Memorandum by Alan M Edwards (AL 42)
I am a Clinical Assistant at the David Hide
Asthma and Allergy Research Centre based at the St Mary's Hospital
NHS Trust, Newport Isle of Wight. I am responding to a letter
sent to Dr SH Arshad, Medical Director of the Centre. Dr Arshad
left the Centre in December 2003 to take up a post as Senior Lecturer
at a new medical school in Stoke on Trent. The Centre is currently
seeking to appoint a new Medical Director.
The David Hide Centre was established in the
1980s to undertake research into allergy and allergic disease.
One of the research projects undertaken, the investigation of
the effect of dietary artificial colours and preservatives on
childhood behaviour (Attention Deficit and Hyperactivity Disorder),
did hit the national press, television and radio last week after
its publication. The Centre is a private trust but is located
in the confines of St Mary's Hospital and in addition to research
also provides a NHS allergy service to the island. The staffs
are employed as either NHS personnel, joint NHS/Research or Research
only.
I joined the Centre in April 2001. Previously
my main career had been in the clinical development of drug treatment
for allergic disease in the pharmaceutical industry but I have
worked as a clinical assistant in two other allergy clinics, at
Leicester General Hospital, Leicester in the 1970s and 1980s and
in the Royal South Hants Hospital, Southampton from 1995 to 2001.
I was also a member of a working party set up by the British Allergy
Society to examine allergic disease in the 1990s.
The population of the Isle of Wight is 137,000
but does increase in the summer months with visitors. The Centre
provides up to eight allergy clinics/week covering both adults
and children and just about manages to keep the appointment waiting
times down to less than six months. One factor in this is the
large increase in allergy and allergic disease amongst the population.
The prevalence of three manifestations of allergy, asthma, allergic
rhinitis and eczema has been compared in two birth cohorts, one
being the 1,536 newborns born on the island between January 1989
and April 1990 with the 969 newborns born between September 2001
and August 2002 (Pereira BN et al. EAACI presentation 2003).
The cumulative prevalence of reported asthma amongst parents and
siblings of these newborn infants increased from 8.64% to 21.58%,
that of allergic rhinitis from 15.54% to 25.03% and that of eczema
from 12.55% to 24.04%.
Allergic disease is a consequence of the reaction
between the individual genetically predisposed to become sensitised,
and substances (allergens) in the surrounding environment. These
substances can be airborne, as exemplified by house dust mites,
plant pollens and animal material or swallowed as foods and drinks
or act as contact allergens such as soap powders. Sensitisation
and exposure to airborne allergens results in asthma, allergic
rhinitis, and allergic conjunctivitis and allergic eczema and
to contact allergens as contact dermatitis. Exposure to food allergens
can result in a range of clinical manifestations some of which
are controversial but anaphylaxis, urticaria and angioedema, allergic
eczema, allergic asthma, allergic rhinitis, irritable bowel syndrome,
behaviour disorders (ADHD) in children and cow's milk allergy
in infancy are all conditions that are recognised being caused
by food allergens in certain cases. Certainly these are all conditions
that are referred to allergy clinics for investigation.
The staff required to provide allergy services
need to be a team of medical personnel covering a range of disciplines
and skills. The doctors need to be able to deal with both adults
and children and to have a working knowledge of respiratory disease,
ENT disease, ophthalmology, dermatology, gastroenterology, behaviour
disorders in childhood as well as basic immunology and resuscitation
techniques to allow the use of immunotherapy. There is a need
for specialist nurses skilled in the administration of inhaled
drugs, in the use of topical treatments for skin diseases, and
able to carry out lung function tests, allergy skin prick tests
and allergy patch tests, to advise on methods of reducing exposure
to allergens and also able to administer immunotherapy injections.
There is a need for specialist dieticians with knowledge of allergy
and immunology who are able to use elimination and reintroduction
diets and challenge tests in the investigation of food allergy
and intolerance. Finally the allergy unit placed within a general
hospital so that access to specialists in the clinical disciplines
is available for referral for the diagnosis and treatment of those
patients who are not suffering from allergies.
We are very fortunate at the David Hide Centre
in that due to the foresight of its founder, Dr David Hide, (sadly
deceased), all of the medical, nursing and dietetic skills are
available. The referred patient is able to see at a single visit,
the doctor to make the diagnosis, the specialist nurse to carry
out the necessary allergy tests and to advise on allergen exclusion,
on the correct use of inhaled drugs and the use of topical skin
preparations including wet-wrapping. They are also able to see
a specialist dietician who will start the process of elimination
and challenge for food allergy and intolerance and advise on the
details of exclusion diets. In addition we can carry out immunotherapy
treatments and conduct single blind or double blind challenges
for food allergy. For children these may need to be carried out
in the children's ward in the hospital, to which we also have
access. All this is against a very active background of allergy
research.
I suspect that the allergy service provided
at this centre is unique. Certainly at other allergy clinics at
which I have worked where access to specialist nurses and dieticians
was not always available, the service provided was less than adequate.
Allergic disease is not always regarded as a
disease that requires specialist investigation and treatment.
It is mostly not life threatening apart from the increasing problem
with anaphylaxis to peanuts which can and has resulted in the
death of teenagers. However the chronicity of allergic diseases,
particularly eczema and asthma in both adults and children can
cause a great deal of distress. There is also an increasing problem
of ADHD in young children causing distress at home and at school.
All of these conditions deserve adequate investigation and treatment
by specialist teams.
As an example of why a specialist and team approach
is necessary; I have recently had referred two healthy young men,
aged 15 and 16 who wish to join the armed services as a career.
They were diagnosed as having peanut allergy as infants or children.
This has been successfully managed by avoiding eating peanuts.
It is apparently now a rule that the armed services will not accept
anyone with peanut allergy. Why? We are having to carry out skin
tests and blood tests to confirm and evaluate the allergy. The
nurses and dietician will then perform peanut challenges (with
physician backup) under controlled conditions to see how great
a risk still exists. It would be sad if these young men are denied
a chosen career on the basis of a theoretical risk. However it
is going to require the skills and knowledge of a specialist team
to evaluate the nature of this risk.
Finally I must make it clear that the views
expressed in this memorandum are my own personal ones and may
not reflect the views of my colleagues at the David Hide Centre,
nor the Trustees of the centre nor the staff and management of
St Mary's Hospital NHS Trust.
June 2004
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