelated individuals50,94,102, but this similarity ponents have been reported to inhibit viruses, such was not strongly affected by zygosity94,102, emphasizing as rotavirus, norovirus, enterovirus, influenza virus the importance of the shared environment over human genetic composition. In an early study of adult twins, no greater similarity of virome samples was seen in twin pairs3. In a more recent study with a larger cohort of adult monozygotic twins, some were found to have greater sim­ Breastfeeding ilarity in virome composition compared with unrelated individuals, but in other co-twin pairs the microbiota and Diet Medication the virome had diverged to the degree that the twins were no longer notably similar128. Collectively, studies of the gut virome in twin pairs so far show similarities early in life, but not stronger similarities in monozygotic twins versus dizygotic twins, thus emphasizing the importance of shared environmental factors in colonization versus contributions of genetic make-up. Genetics Cohabitation However, in inherited diseases such as primary immuno­deficiencies, the effects of genetics on the virome are well established. In some cases, phenotypes of mutations in human genes can only be understood by considering the interaction with the virome. One drastic example involves epidermodysplasia verruciformis (also known as treeman syndrome, which is a rare heritable skin disease). In the presence of a mutation in TMC6 Ageing Geography (EVER1) or TMC8 (EVER2), skin papillomaviruses replicate aggressively and cause massive inappropriate Disease outgrowth of skin cells, resulting in treeman syndrome (reviewed in ref.129). Other primary immunodeficiencies may similarly allow specific viruses or microorganisms Fig. 4 | Factors that shape the human virome. Major factors include the diet6, breast milk to replicate unchecked, resulting in distinctive disorders. or formula feeding49,94, medications (including antibiotics and immunosuppressants)12,131, The effects of immunodeficiencies on the skin virome host genetics3,50,94,102,128,130, cohabitation53, geography49,65,131–134, presence of disease were mentioned above; also, virome studies of individ­ (Table 1) and ageing133. uals undergoing treatment for X-linked severe combined 522 | August 2021 | volume 19 www.nature.com/nrmicro 0123456789();:  Reviews immunodeficiency (SCID-X1) revealed distinctive out­ indicating another dimension of age-dependent pat­ growths of several viral lineages in the gut130. An inter­ terns133. Effects of ethnicity and medication were also esting question for future investigation is how much of found in a large Chinese cohort131. Cohabitation is also a the phenotypes of diverse human genetic diseases are a factor — in an early study, members of the same house­ result of altered interactions with the normal virome. hold shared more similarity in the oral virome com­ pared with those from different households53, suggesting Geography and stochastics of colonization. Large-scale transmission of the virome via close contact. virome studies have provided evidence that geographic Thus, nascent studies of factors affecting the virome location and stochastics of colonization have strong highlight diet, geography, age and health status as major impacts on human virome variation. A study of human correlates of virome structure. Genetics is less clear, at faecal samples from different regions within China least in studies so far of healthy twins. More studies of reported variation of the phage population structure large cohorts with linked comprehensive metadata will and found that geography had the strongest impact be helpful going forward. compared with other variables, including diet, ethnic­ ity and medication131. Geography has been associated The virome in health and disease with the eukaryotic virus populations as well. An early Virome populations can influence their human hosts in study found geographic variation in eukaryotic viromes numerous ways. Eukaryotic viruses that infect human in children with diarrhoea from two locations within cells establish infections, trigger immune responses and, Australia, with differential prevalence of Adenoviridae sometimes, cause diseases. Phages can affect the host and Picornaviridae132. A blood virome analysis of eukar­ indirectly via modulating of bacterial composition and yotic viruses in a Chinese population revealed a distinc­ bacterial fitness. Some phages and human cell viruses tive pattern for people living in the southern part of can be integrated into cells of their respective hosts, on China65. Moreover, one study of the infant virome found occasion transferring new functionality to host cells. a higher prevalence of viruses infecting human cells in Some phages may also interact with human cells directly cohorts of people of African descent than in cohorts and trigger immune responses (Fig. 5). Recent examples from the United States49. A recent study collected public of host–virome interactions in health and disease are metagenomic data sets and built a virome database with discussed below (for reviews, see refs135,136). >30,000 viral genomes, and found higher viral diversity in populations from non-western countries compared Interactions between bacteria, phage and their human with populations from western countries133. Similar hosts. Relatively little is known about the impact of results were reported in another study134. Thus, effects phage predation on human bacterial communities. of geography are quite prominent. A window on phage predation and host health is pro­ vided by phage therapy, in which phages are deliberately Additional factors. Additional factors have been tested applied to human individuals to treat bacterial infec­ and reported to influence the human virome. One study tions. As more drug-resistant bacteria are emerging, tested age using public data, and found that viral diversi­ there is increased interest in this approach (reviewed in ties in early life and in older individuals (>65 years of age) ref.137). Recently, several studies have used phage cock­ are lower than those in healthy adults (18–65 years of age), tails to treat bacterial infection in a few individuals, with apparent success (reviewed in ref.138) motivating larger Eukaryotic viruses clinical trials. Evidence that the phages are in fact creat­ Cause acute and chronic infections ing evolutionary pressure on pathogenic bacteria in these studies comes from the observation that bacteria often mutated to become resistant to the therapeutic phage. Protect the host from viral infections and Phages may even be useful to treat additional diseases. trigger the development of innate immunity For example, a phage cocktail targeting adherent invasive Escherichia coli strains has been suggested recently as a Phages treatment for Crohn’s disease139. Activate immune reponses via TLR signalling Phages can move DNA between cells and, thereby, introduce new functionality to bacterial genomes, which Host-associated may modify bacterial fitness and virulence (reviewed in Modulate bacterial bacteria ref.140). In a recent study using a mouse model, the stool abundance virome was analysed after antibiotic treatment, showing that there was an enrichment of phage-encoded genes Transfer DNA and for antibiotic resistance141, which increased resistance in modify bacterial the bacterial community. fitness and virulence Prophage induction can also lead to bacterial cell lysis, regulating bacterial abundance. A recent publica­ tion investigated diet-mediated prophage induction of Fig. 5 | Host–virome interactions. Eukaryotic viruses have both detrimental (red arrow) human-associated bacterial strains in vitro, revealing and beneficial (blue arrow) effects on host health. Phages interact with the host directly that several common food compounds can inhibit bac­ or indirectly via the host-associated bacterial community and pose undetermined effects terial growth by inducing prophages, including artificial (green arrow) on host health. Data based on refs68,137–144,149–151. TLR, Toll-like receptor. sweeteners142. NAtuRe RevIews | MicRobiology volume 19 | August 2021 | 523 0123456789();: Reviews Recent in vitro and animal studies indicated that infections through the induction of type III interferons phages may interact with the host immune system in the intestinal epithelial barrier150. Depletion of murine directly. Phages may be taken up by immune cells and gut viruses using an antiviral cocktail inhibited the devel­ trigger immune responses, without the mediation of opment of the intestinal intraepithelial lymphocytes, at bacteria, via Toll-like receptor (TLR) signalling. A recent least in part151. So far, all of these studies showing positive publication reported that phages produced by pathogenic effects were performed in model organisms — it will be bacteria can be taken up by immune cells (dendritic cells, of interest to determine how much beneficial immune B cells and monocytes) in mice to induce type I inter­ instruction may be directed by the virome in humans. feron responses via TLR3 signalling143. Another study Thus, both phages and eukaryotic viruses can pro­ showed that interferon-γ (IFNγ)-producing CD4 + mote host health through interactions with the host T cells and CD8+ T cells were increased in mucosal sites immune system. However, virome studies using human in germ-free mice fed an E. coli phage isolated from the cohorts suggest that dysbiosis of the virome is associ­ human gut144. Furthermore, this study also revealed ated with multiple diseases. These studies emphasize the that Lactobacillus, Escherichia and Bacteroides phages balance between beneficial and harmful roles of viral can stimulate the production of IL-12, IL-6, IL-10 and populations in humans and other organisms. IFNγ via the nucleotide-sensing receptor TLR9 (ref.144). Collectively, the interactions among phages, bacteria and Conclusions and perspectives the host immune system likely have important roles in The virome field has come a long way since the first host immune homeostasis. paper in 2002 that reported metagenomic sequencing of a viral specimen. The methods for study have advanced, Human disease-associated virome signatures. Studies although there are still many challenges associated with of interactions between the virome with human dis­ working with metagenomic dark matter. Human virome eases are just starting. Of course, numerous individual population diversity and composition is being docu­ viruses are well known to cause morbidity and mortality. mented for many body sites — one consistent conclusion Studies of whole viral populations have now also begun is that each individual harbours diverse and distinctive to show patterns associated with disease states. Some viral communities. Future studies are needed to clar­ recent examples are described below. ify the DNA and RNA viromes at different anatomical The virome has been considered to be a potential sites and to link the alterations of viral composition to trigger of autoimmune diseases. In one study, changes specific diseases. We now have a detailed picture of the in viral populations were both directly and inversely stepwise nature of the assembly of the human virome associated with the development of paediatric type 1 after birth. The impact of viral colonization during early diabetes16. Virome signatures have been associated with life on long-term health outcomes is still unknown and paediatric and adult inflammatory bowel disease in sev­ warrants careful study. Breastfeeding appears to have an eral studies11–15, including a reproducible expansion of important role during viral colonization; how the antivi­ Caudovirales and a reduction of Microviridae. Whether ral components in breast milk interact with the different this is a consequence of altered dysbiotic bacterial popu­ components of the virome warrants further investiga­ lations or is more deeply involved in the disease process tion. Emerging data indicate that factors that influence remains to be clarified. A metagenomic study showed the human microbiome also often influence the virome that children with frequent exposure to enterovirus as well, so that sorting out the influence of each will be between 1 and 2 years of age have a higher risk of coeliac a challenge going forward. Resident viruses are not only disease145. Recent studies revealed that the relationships actively interacting with other microorganisms but also between phages and bacterial populations may influence with the mammalian immune system. Many intriguing growth stunting in children146,147. Examples of proposed conclusions have so far only been obtained in animal associations between diseases and viral population studies or in vitro experiments, focusing attention on structure are listed in Table 1. translation to studies in humans. Associations between Studies using animal models have indicated that alterations of virome and disease states are being iden­ some eukaryotic viruses may even be beneficial to the tified more commonly, but in many cases causality and host (reviewed in refs135,148). For example, persistent molecular mechanisms remain to be worked out. The infection by a strain of murine norovirus can compen­ vast world of the human virome is beginning to be sate for the absence of bacteria in gnotobiotic mice, understood, laying the ground work for numerous future allowing restoration of intestinal morphology and pro­ studies of its importance. moting lymphocyte differentiation149. Murine astrovirus protected immunodeficient mice from enteric norovirus Published online 30 March 2021 1. Breitbart, M. et al. Metagenomic analyses of an 5. Minot, S., Wu, G. D., Lewis, J. D. & Bushman, F. D. 8. Breitbart, M. et al. Genomic analysis of uncultured uncultured viral community from human feces. Conservation of gene cassettes among diverse marine viral communities. Proc. Natl Acad. Sci. USA J. Bacteriol. 185, 6220–6223 (2003). viruses of the human gut. PLoS ONE 7, e42342 99, 14250–14255 (2002). 2. Zhang, T. et al. RNA viral community in human feces: (2012). 9. Aggarwala, V., Liang, G. & Bushman, F. D. Viral prevalence of a pathogenic viruses. PLoS Biol. 4, 6. Minot, S. et al. The human gut virome: inter-individual communities of the human gut: metagenomic 0108–0118 (2006). variation and dynamic response to diet. Genome Res. analysis of composition and dynamics. Mob. DNA 3. Reyes, A. et al. Viruses in the faecal microbiota of 21, 1616–1625 (2011). 8, 12 (2017). monozygotic twins and their mothers. Nature 466, 7. Minot, S., Grunberg, S., Wu, G. D., Lewis, J. D. & 10. Shkoporov, A. N. & Hill, C. Bacteriophages 334–338 (2010). Bushman, F. D. Hypervariable loci in the human gut of the human gut: the “known knknown” of the 4. Minot, S. et al. Rapid evolution of the human gut virome. virome. Proc. Natl Acad. Sci. USA 109, 3962–3966 microbiome. Cell Host Microbe 25, 195–209 Proc. Natl Acad. Sci. USA 110, 12450–12455 (2013). (2012). (2019). 524 | August 2021 | volume 19 www.nature.com/nrmicro 0123456789();:  Reviews 11. Fernandes, M. A. et al. Enteric virome and bacterial applied to phage populations in the human gut. 65. Liu, S. et al. Genomic analyses from non-invasive microbiota in children with ulcerative colitis and Crohn Nat. Rev. Microbiol. 10, 607–617 (2012). prenatal testing reveal genetic associations, patterns disease. J. Pediatr. Gastroenterol. Nutr. 68, 30–36 39. Shkoporov, A. N. et al. The human gut virome of viral infections, and Chinese population history. (2019). is highly diverse, stable, and individual specific. Cell 175, 347–359.e14 (2018). 12. Liang, G. et al. Dynamics of the stool virome Cell Host Microbe 26, 527–541.e5 (2019). 66. Castillo, D. J., Rifkin, R. F., Cowan, D. A. & Potgieter, M. in very early-onset inflammatory bowel disease. 40. Abeles, S. R. et al. Human oral viruses are personal, The healthy human blood microbiome: fact or fiction? J. Crohn’s Colitis 14, 1600–1610 (2020). persistent and gender-consistent. ISME J. 8, Front. Cell. Infect. Microbiol. 9, 148 (2019). 13. Clooney, A. G. et al. Whole-virome analysis sheds light 1753–1767 (2014). 67. Zárate, S., Taboada, B., Yocupicio-Monroy, M. on viral dark matter in inflammatory bowel disease. 41. Abeles, S. R., Ly, M., Santiago-Rodriguez, T. M. & & Arias, C. F. Human virome. Arch. Med. Res. 48, Cell Host Microbe 26, 764–778.e5 (2019). Pride, D. T. Effects of long term antibiotic therapy 701–716 (2017). 14. Norman, J. M. et al. Disease-specific alterations in on human oral and fecal viromes. PLoS ONE 10, 68. Nguyen, S. et al. Bacteriophage transcytosis provides the enteric virome in inflammatory bowel disease. e0134941 (2015). a mechanism to cross epithelial cell layers. mBio 8, Cell 160, 447–460 (2015). 42. Dutilh, B. E. et al. A highly abundant bacteriophage 1874–1891 (2017). 15. Zuo, T. et al. Gut mucosal virome alterations in discovered in the unknown sequences of human faecal 69. Foulongne, V. et al. Human skin microbiota: high ulcerative colitis. Gut 68, 1169–1179 (2019). metagenomes. Nat. Commun. 5, 1–11 (2014). diversity of DNA viruses identified on the human skin 16. Zhao, G. et al. Intestinal virome changes precede 43. Guerin, E. et al. Biology and taxonomy of crAss-like by high throughput sequencing. PLoS ONE 7, e38499 autoimmunity in type I diabetes-susceptible children. bacteriophages, the most abundant virus in the (2012). Proc. Natl Acad. Sci. USA 114, E6166–E6175 (2017). human gut. Cell Host Microbe 24, 653–664.e6 70. Hannigan, G. D. et al. The human skin double-stranded 17. Kim, K. W. et al. Distinct gut virome profile of pregnant (2018). DNA virome: topographical and temporal diversity, women with type 1 diabetes in the ENDIA study. 44. Edwards, R. A. et al. Global phylogeography and genetic enrichment, and dynamic associations with Open Forum Infect. Dis. 6, ofz025 (2019). ancient evolution of the widespread human gut virus the host microbiome. mBio 6, e01578-15 (2015). 18. Han, M., Yang, P., Zhong, C. & Ning, K. The human crAssphage. Nat. Microbiol. 4, 1727–1736 (2019). 71. Tirosh, O. et al. Expanded skin virome in DOCK8- gut virome in hypertension. Front. Microbiol. 9, 3150 45. Yutin, N. et al. Discovery of an expansive bacteriophage deficient patients. Nat. Med. 24, 1815–1821 (2018). (2018). family that includes the most abundant viruses from 72. Santiago-Rodriguez, T. M., Ly, M., Bonilla, N. 19. Nakatsu, G. et al. Alterations in enteric virome are the human gut. Nat. Microbiol. 3, 38–46 (2018). & Pride, D. T. The human urine virome in association associated with colorectal cancer and survival 46. Shkoporov, A. N. et al. ΦCrAss001 represents the with urinary tract infections. Front. Microbiol. 6, 14 outcomes. Gastroenterology 155, 529–541.e5 most abundant bacteriophage family in the human (2015). (2018). gut and infects Bacteroides intestinalis. Nat. Commun. 73. Garretto, A., Miller-Ensminger, T., Wolfe, A. J. & 20. Sender, R., Fuchs, S. & Milo, R. Revised estimates 9, 1–8 (2018). Putonti, C. Bacteriophages of the lower urinary tract. for the number of human and bacteria cells in the 47. Sutton, T. D. S. & Hill, C. Gut bacteriophage: current Nat. Rev. Urol. 16, 422–432 (2019). body. PLoS Biol. 14, 1–14 (2016). understanding and challenges. Front. Endocrinol. 10, 74. Jakobsen, R. R. et al. Characterization of the vaginal 21. Kieft, T. L. & Simmons, K. A. Allometry of animal– 784 (2019). DNA virome in health and dysbiosis. Viruses 12, 1143 microbe interactions and global census of animal- 48. Rascovan, N., Duraisamy, R. & Desnues, C. (2020). associated microbes. Proc. Royal. Soc. B. 282, Metagenomics and the human virome in asymptomatic 75. Li, Y. et al. Semen virome of men with HIV on or 20150702 (2015). individuals. Annu. Rev. Microbiol. 70, 125–141 (2016). off antiretroviral treatment. AIDS 34, 827–832 22. Sherrill-Mix, S. et al. Allometry and ecology of the 49. Liang, G. et al. The stepwise assembly of the neonatal (2020). bilaterian gut microbiome. mBio 9, e00319-18 virome is modulated by breastfeeding. Nature 581, 76. Ghose, C. et al. The virome of cerebrospinal fluid: (2018). 470–474 (2020). viruses where we once thought there were none. 23. Jacob, F., Sussman, R. & Monod, J. On the nature 50. Lim, E. S. et al. Early life dynamics of the human gut Front. Microbiol. 10, 2061 (2019). of the repressor ensuring the immunity of lysogenic virome and bacterial microbiome in infants. Nat. Med. 77. Meyding Lamade, U. & Strank, C. Herpesvirus bacteria [French]. C. R. Acad. Sci. 254, 4214–4216 21, 1228–1234 (2015). infections of the central nervous system in (1962). 51. Bushman, F. D., McCormick, K. & Sherrill-Mix, S. immunocompromised patients. Ther. Adv. Neurol. 24. Nishizawa, T. et al. A novel DNA virus (TTV) associated Virus structures constrain transmission modes. Disord. 5, 279–296 (2012). with elevated transaminase levels in posttransfusion Nat. Microbiol. 4, 1778–1780 (2019). 78. McGavern, D. B. & Kang, S. S. Illuminating viral hepatitis of unknown etiology. Biochem. Biophys. 52. Zapor, M. Persistent detection and infectious infections in the nervous system. Nat. Rev. Immunol. Res. Commun. 241, 92–97 (1997). potential of SARS-CoV-2 virus in clinical specimens 11, 318–329 (2011). 25. Takahashi, K., Iwasa, Y., Hijikata, M. & Mishiro, S. from COVID-19 patients. Viruses 12, 1384 (2020). 79. Aagaard, K. et al. The placenta harbors a unique Identification of