Examination of Witnesses (Questions 300-317)
Professor Anthony Newman Taylor, Mr Rob Miguel, Professor
Raymond Agius and Dr David Orton
10 JANUARY 2007
Q300 Lord May of Oxford: I had occasion
recently in a different context to meet with the British Paediatric
Surveillance Unit and, first of all, many of the cases of allergy,
and particularly in our visit to St Thomas', are among younger
people. The British Paediatric Surveillance Unit has the responsibility,
as I understand it, for collecting data on things that are not
very prevalent. I did really wonder a bit about the sensibleness
of the conjunction of that constraint with the need for really
good data on the incidence among very young children. Do you have
a comment on that?
Professor Agius:
My Lord Chairman, our remit extends to people in employment who
either present themselves to their GPs, specialists or occupational
physicians.
Q301 Lord May of Oxford: Yes, but
setting that aside, do you feel that the question of getting good
statistics on really young people is handled well, because after
all you are one of the experts on these databases?
Professor Agius:
We have put forward proposals for research that would involve
studying cohorts of young people and some work has been done on
that but perhaps not enough. There are, for example, asthma cohorts
already in existence, some of which my colleague, Professor Newman
Taylor, is involved with. If there were to be funding to permit
those to be followed up prospectively they might give us some
answer to your question. As to rare conditions, specifically we
encourage our doctors to report things which are rare even if
they come outside the sampling frame. If I may explain, my Lord
Chairman, so as not to tire our doctors out too much we sometimes
target them at specific times of the year at which at random we
ask them to report and we encourage them to report rare things
at other times as well. In conjunction with the research which
I have already described, we also have got research trying to
relate rare causes of asthma, and indeed of dermatitis, to chemical
structures and so on to try and develop a strategy to be able
to identify early novel causes of occupational asthma and occupational
dermatitis.
Q302 Lord May of Oxford: Finally,
here is a chance for you to lay down a marker, but I am curious
how long the project you have in hand is going to continue, where
the future funding is going to come from and, more generally,
how you feel about the funding for this kind of vital factual
underpinning of what we are talking about?
Professor Agius:
The HSE funding for data collection from the specialist schemes
ended when data collection finished at the end of last month,
we are now carrying the schemes partly through reserves of funds
and partly through charitable support. The HSE provided us with
a commitment in principle 10 months ago to fund specialist schemes
for a further five years, but they tell us that they are under
severe financial constraints and so far that commitment has not
been made good into a contract, which we seriously need because
we have good staff leaving. In so far as the GP schemes, these
are funded for data collection into November of next year. Funding
in occupational allergic disease, as in all occupational disease,
I think is very much a Cinderella issue. It does not engage the
same sort of high profile as funding for other causes of ill-health.
A lot of the funding, these days, what little there is, comes
from charities like the Colt Foundation and so on. Funding from
government is tiny and we are told by the HSE that it is now severely
constrained compared with what it was before.
Q303 Earl of Selborne: I will follow
up that point because it is clear that RIDDOR was never providing
the information which was accurate it was under-reporting of ill-health,
according to what Professor Agius has told us, and Health and
Safety required RIDDOR, to provide itself with the information
on ill-health caused through allergic diseases, yet you have not
apparently expected the Health and Safety Executive to replace
RIDDOR by funding the Manchester University schemes. Would you
like to comment on that?
Professor Agius:
We are hopeful and optimistic that we will be able to persuade
the HSE to make tangible its in-principle commitment to extend
the funding of these schemes for a further five years. So far
that has not happened but we are hopeful that it will. We appreciate
that they are under severe financial constraints. Having said
that, we do feel that, as an area which contributes a great deal
to the health burden of the nation, not just occupational allergic
disease but occupational diseases in general, it is grossly underfunded
and tends to fall between various stools.
Q304 Lord Soulsby of Swaffham Prior:
The written evidence that we received from the Government is that
there is no simple test for objectively confirming cases of work-related
allergic disease. Do you think that the introduction of standard
criteria for diagnosis for accepting an occupational origin would
be useful in measuring the incidence of these diseases and what
should be the criteria?
Professor Newman Taylor:
I will restrict my comments to asthma. In fact, there are methods
which are available which can be applied that provide confidence
in the diagnosis of occupational asthma. One can ask those in
whom it is suspected to make regular measurements of their peak
flow, which is the maximum flow of air which can be achieved at
the mouth, at regular intervals over several days when they are
at work and away from work and compare the two. In many of the
cases you can see a real difference between the two as the asthma
occurs, becomes increasingly severe at work and improves away
from work. It can be that you need a period of more than a two-day
weekend to see sufficient improvement, but it is certainly a useful
diagnostic tool. In those cases where there is evidence for an
immunological response, then one can identify that in terms of
skin tests or specific Ig antibody in the blood. In the final
analysis, if it is really important to know what is the cause
of asthma in an individual case, it is possible to do inhalation
tests, but inhalation tests are potentially hazardous and, therefore,
need to be undertaken in careful conditions in specialist centres,
which is the situation now. The answer is that while there is
no single simple test which says yes or no, there is a number
of investigations which can lead one to being confident as to
whether it is present or not. I think that if one were to introduce
standardised criteria in relation to each of those, that could
only be helpful. With comparable diagnostic criteria it allows
comparisons of disease rates at different times and different
places. Whether that will enable one to better know what the incidence
of the disease is I think is a different question, because that
is a matter of recognition and attribution of the asthma to a
specific agent and then of reporting that, which is something
we have been discussing. I can see potential benefits; I would
question whether it will improve knowledge of the incidence of
the disease though.
Dr Orton: From the
dermatitis perspective, I would have concerns and difficulties
in making these criteria because the assessment of dermatitis,
as I have alluded to before, is extremely complex with constitutional
genetic factors, irritancy as well as allergy. Although we have
a standardised test to identify if somebody is allergic to a chemical
substance, those substances are not only found at work, but they
are also found in people's domestic environments and it is a very
confused area and needs teasing out. Often, certainly in medico-legal
cases, it is down to a degree of subjective interpretation and
one's own experience.
Q305 Lord Soulsby of Swaffham Prior:
Basically you are both saying that we are not at the present stage
of utilising the standard tests for evaluation.
Professor Newman Taylor:
I think there is a number of tests which are utilised in the diagnosis
of asthma and that one can use standardised criteria for deciding
whether or not they are likely to be positive or negative, but
there is clearly an important element of individual judgment in
relation to the results of those investigations which leads you
to determining whether or not it is likely to be due to the particular
occupational agent.
Dr Orton: For skin,
I would say that those tests are less conclusive.
Mr Miguel: All the
tests are non-conclusive and I think it is very important to remember
that any poorly-validated criteria should not exclude anyone from
employment and a past history of occupational asthma, asthma or
dermatitis should not exclude people. I think it is a question
of running an array of tests. The immunological tests are 50-50,
as I understand. This has to be backed up probably by a questionnaire
which is a good way of finding out and health practitioners need
to ask the right questions. When they see these people, they need
to be aware of sensitisers in the workplace, the type of work
that person is doing and what materials they are using. The list
of sensitisers used by the DSS is very limited and there is a
further extensive list of sensitisers and health practitioners
need to be aware of those.
Q306 Baroness Platt of Writtle: Is
the prevalence of latex allergy now under control or are there
any other outstanding issues in this field that need to be addressed?
Is there a danger for people who work in supermarkets and shops
that latex-containing packaging may produce or exacerbate contact
dermatitis?
Dr Orton: In my own
experience and from looking at the evidence, certainly amongst
healthcare workers you can see that the level of problems related
to immediate allergic responses to latex have now plateaued out.
My other colleagues might be in a better position with regard
to the reporting mechanisms to confirm that. With regard to whether
there are any outstanding issues, I would like to bring something
to the fore. Often either for healthcare workers or patients who
are sensitised to latex, hospitals and dental practices constitute
very important sources of exposure and a danger for those individuals.
Currently the procurement of latex-free equipment for hospitals
and dental practices is undertaken on an individual basis amongst
individual trusts and this is both time-consuming and a difficult
process to obtain the necessary information from manufacturers.
I think it would be extremely helpful to have some form of centralisation
for this so that individual trusts are not duplicating the work
involved and that it becomes an overall easier process. With regard
to the question of supermarkets, the wearing of latex gloves and
dangers to the public, I think certainly people are trying to
move away from wearing latex gloves altogether in supermarkets
and the healthcare setting to try and prevent problems. In terms
of the dangers for consumers from shop workers wearing latex gloves,
there is very little danger of people developing sensitisation
to the rubber chemicals that are added to the gloves, which are
often responsible for the delayed allergic response producing
dermatitis. There have been case reports of residual proteins
within gloves that are thought to have become transferred onto
foods causing the immediate type of allergic response in consumers
and even from seals around foods. However, I think that those
are a minority of cases and it would involve individuals who are
extremely sensitive to the latex proteins.
Q307 Baroness Platt of Writtle: What
about packaging?
Dr Orton: These recent
case reports in the literature. Well, I think that one has to
be aware of it and always think about that in one's assessment
of a patient, but I am not aware that it is a major problem and
it probably would affect a minority of individuals.
Q308 Lord Colwyn: I wonder if I can
make an observation on that. Having worked as a dentist for about
40 years, I suppose I wore gloves for the last 10 or 15 years
of my practising life and had terrible problems when I first had
to wear these gloves. I thought I had latex allergy, but in fact
it turned out to be the fact that I was wearing rubber on my hands
for eight or nine hours a day and the hands sweat. I think it
was something to do with that rather than dermatitis, and I do
not know how you tell the difference.
Dr Orton: Glove reactions
are extremely common and just the occlusive effects of wearing
the gloves, whatever the material, are probably the commonest
cause of a reaction to a glove. Also one has to identify if there
is an allergic component, if it is the immediate allergic response,
for example to the latex proteins, or a delayed allergic response
to the rubber chemicals that they add to the latex, which are
usually the ones that give rise to the dermatitis developing,
or a combination of both. That involves investigating people further.
Q309 Lord Taverne: You have told
us something about the funding, or the lack of funding, for the
collection of data. What about the funding for research in general?
Who currently funds the majority of research into occupational
allergic diseases in the United Kingdom and—I am sure the
answer will be "There is not enough of it"—is
there any particular section which is particularly under-funded?
Professor Agius:
My Lord Chairman, within occupational disease I would not say
there is a section which is particularly under-funded because
there is serious under-funding across the board. At the moment,
the situation is worse than it has been for some time because
at least in the past there was a mechanism whereby one could apply
for money from the Health and Safety Executive whereas now that
does not exist at all. There are some charities, like the Colt
Foundation and the British Occupational Health Research Foundation,
which will support research in this area, but otherwise if one
has a project which is of some interest perhaps to the Medical
Research Council or to the Department of Health specifically we
try and approach them, but by and large that is not seen as their
remit, so the situation is dire across the board. I wonder whether,
my Lord Chairman, my colleague, Professor Newman Taylor, might
add to that.
Professor Newman Taylor:
I think the situation is as has been described. The majority of
the funding that goes into research on occupational allergic respiratory
disease now comes from charitable sources, of which the Colt Foundation
is a major provider of funds for research into occupational ill-health,
but also specialist charities, such as the British Lung Foundation
and Asthma UK, when there are areas within their interest, will
also support it. I think the issue in relation to the Health and
Safety Executive is a particular concern because for several years
now the Health and Safety Executive has predominantly funded contract
research for external individuals to apply for. What we now understand
is that the Health and Safety Executive, because of the concerns
which have been previously shared, is only able to fund research
within occupational disease within the Health and Safety Executive
and Health and Safety Laboratory. That is a situation which may
change, but it is a situation which appears to be the case at
the present time. This has a number of problems: not only is it
difficult to undertake research within the field, but it also
provides problems in terms of retaining people in the field and
attracting people to come into the field, because if there is
not research funding for it then this is not an area of growth,
and therefore of interest, for people who would follow in the
future. Unless something is done to change the situation we risk
finding ourselves in a few years without experts in this field
because experts need to be doing research and research needs to
be funded.
Q310 Lord Taverne: Are we in a much
worse position in this country than, say, developed countries
in the rest of Europe or North America?
Professor Newman Taylor:
I think we are in a worse position than Scandinavia, particularly,
where they have invested quite heavily in occupational disease
and have institutes. We are probably in a worse position than
is the situation in Canada. The United States is more difficult
to say, but probably there is still a higher proportion of funding
that is going to this area in the United States than here, but
in relation to Scandinavia and Canada we are certainly worse.
Dr Orton: Within
skin, I would reiterate the same, that certainly in other parts
of Europe, particularly in Scandinavia and even in Australia they
have specific institutions looking into occupational skin disease.
We are very much behind.
Q311 Baroness Perry of Southwark:
I am disturbed by your answer to the previous question and I wonder
what research is currently going on to identify those people who
are at risk of developing occupational asthma?
Professor Newman Taylor:
There has been quite a lot of work which has been done on that
over the last 20 years and there has been work which has looked
at the risk to people who are several atopic, that is to say they
have skin reactions to pollen, mites and moults and things, and
also looking at some genetic markers, such as HLA, to see whether
or not these people are at greater risk of developing occupational
asthma. We have some evidence that is the case, that atopics working
with laboratory animals, in bakeries or with enzymes are at greater
risk. Similarly with HLA, in relation to some low molecular weight
chemicals, platinum salts anhydrides as well as with laboratory
animals, there is evidence that there is also an increased risk.
The problem is that these factors only contribute a minority to
the risk of the disease and the concern that has been expressed
already, which I share, is that we are not in a position where
those markers can be used to identify those people who will develop
a disease and, therefore, prevent them from being exposed. The
really important determinant of illness with occupational asthma
is the level of exposure, and the focus needs to be really on
the environment to reduce the level of exposure in order to reduce
the number of those who become sensitised. We looked at some data
which we had some years ago in terms of laboratory animal allergy,
and asthma caused by laboratory animals occurs about five times
more frequently in atopics than in non-atopics, but it will occur
in only a minority of atopics and so if you are atopic the chances
of you getting asthma are much less than of not getting asthma.
What it meant in terms of a pre-employment screen, if one was
going to use it for that purpose, was that you would need to exclude
seven people to prevent one case and that, clearly, is not sufficiently
discriminating to be used for that purpose. Much more important
really, it seems to me, is that the focus needs to be on improving
the environment in which the individual is working in order to
prevent the case developing in the first place.
Q312 Baroness Perry of Southwark:
Do you think there is a long-term hope of eliminating it entirely?
Professor Newman Taylor:
I think that it will be difficult in some circumstances. Laboratory
animals is quite a good example, people have to handle animals,
you pick an animal up, it is likely to urinate on you, if it urinates
it will scratch you, all of these things could happen, the dust
gets into the air. You could do a lot to reduce the level of exposure
and, therefore, reduce the incidence. To eliminate it I think
would be very difficult.
Mr Miguel: My Lord
Chairman, that is interesting what my colleague is saying especially
about HLA. I think it is quite worrying if we are going to go
down the lines of genetic testing in terms of excluding people
from employment and, as was rightly said, it is not conclusive.
For example HLA B27, there is a predominance of HLA B27 in people
with back problems, but only two per cent of that group has been
identified as having back problems, so it is not conclusive and
it is possible then to screen out 98 per cent. What we are worried
about, as a trade union movement, is that we are going to go down
the lines of genetic testing and atopy which precludes people
from employment when it should not. The facts that Professor Newman
Taylor is talking about are very worrying if we are going to use
that information for pre-employment screening, which I think there
is a danger that could happen.
Professor Newman Taylor:
To reassure Mr Miguel, that was happening 20 years ago and the
research which we have undertaken demonstrating the importance
of exposure has led most employers to abandon that as a means
of pre-employment testing.
Q313 Chairman: I suppose the other
side is that you could be looking at people whose career advice
at school level might be better targeted in the random or absent
career advice that some youngsters get where they tend to fall
into certain patterns of occupation, so there may be some benefit
in the longer term of being able to steer youngsters to develop
in different pathways.
Professor Newman Taylor:
I think, as yet, we still probably do not have sufficient information
to be able to give good advice on that basis. I agree with you,
maybe someone who has asthma who is going to work in an environment
where they are coming into contact with isocyanates, but on the
basis of atopy, HLA testing or whatever, it is very important
not to discriminate.
Mr Miguel: To make
a point on the issue just raised, due to the small genetic pool
that we have, you will find if you started carrying out that testing
on children no-one would be in employment anywhere.
Q314 Chairman: You have painted a
gloomy picture of the future really because we are not having
the next generation of researchers coming up through the ranks
and emerging, but if one tries to take a more optimistic view
I wonder what you feel the most promising areas of research into
industrial allergic skin disorders are in particular and who is
co-ordinating and leading on this research?
Dr Orton: There are
two areas there that need mention here. The first is work into
persistent post-occupational dermatitis, which seems to affect
maybe 10 per cent of the workforce, and that is being co-ordinated
at the Institute of Occupational Dermatology Research and Education
in Melbourne, Australia by Dr Rosemary Nixon and closer to us,
in Germany, there is Professor Thomas Diepgen in Hamburg who is
looking at the effect of intervention in patients with hand eczema,
because primarily occupational skin disease does involve the hands.
There has been some evidence produced to date about these targeted
education programmes, getting individuals who are in wet work
occupations to understand the function of the skin, what signs
they should look out for if the skin is being damaged by exposure
to irritants, or indeed allergens, and what measures they need
to take to treat it. It is changing the individual's behaviour
with regard to treating the skin at an early stage which is having
beneficial effects. Certainly, in hairdressers and healthcare
workers there is published data which supports this. Obviously
more work is being done in this field, but going back to Professor
Newman Taylor's point—reducing exposure is the key aim here.
Q315 Chairman: It is the key aim.
Do members of the Committee have other questions that they wish
to ask or other points that you wanted to make?
Mr Miguel: My Lord
Chairman, this is not my field so I do not know much about it.
I was reading some articles about desensitisation techniques.
One of them—and I am sure my colleagues will put me right
or wrong—was to inject people suffering from hay fever and
asthma with bacteria which used to be found in kitchen sinks which
no longer exists, to desensitise them for about a year. I do not
know if any work is being done on that, but that sounds promising
and if we are able to get a technique where we could desensitise
people then that would be relevant research.
Professor Newman Taylor:
The situation at the present time is that if we were looking at
desensitisation with occupational allergens, potentially the most
promising might be the laboratory animal urine proteins. Professor
Kay and his colleagues have done a great deal of work to make
this safe because in the past it was not done sufficiently safely.
If I was going to promote a single area where one is looking at
that as a means of switching off the disease, so to speak, it
would be laboratory animal allergy where we know enough about
the proteins that cause it to be able to make some progress. I
wonder if I could make one other point and that is that you talked
about research. It seems to me that what has been achieved in
the last decade or so is that we have learned what the major causes
of occupational allergic disease and occupational asthma in our
community are. We have come to understand that it is more the
level of exposure than personal susceptibility and where there
needs to be a focus for research it is translating that knowledge
of exposure response relationships into effective means of preventing
the disease or reducing the incidence of the disease. As I have
said, with latex and enzymes that has been achieved. We need to
be looking at the means to be able to reduce disease incidence
in other situations like with bakery workers and flour, supermarkets
and isocyanate workers in garages, if we are going to make a further
impact on this disease.
Lord May of Oxford: It is a good question
and it may reassure you that the Committee has been excellently
organised. We had a visit to St Thomas' where some of this research
is going on, and my personal impression, for what it is worth,
is that there are still more questions than answers. There is
a lot of progress occurring but we are a very long way from having
a silver bullet that is universal. There is progress more on some
kinds of things than others.
Q316 Chairman: Professor Agius, did
you have another point?
Professor Agius:
My Lord Chairman, I would have thought that the role of de-sensitisation
would be exceedingly limited to some exceptional areas, although
I defer to Professor Kay and Professor Newman Taylor in this respect.
I think the emphasis, as Professor Newman Taylor has said, has
to be in most respects to apply what is already known and to undertake
the lines of research that determine the incidence of occupational
asthma, occupational rhinitis and occupational dermatitis and
to relate that to exposure. Historically, this country has made
significant strides in those areas in the past and has led. At
the moment things are slipping away through our fingers.
Q317 Chairman: Dr Orton, do you have
any additional points you wish to make?
Dr Orton: I think
they have really been made.
Chairman: Then could I thank you all
for coming and the work that you put into giving us evidence today.
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