Examination of Witnesses (Questions 560-579)
DR JEAN
MONRO, DR
DAMIEN DOWNING,
MR DON
HARRISON AND
PROFESSOR SIMON
WESSELY
21 FEBRUARY 2007
Q560 Baroness Platt of Writtle: If a
patient seeks medical advice about a possible allergy what are
the differences in approach between an environmental allergist
and an NHS allergy specialist?
Dr Downing: So I am an environmental allergist
then! Fair enough. Somebody who comes to see a member of our society
with these things would be approached on a much broader basis
and we would be looking at not simply the narrow definition of
allergy that has been used, which is kind of falling apart these
days, but is still there, which is that allergies cause IgE-mediated
diseases such as asthma, eczema and so forth. We see a lot of
people with a huge range of other diseases that have been shown
in individual instances to have allergic or hypersensitivity mechanisms
involved in them, and the link between food intolerance and arthritis
would be an obvious example of that. So somebody coming to one
of our clinics would be assessed in those terms and would also
have their nutritional status looked at, and they would have their
toxicological status considered as well, and of course we would
also rope in lifestyle and psychological factors.
Q561 Baroness Perry of Southwark: I would
like you to explain to us something about what I think is called
the provocation or neutralisation test which is used by environmental
allergists; how does it work?
Dr Monro: It is a form of low-dose immunotherapy.
In your previous questioning you were asking the panel on homeopathy
and they said that the doses used were very infinitesimal whereas
in neutralisation techniques the doses are tested for an individual
according to the individual's responses and it is a form of low-dose
immunotherapy. It has been used as a sublingual form of immunotherapy
and there are now some 3,000-odd papers on sublingual immunotherapy
and how effective it can be. I think Dr Brostoff said that it
was a technique that was approved by the European Academy of Allergy
and accepted by them. Furthermore, low-dose immunotherapy has
been shown to be the most effective disease-modifying form of
treatment as opposed to disease-suppressing form of treatment
for people with allergies.
Q562 Baroness Perry of Southwark: As
I understand it, the provocation test comes first and then is
followed by the neutralisation vaccines. Am I right? Perhaps you
could tell me what quality controls there are for those vaccines
that are used?
Dr Monro: What is used is a series of different
strengths of vaccines starting with one particular strength and
it is titrated as a low dose from there in strengths of perhaps
one part in five, so the strengths of the initial vaccine are
well known and they have been established. The dilutions are parts
of that, perhaps one in 25 or one in 125 parts, just as an example,
so that when one knows the original strength one can calculate
what the strengths of the others are. The point about it is that
immunotherapy has been shown to be beneficial. I can quote from
a paper from Nature Reviews Immunology in October last
year which says: "It will prevent the onset of new sensitisations
to different allergens, reduce the development of asthma in patients
with allergic rhinitis caused by inhaled allergens, and it is
disease modifying rather than palliative.
Q563 Baroness Perry of Southwark: Where
did you say that article appeared?
Dr Monro: That is from Nature Reviews Immunology,
volume six, October 2006.
Q564 Baroness Perry of Southwark: I was
going to ask about a double blind study of the provocation tests,
which I am still not quite clear about. You have talked a lot
about the immunisation programme but I am not quite clear what
the provocation test is. I wanted to press you really on the study
that was published in the New England Journal of Medicine
in 1990 where they said that the provocation test had no value
in identifying food sensitivities. Has there been any study afterwards
specifically on the diagnostic test?
Dr Monro: Yes, there have been and I have a
dossier of information about it. That paper was by Jewett and
it was critiqued by a number of people who actually practised
provocation neutralisation. He did not actually practise it, he
is an orthopaedic person, but the point is that the critique has
shown that the techniques that he was recommending were not entirely
valid.
Q565 Baroness Perry of Southwark: So
the provocation test is what, giving somebody a dose?
Dr Monro: It is giving a dose of allergen which
is at a particular strength that I have mentioned and then that
can provoke symptoms in a person which can be nullified by a weaker
strength.
Q566 Baroness Perry of Southwark: So
how many provocation tests would you have to have before you could
identify what it was that the patient was allergic to?
Dr Monro: Whatever the strength of solutions
it is that is being used, say wheat diluted to a fifth of a standard
concentration, that can be used as provocation. The next weaker
dose could be used as a treatment, so it is a series of different
strengths.
Q567 Baroness Perry of Southwark: How
do you find out which allergen the patient is reacting to? Would
they have to have 20 or 30 different allergens given to them as
provocation?
Dr Monro: They may have to but quite often if
one has a history of a problem in an individual—and that
is where the skill of the environmental physician is used—you
identify the things that you suspect might be a problem and that
is the item that is tested, and you might have three or four items
in an individual or you might have ten.
Q568 Baroness Perry of Southwark: Since
that New England Journal article in 1990, have there
been any research reports showing that the 1990 report was wrong,
that these provocation tests do work, and can you give us a quote?
Dr Monro: Yes I can, I have got a dossier of
them but, in addition, as I say, since then there has also been
a vast literature on sublingual immunotherapy, which is part of
the provocation testing technique, which shows that low-dose immunotherapy
is very effective, and I am happy to provide the Committee with
the relevant documents.
Mr Harrison: I agree with the validity of the
provocation test certainly but we use a different type of testing.
We use the type of testing beloved of Professor Corrigan. We use
muscle testing, we use kinesiology. The test is comparatively
short and it can be anywhere between 20 and a couple of hundred
allergens. The case history taking has to be long. The remedies
that are used and that are produced in our own pharmacy are dilutions
of one in 100. In other words, they are homeopathic centesimal
dilutions going up to the 30th centesimal potency; sometimes to
the 200th and sometimes higher, but usually the 30th is adequate,
and so we are way beyond the level of actual material in our remedies;
we are looking at energy medicines rather than anything else.
The test is short and more time is probably devoted to the case
history.
Q569 Chairman: Again I am going to shorten
you because Professor Wessely has been patiently waiting to make
a comment.
Professor Wessely: The Jewett test in the New
England Journal was one of a large number of double blind
provocation studies and what these show is that where the blindness
is maintained thoroughly, in other words neither the patient nor
the doctor is able to guess or work out what the provocation is,
they give consistently negative results, no better than chance
alone. Where either the doctor or the patient is unblinded, they
give positive tests. It is for that reason that the provocation
tests are not used to diagnose sensitivities.
Q570 Baroness Perry of Southwark: I am
grateful for that. Could I just return to the difference between
the neutralisation process that Dr Monro is talking about and
conventional sublingual therapy which we have certainly seen practised
for example in Germany and elsewhere. What is the difference between
the two?
Dr Monro: The difference is simply that one
uses in a neutralising technique a series of different solutions
and one uses the solution which produces no adverse effects as
a treatment, the strength can then be increased. It is perfectly
safe to do sublingually because there are known to be very few
what are called mast cells in the mouth and under the tongue so
that a person can be given a treatment very safely without the
likelihood of adverse effects. So the neutralisation technique
is to find a strength which gives no symptoms and then you can
increase the dose thereafter sublingually in a form of low-dose
immunotherapy.
Q571 Baroness Perry of Southwark:So
it is different from the sublingual therapy which is used in conventional
allergy treatment?
Dr Monro: It is not entirely different. As I
say, one can use one of the strengths and then build it up so
that in fact it becomes the same thing.
Q572 Chairman: Could I just clarify,
would that technique apply to something like peanut allergy?
Dr Monro: Yes it has been used for peanut allergy
but it is not commonly used and there have been only two reports
of sublingual immunotherapy causing any major effect, and that
was when it was done in a rush desensitisation for peanut allergy.
Q573 Lord Colwyn: This is a question
for Dr Downing. In your evidence you said that allergic patients
tend to be deficient in several of the vitamins and minerals necessary
for optimum function of the immune system; correcting such deficiencies
seems to improve their general health and lessen their hyper-reactivity."
I would agree with that statement, namely that possibly zinc and
vitamin C are some of the major offenders. Can you give us an
answer on what is the evidence for this statement—and you
are going to have to do it in about 60 seconds!
Dr Downing: It is a good job that I prepared
a written response which gives a number of things. The short answer
is, yes, there is quite a bit of evidence but that environmental
allergies, as we are now calling them, are no different from the
rest of allergy in that respect, it is true of all asthmatics
and allergics.[7]
Lord Colwyn: Are you aware of any control trials
that have been undertaken which have been published and peer-reviewed?
Dr Downing: On treatment?
Q574 Lord Colwyn: Yes.
Dr Downing: Somewhat more limited.
Q575 Lord Colwyn: To support your claim
about vitamins and minerals?
Dr Downing: You are talking about an intervention
trial if you say a control trial. There have been studies that
have shown—and I have a number here—that allergics
in general are short on a variety of nutrients of which you are
quite right zinc leads the league with vitamin C and the B vitamins
and so forth.
Lord Colwyn: My apologies for having
to cut it so short.
Q576 Lord Rea: Again asking a question
that could occupy an hour, is there a possibility that some allergy
treatments simply have a placebo effect rather than decreasing
their true allergic response?
Mr Harrison: Yes, I think so. I do not think
that is anything new. I think that we must marshal all the aspects
of treatment, both physical and psychological, in the treatment
of a patient as a whole because, as I said, the allergy problem
is a very complex problem and many, many patients come to us having
run the gamut of the NHS, regretfully unsuccessfully, because
all aspects of their problem are not addressed. Lifestyle must
be looked at; the comfort of the patient must be looked at; the
psychology of relationships must be looked at; and anything that
reduces the stress. The allergy picture on test reduces as the
stress level reduces, so if we can get the patient to reduce their
stress level, if we can give them a belief in a positive outcome,
then that reinforces the physical aspects of the treatment, so
we must bring all these things together.
Professor Wessely: Yes, obviously the placebo
effect occurs across medicine and all of us would be a lot poorer
if it did not. There is also the nocebic effect as well, I am
afraid, which is where the placebo effect makes you worse. For
example false allergy testing can make you worse by reinforcing
the belief that you have an illness that in fact you do not and
that there is a relationship between things when there is not,
and by drawing attention away from the real cause of illnesses,
so it is not just a straight situation. There is also a lot of
literature on the nocebic effects of some interventions and tests,
all of it highly relevant to this subject.
Q577 Lord Haskel: You have told us about
the regulation of practitioners. What about the clinics and the
allergy treatments which are provided; are these adequately regulated
and what could the Government do to protect the public from ineffective
allergy treatments offered in these clinics?
Mr Harrison: I can only speak about the treatments
that our members offer. The remedies that they receive are made
in a homeopathic way. They are remedies which have been tried
and tested and produced for our members, something like 20,000
remedies a year, and these are going to patients who are either
self-referred or referred by friends or, more importantly, referred
by GPs. As far as the Government is concerned, it is already regulating
the preparation of homeopathic medicines. The distribution of
them should not be open to the normal aspects of commerce because,
for instance, putting allergy neutralisation remedies on the shop
shelf would be entirely irresponsible—no doubt very attractive
as a money-making proposition but totally irresponsible—because
people would just go and help themselves, dip into them, take
this or that and waste their time and money. How the Government
would regulate homoeopathically prepared medicines further, I
am afraid that is beyond me, I do not think they could manage
it.
Dr Downing: If you are talking about doctors
running clinics of this sort, then it is hard to see how we could
be more regulated, quite honestly.
Q578 Lord Haskel: It is the clinics and
the treatment clinics which they provide that we are concerned
about.
Dr Downing: Yes, a clinic run by a doctor of
that sort would come under the terms of the Health Care Commission
and therefore also the National Minimum Standards. A number of
us have either gone through the process or are going through the
process at present, and I am myself, and I have to say that it
has been challenging but I think it has been valuable and enabled
us to improve what we do and the service that we provide.
Q579 Lord Broers: But are you required
to do that?
Dr Downing: Yes.
7 Please see supplementary evidence. Back
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