Examination of Witnesses (Questions 800-819)
Dr Glenis Scadding, Dr Clare Mills, Ms Donna Covey
and Ms Lindsey McManus
15 MARCH 2007
Q800 Chairman: Dr Mills?
Dr Mills: The British Society of Allergy and
Clinical Immunology has a list of people and that is where I point
people to because I feel that is a trusted list of accredited
people who know what they are doing.
Dr Scadding: I agree. Anyone can set up as an
allergist and it should simply not be allowed, we should have
some kind of proper accreditation with a recognised qualification.
Q801 Chairman: Are there false claims
being made over allergy treatments?
Dr Scadding: Yes.
Q802 Lord Colwyn: I think we covered
this subject in the earlier questioning and it is about the University
of York study that was commissioned by Allergy UK. Is there anything
you want to add to that? You probably heard our discussion.
Ms McManus: I think Dr Hart covered it very
adequately. The study that we commissioned was on over 5,000 people
and of those who stuck to it rigidly, which was something like
67 per cent, I believe, 75 per cent found a huge improvement in
their condition.
Dr Scadding: It is well known that irritable
bowel syndrome can respond to dietary exclusion, I have no dispute
with that. What I do dispute is that it is worth making any attempt
to identify IgG antibodies, we all make IgG antibodies to food.
Dr Pamela Ewan will tell you that 100 per cent of the population
she studies had IgG antibodies to egg and I see no way in which
this can be used to guide diet. In the Gut paper, which
is the best paper produced, the sham group did not avoid dairy
or wheat, which are the two major problems with IBS patients,
and, therefore, it is not surprising that at the end of the study
there was a 10 per cent difference. In that paper the number needed
to treat was nine, whereas if you do an exclusion diet the number
needed to treat is somewhere between two and 2.5, so I do not
think there is any point in spending money on IgG antibody tests,
you are better off going to see a dietician and using an exclusion
diet followed by re-introduction. The IgG antibody tests are liable
to leave patients on diets that are inadequate and patients often
like to think they are improving and they carry on in the teeth
of very little improvement and may end up malnourished.
Q803 Lord Colwyn: Are these self-testing
kits you are referring to?
Dr Scadding: No, this the York Laboratories
blood testing.
Q804 Lord Colwyn: Tell us what you
think about self-testing kits and are they sufficiently regulated?
Dr Scadding: They should be banned. I am very
sorry, but I saw a child this morning before coming here. We did
skin tests, which are well recognised, and she had skin tests
to house dust mite and also to tree pollens. She has absolutely
no symptoms referable to the tree pollen whatsoever, she does
not have spring hayfever, she has good symptoms related to the
house dust mite, so I treated her with house dust mite avoidance
and immunoallergy therapy. If she had got a kit then she would
have felt that she was tree pollen allergic as well and something
had to happen about that. She has sensitisation but not clinical
disease, and if you do a test only about half the people with
that positive test will have clinical disease, so you cannot have
self-testing kits, they are going to lead to misdiagnosis, wrong-allergen
avoidance. You need both the test and a detailed history taken
by somebody who has some experience of allergies to be making
an interpretation of tests.
Q805 Lord Colwyn: Of course the number
of experts are so few and far between, inevitably you are going
to be using tests.
Dr Scadding: Absolutely, people and training.
A lot of primary care nurses are being trained in doing skin prick
tests and interpreting them in places like the Respiratory Training
Centre at the Athenaeum in Warwick and I think that may be a way
forward.
Dr Mills: I would just like to endorse what
Glenis has said and for food allergy it is even worse. There are
a lot of people who will have apparently been sensitised to foods
like wheat but do not have any symptoms, and that can be really
problematic when people eliminate important food groups from their
diet.
Q806 Chairman: What about the issue
of inflammatory bowel disease that we heard about in the last
evidence session?
Dr Mills: In terms of the IgG?
Q807 Chairman: Yes.
Dr Mills: It is not particularly my area of
expertise, but I think that it is a symptom in that people do
benefit from dietary interventions, but the link at a molecular
basis between IgG and irritable bowel syndrome is not apparent
and we make these antibodies to our food protein as part of our
normal functioning.
Q808 Chairman: Ms McManus, this was
a study that, if I am right, your organisation commissioned. I
wonder if you have anything that you want to add to what has been
said?
Ms McManus: The main thing that I have to say
is it is because of a lack of NHS services, we have nowhere else
to send these people to. We would give the York test purely because
it is the only one that has undergone clinical trials, particularly
for IBS, and that is why we are happy to endorse it for those
kinds of symptoms, but we would not recommend any other test.
Q809 Baroness Perry of Southwark:
A question for Dr Mills really. What role does the Institute of
Food Research play in the primary prevention of allergic disease?
Dr Mills: I have been thinking about how to
answer this one. If you see preventing allergic disease in two
parts, the first part is preventing somebody becoming allergic,
how do we stop people even producing IgE. At a fundamental level
we still really do not understand the mechanism whereby one person
becomes allergic and another one does not, we really do not at
a very fundamental level, and that is where the IFR has a role
because we have a lot of the BBSRC-funded research on a fundamental
level of what are the molecular mechanisms underlying that and,
particularly, there is the dialogue between the gut bacteria and
the human host in early years understanding that at a molecular
level. I think that is fundamental in designing preventative strategies
that really work in an incontrovertible way. That is one level.
The other level is somebody who gets allergic and how do you prevent
them from getting an allergic disease. We have heard about immunotherapy
and one of the things that we are developing is possible oral
vaccination strategies using engineered lactic acid bacteria,
but there is another level related to my own personal research
which is understanding the allergens in foods and how they trigger
allergic reactions to food. That is very important when you start
looking at doing allergenic risk assessments of novel foods, you
do not want to introduce a novel food that is going to cause problems,
like peanut, and how do you do that. That is part of the role,
for example, I have in putting into the advisory committee on
novel foods and processes which do that. The IFR provides lots
of fundamental research which underpins that. The other thing
we have is a big database that we set up with EU funding which
has a lot of information about foods that people are allergic
to and I think providing them with that information is where we
see us working hand in hand with the allergic consumers.
Q810 Baroness Perry of Southwark:
Following on from that, do you think it is appropriate that the
current government advice still recommends the avoidance of peanuts
for babies who have a family history of allergies?
Dr Mills: That was founded on research that
was done some years ago and I think an awful lot has happened
since then.
Q811 Baroness Perry of Southwark:
Exactly.
Dr Mills: I suspect the Food Standards Agency,
which is particularly involved in some of that, is probably wanting
to go back and re-examine it, particularly in the light of the
recent studies where in the USA they have been introducing peanut
in an effort to desensitise; clearly, that has to be done under
clinical supervision because you do not want a child to have an
adverse reaction. I am involved in this big European study and
we also work with people from around the world and in Ghana, where
they eat a lot of peanuts, they introduce peanuts as a weaning
food in subsistence farming and eat peanuts as a very large amount
of the diet. I think understanding how the exposure aspects affect
allergy there are lots of lessons we can learn from other communities
around the world I think to help prevent that in the future.
Q812 Lord Colwyn: We heard from Gideon
Lack from the hospital over the road about the work he is doing.
I imagine it will not be long before you identify the cause of
the allergy in the peanut and then genetically modify it?
Dr Mills: Some people have already started doing
that. One of the difficulties is that there are quite a lot of
proteins in the peanut that cause allergy and if you remove them
by genetic engineering you will not have a peanut any more, it
will be something else.
Dr Scadding: I was going to mention Gideon Lack's
work of feeding peanuts early to babies but you already know about
it.
Q813 Baroness Perry of Southwark:
Yes, indeed, thank you. Apart from food avoidance, are there any
other effective treatments which can be recommended for people
with food allergies?
Dr Mills: Not at the moment.
Q814 Baroness Perry of Southwark:
Really?
Dr Mills: If you have got food allergy you spend
your life reading labels. My other plea is really if we are going
to address these issues and get to the bottom of them, we need
some joined-up thinking with the fundamental science, the biological
science and the clinic, but we also need the social science. In
the work we have done in EUROPREVAL, my EU project with economists,
we have shown in preliminary evidence that in the families which
have to live with food allergies it is women who bear a disproportionate
burden of the cost because they are the carers and have significantly
lower socio-economic status. They miss a lot of work because of
hospital appointments and so on, so there is a big economic burden.
I think that is a given for allergy as a whole and is part of
the equation in saying, "Well, okay, immunotherapy may not
be perfect but it is going to give a benefit to quite a lot of
people". It might cost more, but if you have somebody who
is 14 and they are going to have that for the rest of their life,
that is a long time for somebody to have to suffer that burden
of disease and we need to do some sums which incorporate that.
Q815 Baroness Perry of Southwark:
Of course it is expensive to the economy anyway because they have
time off work.
Dr Mills: But we do not have the numbers which
back that up.
Q816 Baroness Perry of Southwark:
What do you think the Government should do to educate patients
about their food allergies or intolerance for those with true
allergy about emergency medication?
Dr Mills: We did some work quite a few years
ago looking at this, and trust is a very important part of giving
people information. There are two groups that are pivotal in all
of this. The first is the clinic, the clinician and the doctor,
and the second is the allergic patient groups. Those are two providers
of information that are very, very important and I think they
should be supported in doing that. I see us as a fundamental science
institute providing that information in a form which allergic
consumers can use to pass on to their membership.
Q817 Baroness Perry of Southwark:
We heard evidence from Dr Jean Monro who said she could treat
food allergy with sublingual therapy, even for peanut allergy.
What do you say to that, particularly Dr Scadding?
Dr Scadding: I think we need proper trials of
sublingual immunotherapy. There are reports from the American
Academy of Allergy and Immunology on the sheer sublingual desensitisation
to hazelnut, so it may be a possibility, but it needs to be properly
done in a very carefully-controlled setting.
Dr Mills: I think the options for that may also
be more viable for those people who suffer nut allergies which
are associated with pollen allergies and that is a much more realistic
therapy for food allergy as opposed to the people who are just
allergic to nuts.
Q818 Chairman: Leaving aside the
need to improve allergy services, I wonder if you would agree
that is number one to improving allergy services but, if we put
that on the side, what are the most important areas that now need
to be addressed to improve the services for patients generally
in terms of prevention, treatment, research and so on?
Ms McManus: I think for Allergy UK it is education.
Q819 Chairman: Of?
Ms McManus: Primary care, local GPs and practice
nurses. They are the first port of call.
Ms Covey: For us there is a real issue about
research. Asthma UK funds a fair amount of research into asthma
generally and also the allergic mechanism of asthma but really
it should not just be left to a charity through voluntary donations
to be trying to move this debate forward. Our Basic Asthma Research
Strategy identified a number of priorities and that is how we
bring together a whole tranche of different scientists, clinicians
and other experts to try and say, "Well, if we have to focus
on asthma research what should we do?" That identified a
number of areas that were allergy-explicit, in particular the
whole issues around how allergy and allergic asthma develop. There
are things like the hygiene hypothesis that people still cannot
agree on, but if we could get to the bottom of it it might be
a really useful way forward from where I sit as a lay person.
We are keen to see more work into the role of infection in producing
allergic inflammation, the relationship between infection and
allergy. Also we need to see more research into immunology, which
we have already talked about, and new treatments for allergy,
including the potential vaccines we have for allergy. I think
in the long term what we really want to see is allergy taken much
more seriously and much more research on these issues so we can
start to understand what the real answers are going forward, not
just to enable them to live with allergic conditions but also
to reduce the amount of allergic conditions in the UK going forward
because it is an epidemic and it is a growing epidemic.
Dr Mills: I have already said I think we need
to have better joined-up and a greater proportion of fundamental
research into the biology because the clinicians are not going
to get the answers that we need, they have a different role to
play.
Dr Scadding: I think we need to look at primary
prevention: whether we can mimic bringing up children on a Bavarian
farm with something like endotoxin; whether something else like
vitamin D is playing a role is an interesting idea from America,
that lack of vitamin D may be relevant since this helps to regulate
T-cells; whether secondary prevention is possible; whether we
can switch off with immunotherapy early on in the course of disease,
switching off rhinitis and preventing the downward slide into
more complex allergies; and I think the link with infection is
very important. If we could cure the common cold we could prevent
an awful lot of exacerbations of asthma, sinusitis and otitis
media with effusion. Then, finally, there is a possibility that
bacterial infection may be a complicating factor of many allergies,
we see it with polyps, atopic dermatitis and asthma and whether
by then it is too late to do anything about the allergy because
there is the secondary problem of a chronic bacterial presence
and a different kind of T-cell infiltrate.
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