APPENDIX 5: VISIT TO THE MRC-ASTHMA
UK CENTRE IN ALLERGIC MECHANISMS OF ASTHMA, EVELINA CHILDREN'S
HOSPITAL
13 December 2006
Members visiting the hospital were: Lord Colwyn,
Baroness Finlay of Llandaff (Chairman), Lord May of Oxford, Lord
Rea, Earl of Selborne, Viscount Simon, Lord Taverne. In attendance:
Dr Christopher Johnson (Clerk), Miss Sarah Jones (Clerk), Professor
A. B. Kay (Specialist Adviser), Dr Cathleen Schulte (Committee
Specialist).
The Committee was welcomed to the hospital by Dr
Edward Baker (Joint Director of Clinical Leadership and Medical
Director, Guy's and St Thomas' NHS Foundation Trust), Professor
Richard Trainor (Principal, King's College London), Professor
Robert Lechler (Vice-Principal (Health), King's College London),
Professor Gideon Lack (Head of Paediatric Allergy) and Professor
Tak Lee (Director of the MRC-Asthma UK Centre). Parts of the hospital
had been designed by children, who had named the floors and wards,
and played a part in the design of the furniture.
Presentations
Professor Trainor and Professor Lechler provided
an overview of King's College London and how the Centre sat within
the Health schools of the College. King's College London had more
MRC centres than any other institution and placed great importance
on asthma and allergy, hence its decision to partake in the development
of the MRC-Asthma UK Centre for research. With regard to asthma
and allergy, the most important area of research was translational
work, which developed laboratory findings into practical treatments.
Professor Lee summarised the activities of the Centre
which was a collaboration between the MRC, Asthma UK, King's College
London, Imperial College London, and the NHS. The NHS provided
a vital infrastructure and access to patients through the Guy's
and St Thomas' NHS Foundation Trust, King's College Hospital Trust,
Royal Brompton Hospital Trust and St Mary's Hospital Trust. This
was the only centre of its kind in the country. Previously, research
into allergic disorders had been fragmented between different
units, but the development of the MRC-Asthma UK Centre meant that
all the organisations had been able to combine their research
strengths into one cohesive strategy for the first time. The centre
employed 21 senior scientists of whom 11 were clinicians, and
worked in partnership with a network of general practices in the
East of London. Its mission was to make discoveries to inform
new treatments and preventative strategies, and the priorities
for research were informed by national consultations on asthma
research convened by Asthma UK.
In addition, the Centre provided an environment for
research training and had been awarded 10 PhD studentships by
the MRC and Asthma UK. The Centre also supported NHS trainee allergists
in partner hospital trusts by providing research experience. But
although the centre was able to help train new allergy specialists,
there were very few jobs within the NHS for them to take up.
Professor Lack explained that collaboration between
clinicians and researchers was vital for translational research
as it enabled clinical trials to be carried out in children, and
allowed the fast tracking of discoveries into clinical practice.
The Children's Allergy Service at the hospital was extremely valuable
as it could see 3,000 outpatients a year, and around 500 day-cases.
The hospital employed three paediatric allergy consultants, three
paediatric allergy nurses and a paediatric dietician. King's College
London employed an additional nine clinical research staff, scientists,
and administrative staff who worked side by side with the clinical
team. Allergic disorders often crossed the boundaries of specialist
consultants. Therefore the hospital arranged weekly multi-disciplinary
meetings involving nurses, consultants and dieticians, and the
paediatric allergy service held joint allergy clinics with other
paediatric services (such as gastroenterology, every two weeks)
and with adult allergy services. This integration of services
was important as it enabled research into the way in which lifestyle
modifications in childhood could reduce the risk of allergy in
later life.
Discussion focussed on the following points:
- There were various types of asthma
which needed to be treated in different ways. Although steroids
were a common treatment for most types of asthma, "steroid
resistant asthma" was resistant to this treatment. Current
knowledge of this topic was limited, so further research was needed
to develop an understanding of the various phenotypes, and to
establish which patients responded to which treatments.
- When the hospital had first opened, the majority
of patients had been referred from local GPs. Over time there
had been an increase in the number of tertiary referrals, and
the number of referrals from outside London. There had also been
an increase in the number of referrals from departments such as
dermatology, gastroenterology, and ENT, which demonstrated the
unmet need for allergy services. The number of complex allergy
cases, where children were allergic to multiple allergens and
suffered from multiple allergic disorders, had also increased.
- The capacity for allergy treatment needed to
be increased. There was no framework for allergy treatment within
the NHS, so the disease burden was not fully known. When allergy
specialists completed their training there was a lack of jobs
in the NHS for them to enter, and the relative paucity of allergists
in the United Kingdom meant that there were few people who could
adequately train specialists and GPs. It was felt that PCTs did
not have the money or resources to solve this problem, and as
the full disease burden of allergic disorders was still unknown,
PCTs would not be able to judge the services needed.
- Allergy was not coded as a single disease for
research purposes; the majority of funding was provided for asthma
research. Allergy funding in general was focussed on projects
examining the mechanisms of allergic diseases and, while this
was essential, it was felt that additional funding should be allocated
for research into clinical treatments. There was also a need to
research allergy prevention and to establish reliable advice for
the public on issues such as peanut allergy prevention.
- It was felt that research into allergic diseases
was justified because most of the conclusions did not recommend
difficult, expensive solutions which would be unobtainable. Instead,
the findings of allergy research usually recommended changes in
lifestyle behaviours such as diet, smoking or pet ownership, which
members of the public could easily and quickly respond to.
- There was not enough data on the costs of allergy
treatment. This needed to be addressed even though some aspects
would be hard to measure. For example, a course of immunotherapy
was very expensive and had to be administered by a specialist,
but the effects were long-term and so could reduce the need for
future treatments. Therefore immunotherapy could potentially save
the NHS money in the long-term.
Tour of the hospital
The Committee visited the "Snowy Owl" unit,
a clinical trials unit dedicated to the prevention and treatment
of asthma and other allergic disorders in childhood. The unit
had the capacity to evaluate 30 participants enrolled in clinical
trials every week. The Committee talked to a young boy who was
extremely allergic to egg. Because of the risk of anaphylaxis,
this boy and many others received routine vaccinations in the
controlled environment of the clinical trials unit, so that any
reactions could be dealt with immediately.
Dr George Du Toit (Consultant) and Professor Lack
briefed the Committee on recent research into food allergies.
Cross-sectional epidemiological studies in countries such as Israel,
had demonstrated that early peanut consumption during childhood
was associated with a low rate of peanut allergy in the population.
Professor Lack and his research team were testing these cross-sectional
findings in the LEAP study, which intended to enrol 480 infants
who suffered from either egg allergy and/or eczema who were aged
4-11 months. Half the participants would receive a diet which
regularly contained peanut protein, whilst the other half would
avoid peanut. The study intended to monitor these children until
the age of five, to assess whether peanut consumption or avoidance
caused an increased risk of developing peanut allergy. If the
results showed that introduction of peanut at an early age helped
to protect against allergy, then current DH advice which recommended
peanut avoidance for infants, might actually have been contributing
to the increase in peanut allergy prevalence.
Dr Adam Fox (Consultant), Dr Susan Chan (Consultant),
Ms Patricia Kane (Asthma nurse), Ms Judith Searle (Asthma nurse)
and Ms Hasita Prinja (Paediatric dietician) welcomed the Committee
to the outpatient unit. It was vital that children received regular
allergy testing because some allergies could be outgrown, rendering
allergen avoidance unnecessary. For a diagnosis to be reliable,
the results of allergy tests had to be analysed in the context
of the patient's history.
Finally, the Committee met a seven year old hayfever
sufferer who had been referred to the hospital by a paediatrician
in Oxford. The boy suffered so acutely from sore eyes and itchy
throat that he could not even play outside at school. Skin prick
tests were carried out to establish which allergens caused a reaction,
and it was suggested that the boy might receive sublingual immunotherapy
in the future. This was a convenient treatment which would not
require the patient to attend hospital, would reduce his reaction
to the specified allergen, and could also possibly prevent the
development of other allergic conditions.
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