Memorandum by Asthma UK
1. ABOUT ASTHMA
UK
1.1 Asthma UK is the charity dedicated to
improving the health and well-being of the 5.2 million people
in the UK whose lives are affected by asthma.[7]
We work together with people with asthma, health professionals
and researchers to develop and share expertise to help people
increase their understanding and reduce the effect of asthma on
their lives. As the voice of people with asthma, Asthma UK is
a proactive organisation that offers solutions and puts people
with asthma first.
1.2 Asthma UK is pleased that the House
of Lords Science and Technology Select Committee has decided to
investigate issues surrounding allergy in the UK. This is a significant
issue for the millions of people affected by allergies, and presents
an evolving challenge for health professionals and government.
We welcome the opportunity to share our expertise with the Committee,
and would be very pleased to nominate a representative to give
oral evidence should this be required.
2. DEFINING THE
PROBLEM
2.1 Asthma and allergy are global problems,
and prevalence of both in the UK is among the highest in the world,
which has been highlighted by several recent studies.[8]
2.2 Asthma and allergy are very closely interlinked.
For the majority of people with asthma, symptoms are brought on
through allergic mechanisms. Many common allergens are also common
asthma triggers: 90 per cent of people with asthma tell us that
their symptoms are triggered by dust and 79 per cent say their
symptoms are triggered by pollen.[9]
Additional allergic conditions including allergic rhinitis, conjunctivitis,
eczema and food allergies are also common in people with asthma.
Even non-allergic asthma triggers such as cigarette smoke and
air pollution can worsen the impact of allergic asthma, and there
is much still to be learned about the interplay of different factors
in the development of the condition.
2.3 There are significant flaws in our ability
to accurately establish the total disease burden of allergy, and
particularly allergic asthma. This is in part because of a lack
of funding for research in this area. The UK Clinical Research
Collaboration reported that research into asthma and other respiratory
conditions received a disproportionately low level of funding
in relation to the impact of these conditions, which represents
a huge barrier to the effective development of our knowledge base.[10]
2.4 However, perhaps an even more fundamental
reason for our inability to conclusively establish the total burden
of allergic disease is that current diagnostic procedures mean
that it can remain unidentified. Only 30 per cent of people with
asthma tell us that they have been offered allergy testing to
help them to identify what triggers their asthma.[11]
Skin-prick tests, which can be used to identify allergies, are
not widely applied to people with asthma, meaning that the precise
allergens that trigger symptoms in allergic asthma are not formally
identified or recorded: this can inhibit the quality of treatment
as well as preventing us from forming a complete record of the
extent of allergy in the UK.
2.5 We estimate that over 12.7 million working
days are lost each year as a result of asthma, and that the total
annual cost of asthma to the economy is £2.3 billion.[12]
The high prevalence of allergic asthma means that a significant
proportion of this cost is likely to be directly related to allergy,
but unfortunately, the lack of allergy testing for people with
asthma and the resulting absence of data on the people affected
by it means that precise figures are unavailable. Nevertheless,
the total economic impact of asthma and other allergic conditions
is likely to be very substantial.
3. TREATMENT
AND MANAGEMENT
3.1 As yet it is not clear how to prevent
asthma and allergy, but Asthma UK sponsors approximately £3
million of research into asthma every year. Asthma UK has developed
a comprehensive research strategy to identify priorities by bringing
together the expert knowledge and opinions of people with asthma,
researchers, clinicians, the major UK funding agencies, the pharmaceutical
industry and the Department of Health. The results of these national
consultations provide a framework for the development of Asthma
UK's research programme, which covers basic and clinical research.
We are currently supporting 18 research projects specifically
relating to allergy, which together represent a financial commitment
of £2,470,758.
3.2 In addition, Asthma UK works in partnership
with the Medical Research Council to fund the MRC-Asthma UK Centre
in Allergic Mechanisms of Asthma, which is a world-class centre
of research into allergies and asthma based at Imperial College
London and King's College London. Established in 2005, the centre
aims to understand asthma better and to develop new ways of preventing
and treating the condition, as well as acting as a training ground
for new researchers and as a public voice for new achievements
in asthma research. The creation of a centre of this kind provides
a unique opportunity to translate basic science findings from
the laboratory to healthcare professionals treating people with
allergic asthma and will encourage scientists to fast-track the
development and testing of new treatments.
3.3 It is not certain why the rate of allergy
is so high in the developed world, but there are several promising
areas of research. For example, there is increasing evidence that
infection with gut parasites may protect against asthma and allergy.
Asthma UK and the Wellcome Trust are independently funding clinical
trials to study the effects of hookworm in allergy and asthma
respectively.
3.4 Also, some studies have suggested that
diet may increase a person's risk of developing asthma and allergies.
For example, a recent study funded by Asthma UK showed that children
born to mothers who had a low intake of vitamin E during pregnancy
were five times more likely to have asthma than children whose
mothers had eaten a diet high in vitamin E.[13]
3.5 There is also clear evidence that infants
who contract respiratory syncytial virus (RSV) bronchiolitis are
more likely to develop asthma later in life and in severe cases
they may also be at greater risk of developing allergies. A number
of antiviral therapies are in development for RSV and rhino virus
infections that may potentially prevent asthma development.[14]
3.6 Treatments for allergic asthma are also
developing. Recently a novel therapy called Xolair has been developed
and licensed for use in people with severe allergic asthma. It
is an antibody that binds to and removes the "allergic antibody"
Immunoglobulin E (IgE) from the circulation. It is currently being
appraised by NICE.
3.7 Also, specific immunotherapy aims to
make an allergic person tolerant to the substance causing their
allergy by injecting them with increasing doses of the substance
they are allergic to until their symptoms are abolished or reduced.
However it carries a risk of adverse reaction and trials are underway
to administering the treatment in a quick dissolving tablet under
the tongue (sub-lingual immunotherapy). This approach looks promising
and might provide a new, cost effective way for people to manage
their asthma.
3.8 Nevertheless, the level of spending
on research into allergic conditions is far from adequate. This
is a substantial barrier to the advancement of our understanding
about both the causes and treatment of allergic conditions. The
Department of Health's recent review of allergy services identified
a number of significant gaps in research into treatment, particularly
in our understanding of effective models of service delivery and
the effects of patient knowledge on treatment outcomes.[15]
4. GOVERNMENT
POLICIES
4.1 As well as identifying weaknesses in
our understanding of effective services, the Department of Health's
report illustrated the poor outcomes of current service provision,
which can only be remedied by improving policy. There has been
a lack of strategic direction, with the result that services are
not well integrated and have failed to address the problems associated
with allergy. More explicit attention should be paid to allergy
and allergic asthma, with better services provided in both primary
and secondary care. It is important for the Government to ensure
that NICE guidelines on allergy are commissioned as soon as possible
in order to help structure future treatment.
4.2 However, improving health is not solely
the domain of the Department of Health, and without public health
measures across government, the problems associated with allergic
asthma will not be resolved. There is work to be done across government
and the public sector: in training professionals working with
the public to be aware of what to do in an asthma attack, in securing
asthma- and allergy-friendly workplaces and in improving indoor
and outdoor air quality.
4.3 Poor housing in particular can severely
exacerbate asthma symptoms. Damp conditions in particular allow
common triggers for allergic asthma such as mould and house-dust
mites to thrive. Public health policy and housing policy should
be well co-ordinated at all levels of government, and more attention
could be paid to the improvement of housing conditions with specific
regard to allergy and asthma, particularly in rented accommodation.
The consultation on the Code for Sustainable Homes made reference
to the use of allergy minimising materials, but it remains unclear
whether this will be implemented, or whether it will have any
success.[16]
5. PATIENT AND
CONSUMER ISSUES
5.1 The impact of allergies and allergic
conditions on quality of life can be enormous. Some allergens
are difficult to avoid, meaning that Many people with allergic
asthma are forced to adjust their lifestyles to compensate for
this, or live in fear of a severe asthma attack triggered by an
allergen.
"My quality of life is non-existent. I know
this may sound extreme to a lot of people but I would be prepared
to lose an arm and a leg if it meant my asthma would go away.
I face daily restrictions in every aspect of my life. I can't
go into pubs or clubs because of the smoke, I can't visit friends
because of their pets and people's cigarette smoke. I also have
problems visiting friends for barbecues because the smoke sets
off my asthma. I find it really difficult to do day-to-day activities
on my own—I don't have enough breath to push a trolley around
the supermarket. It's impossible for me to go to the gym and I'm
banned from the local swimming pool as the chlorine and humidity
sets off my asthma. I'm too much of a liability to them. I'm not
allowed on an aeroplane and it's impossible for me to get travel
insurance. Winter is also a problem for me—I can't go outside
because the cold air can set off my asthma." Suzanne
Edwards
5.2 A number of steps can be taken to help
ensure; that patients and the public are better informed about
allergy and allergic asthma. Improvements in our ability to diagnose
allergy would be very beneficial, as would more specialised training
for healthcare professionals, and the provision of better-structured
allergy services. For example, poor knowledge about allergic conditions
often stems from the lack of an integrated and holistic approach
to their treatment. People with multiple allergies are forced
to see multiple specialists for separate treatments rather than
a single allergy specialist, with the result that they are not
well informed about their allergies as a whole.
5.3 It is also noteworthy that many people
are badly informed about what it means to have an allergy, and
about the difference between allergy and intolerance. In addition
to the development of more robust clinical practices and better-informed
health professionals, the production of accessible health promotion
materials available in a variety of locations and formats may
help to resolve this problem.
6. CONCLUSIONS
6.1 Allergy and allergic asthma do not currently
receive the priority they should, in either research or services.
The problems allergic conditions cause are severe for the individuals
affected and for the national economy. There is a clear need for
more research into the basic causes of asthma and allergy, as
well as into the clinical effectiveness of different forms of
treatment service to fully develop our understanding of allergic
conditions. Yet, even with our current level of knowledge, it
is apparent that not enough is being done to treat allergy and
allergic asthma. More diagnostic testing is needed, and services
across both primary and secondary care stand to be improved. Only
then will people with allergic conditions get the treatment they
need.
October 2006
7 Health Survey for England 2001. Joint Health Surveys
Unit, 2003; The Scottish Health Survey 1998. Joint Health Surveys
Unit, 2000; Census 2001 (Office for National Statistics: ONS). Back
8
Prof M Innes Asher MBChB, Stephen Montefort MD, Bengt Björkstén
MD, Christopher KW Lai DM, David P Strachan MD, Stephan K Weiland
MD and Hywel Williams PhD, the ISAAC Phase Three Study Group.
Worldwide time trends in the prevalence of symptoms of asthma,
allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phases
One and Three repeat multicountry cross-sectional surveys. The
Lancet 2006; 368:733-743. Matthew Masoli. Denise Fabian, Shaun
Holt, Richard Beasley. Global Burden of Asthma.2002. Royal College
of Physicians, Allergy: the unmet need-a blueprint for better
patient care, 2003. National allergy strategy group, www.bsaci.org/allergyservices.html,
last accessed 26 September 2006. Back
9
Asthma UK. National Asthma Panel, 2004. Back
10
The impact of conditions was measured in Disability Adjusted Life
Years. UKCRC, UK Health Research Analysis, May 2006: 27. Back
11
Asthma UK. National Asthma Panel, 2006. Back
12
Department for Work & Pensions, Information & Analysis
Department. Office of Health Economics. Compendium of Health Statistics,
15th edition 2003-04. Department for Work & Pensions, Information
& Analysis Department (April 2004). Back
13
Ref: Devereux G, Turner SW, Craig LC, McNeill G, Martindale S,
Harbour PJ, Helms PJ, Seaton A. Low maternal vitamin E intake
during pregnancy is associated with asthma in 5-year-old children.
Am J Respir Crit Care Med. 2006 Sep 1;I74(5):499-507. Epub 2006
Jun 8. Back
14
Ref: Henderson J, Hilliard TN, Sherriff A, Stalker D, Al Shammari
N, Thomas HM. Hospitalization for RSV bronchiolitis before 12
months of age and subsequent asthma, atopy and wheeze: a longitudinal
birth cohort study. Pediatr Allergy Immunol. 2005 Aug;16(5):386-92. Back
15
Department of Health. A review of services for allergy-the epidemiology,
demand for and provision of treatment and effectiveness of clinical
interventions. 2006. Back
16
Office of the Deputy Prime Minister. Proposal for introducing
a Code for Sustainable Homes. 2005. Back
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