Memorandum by the Royal College of General
Practitioners
1. The College welcomes the opportunity
to make submissions to the House of Lords Science and Technology
Select Committee's Call for Evidence on Allergy.
2. The Royal College of General Practitioners
is the largest membership organisation in the United Kingdom solely
for GPs. It aims to encourage and maintain the highest standards
of general medical practice and to act as the "voice"
of GPs on issues concerned with education, training, research,
and clinical standards. Founded in 1952, the RCGP has over 24,000
members who are committed to improving patient care, developing
their own skills and promoting general practice as a discipline.
Please find below a submission to the Committee's
Call for Evidence questions as outlined below the four topic headings:
DEFINING THE
PROBLEM
What is allergy? What is the difference between
allergy and intolerance?
3. The term allergy has evolved in medical
usage over the last century so whereas once it referred to any
type of immunological response, it typically now has a much more
specific meaning referring to an immunological response to an
antigen mediated by specific IgE. These reactions are also sometimes
known as Type 1 or immediate hypersensitivity reactions.
4. At the same time as its meaning becoming
more restrictive in medical usage, the word allergy has also penetrated
lay social discourse, where it is also rapidly evolving, but in
a way that sees it being used in an ever more broad sense.
5. Intolerance reactions are common and
can result in significant morbidity. Although the underlying pathophysiological
mechanisms are often not clearly understood, it is clear that
these reactions are not specific IgE mediated. Clinically, these
are far more variable in onset, less predictable and typically
more transitory than allergic reactions; they are not life-threatening.
What is and what is not known about the origins
and progression of allergic disease?
6. Allergic disorders can affect people
of any age, both genders and all ethnic groups. There are however
considerable variations in prevalence of these disorders internationally.
Allergic conditions often manifest first very early on in life,
often beginning with eczema/dermatitis and food allergy in the
first year of life, progressing onto the development of allergic
rhinitis and asthma in early childhood, and other more systemic
allergic disorders such as urticaria and angioedema typically
manifesting more commonly in middle-age. Anaphylaxis is the most
serious manifestation of allergy and occurs in children and adults.
Why is the incidence of allergy and allergic diseases
rising? Why does the UK in particular have such high prevalence
of allergy?
7. The reasons underpinning these dramatic
recent increases are complex and as yet poorly understood. Whilst
some of the observed increases are likely to be due to a combination
of better recognition, changes in disease labelling patterns and
a lowering in the threshold for diagnosis, there has almost certainly
also been a genuine increase in the incidence and prevalence of
allergic conditions over the latter half of the last century in
the UK and elsewhere. The UK ranks highest in the world for asthma
symptoms, with a prevalence 20-fold higher than that in Indonesia,
it is also near the top of the world ranking for rhinitis and
eczema.[1],[2]
8. The narrow time window in which these
increases have occurred makes it implausible that these changes
are due to genetic factors—rather, they are due to environmental
and gene-environmental interaction factors, which are affecting
large sections of the population, particularly in very early life
(foetal development and/or infancy). Numerous risk factors have
been suggested as being responsible for these increases, but as
yet the reason(s) underpinning these increases remain elusive.
Given the number of identified risk factors, it is likely that
these increases represent complex interactions between a variety
of environmental factors and genetic predisposition.
9. The epidemiological picture has become
even more complex in recent years with indications that there
may be diverging trends in the local and systemic allergic disease
trends: the prevalence of the more local allergic disorders such
as eczema, hay fever and asthma appears to have stabilised in
the UK and may even be declining, although there are no signs
of similar declines in relation to the more systemic allergic
conditions such as food allergy, urticaria, angioedema and anaphylaxis.
What gaps exist in establishing the overall disease
burden for all types of allergy and what are the barriers to filling
these gaps?
10. We currently have no data on Accident
& Emergency consultation rates, hospital out-patient consultation
rates and hospital in-patient prescribing, which makes it difficult
to assess overall disease burden from the point of view of the
NHS. We also have no real idea of loss of time from work or school
or understanding of the impact on day-to-day life, educational
impact, career prospects and social activities of those suffering
from most allergic disorders which renders it difficult to assess
the disease burden posed to individuals who suffer from many of
these allergic problems.
Strategies to filling these gaps include:
— A more comprehensive range of disease
codes and aetiological trigger factors for use in primary and
secondary care (for example, there is currently no codes for peanut
or kiwi allergy in ICD-10).
— Central database of out of hours
contacts (NHS Direct).
— Central database of A&E consultations.
— Central database of out-patient consultations.
— Data linkage potential between different
healthcare datasets to allow more meaningful analysis of overall
disease burden to individuals and populations and also to allow
the study of risk factors associated with disease development
and exacerbations.
— In the light of such large variations,
there is a need for on-going data surveillance, particularly for
food allergy and anaphylaxis.
— Quality of life measures being developed
for the full spectrum of allergic conditions.
In addition to the impact on the health service,
what is the overall socio-economic impact of allergic diseases
(for example, absence from work and schools)?
11. This is likely to be large, but cannot
reliably be measured at present because of the absence of relevant
data collection (see above).
TREATMENT AND
MANAGEMENT
What is the effect of current treatments on the
natural history of allergic disease?
12. There are currently no cures for allergic
problems—rather, what we have is an array of non-pharmacological
and pharmacological approaches which can, in most patients, help
achieve symptom control and possibly result in some modification
of the underlying disease course.
What is the evidence-base for pharmacological
and non-pharmacological management strategies?
13. Whilst the evidence-base for pharmacological
treatment approaches is on the whole good for most commonly used
preparations, there is less secure evidence for allergen avoidance
approaches that are commonly recommended. There is also very little
evidence in relation to important health services research questions
about how best to structure care.
14. The shortage of capacity in allergy
treatment capacity has led the public to look outside the NHS.
This has resulted in the proliferation of questionable allergy
practice in the field of alternative and complementary medicine,
where unproven techniques for diagnosis and treatment are used.
[3]
Is the level of UK research into allergy and allergic
disease adequate?
15. There are currently no dedicated funding
streams for allergies in the UK and there are also no charitable
funding streams for researchers to draw on. Much of the existing
generic funding available from the Medical Research Council and
the Wellcome Trust has, for example, been directed towards basic
sciences and translational research and there has as a consequence
been very little dedicated health services research into allergy.
This problem was highlighted in the recent Department of Health
and Scottish Executive reviews into allergy services and the relative
lack of evidence uncovered in relation to how best to provide
care. In view of the scale of the problem, what is needed is provision
of programme research grants to allow meaningful progress to be
made.
What are the most promising areas of research
into preventing or treating allergy?
16. There is a need for a dedicated Cochrane
review group for allergy to allow relevant high quality evidence
in relation to disease prevention, treatment and organisation
of care to be systematically collated and periodically updated.
Areas of research that need investing in include studying the
role of dietary exposure in pregnancy and infancy, evaluating
the role of prebiotics, probiotics, anti-oxidants, pasteurised
milk and vaccination based strategies, amongst others, and various
combinations of these, for preventing disease onset and progression.
Research is also needed into educational initiatives aimed at
primary care staff and also new models of delivering care such
as General Practitioners with Specialist Interests in allergy.
GOVERNMENT POLICIES
How effective have existing Government policy
and advice been in addressing the rise in allergies?
17. The number of allergy specialists is
totally insufficient to meet the need. Improved links are required
between primary and secondary care. Increasing specialist capacity
in allergy practice would improve diagnostic and treatment advice
and would allow primary care teams to draw on an existing specialist
knowledge base.
18. The only specific government advice
that we are aware of relates to high risk mothers modifying their
diets and those of their infants, but there was no proactive attempt
to assess compliance with this and evaluate its effectiveness.
How is current knowledge about the causes and
management of allergic disease shared within Government?
For example,
— Do housing policy and regulations
governing the indoor environment pay enough attention to allergy?
— How effectively are food policy and
food labelling regulations responding to the rise in food allergies?
19. Current housing policy has not really
considered the issue of allergy in any serious detail. The recent
EU directive about food labelling appears to have been helpful
in allowing food allergy sufferers to better determine the contents
of pre-packaged foods, but there has been no attempt empirically
to evaluate whether food allergy sufferers have found this advice
helpful or satisfactory. Furthermore, issues remain about the
adequacy of current labelling approaches.
PATIENT AND
CONSUMER ISSUES
What impact do allergies have on the quality of
life of those experiencing allergic disease and their families?
20. In some patients, allergic disorders
are relatively short-lived and exert only a relatively minor impact
on day-to-day life. There is however ample evidence that they
can also be life-threatening, and in those with particularly severe
allergy or substantial co-morbidity the concern is that they can
impact on all aspects of day-to-day life. For those with food
allergy, the whole household can be affected and impairment in
quality of life for young people can be comparable or even greater
than those with diabetes. Living with the threat of possibly life-threatening
reactions can be very worrying for all concerned.
What can be done to better educate the public
and to improve the quality of information that is available to
patients and undiagnosed sufferers?
21. A number of measures need to be taken,
including:
— Better undergraduate training for
healthcare professionals which is based on an understanding of
the needs of sufferers.
— Similarly, better postgraduate training
opportunities, particularly for GPs and their teams.
— A national NHS e-library for allergy
with a section also available to the public.
— Map of Medicine for allergies which
patients also have access to.
— A dedicated patient helpline/website,
linked to NHS Direct, for authoritative information being made
available in a range of languages.
Are current regulatory arrangements, for example,
those governing private clinics offering diagnostic and therapeutic
services and the sale of over the counter allergy tests, satisfactory?
22. No, as there are a number of diagnostic
tests available which do not have any sound scientific basis—these
are therefore unhelpful, and potentially harmful, as they can
result in considerable unnecessary restriction of diet etc. Better
regulation would certainly be helpful, accompanied with far better
access to scientifically sound tests in primary care.
23. I acknowledge the contribution of Professor
Aziz Sheikh (Allergy & Respiratory Research Group, Chair;
Professor of Primary Care Research & development, University
of Edinburgh) towards the above comments; additional contributions
were made by Dr Mark Levy (Clinical Research Fellow, General Practice
Section, University of Edinburgh; Editor-in-Chief, Primary Care
Respiratory Journal), Professor David Price (GPIAG, [4]Professor
Primary Care Respiratory Medicine, University of Abderdeen) and
Dr Dermot Ryan (GPIAG, Allergy Lead; Rhinitis Guidelines Working
Party; Rhinitis Guidelines Committee; Royal College of Physicians,
Allergy Working Party). While contributing to this response, it
cannot be assumed that all of those named necessarily agree with
all of the above comments.
9 October 2006
1 The International Study of Asthma and Allergies in
Childhood (ISAAC) Steering Committee, Worldwide variation in prevalence
of symptoms of asthma, allergic rhinioconjunctivitis and atopic
eczema: ISAAC. Back
2
European Community Respiratory Health Survey. Variations in the
prevalence of respiratory symptoms, self-reported asthma attacks
and use of asthma medication in the European Community Respiratory
Health Survey (ECRHS). Eur Respir J 1996; 9: 687-95. Back
3
Bielory L. "Complimentary and Alternative Medicine"
Population based studies: a growing focus on allergy and Asthma.
Allergy; 2002; 57: 6,455-8. Back
4
GPIAG: General Practice Airways Group. Back
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