MULTIPLE CHEMICAL SENSITIVITY TREATMENT AT
BREAKSPEAR HOSPITAL
BACKGROUND
The National Public Health Service (NPHS) was asked to review the evidence on the
treatment of multiple chemical sensitivity (MCS) treatment provided at the
Breakspear Hospital (BH). The request follows the refusal to uphold a funding
request by a patient for the provision at BH of neutralising vaccines for the treatment
of MCS. There is no universally accepted definition for MCS, but it is generally
defined as the development of multiple symptoms attributed to exposure to any
number of identifiable or unidentifiable chemical substances (inhaled, touched, or
ingested) in the absence of clinically detectable organ dysfunction or related physical
signs. 1
THE TECHNOLOGY
BH is a privately owned and run day hospital in Hertfordshire specialising in the
treatment of patients with allergies and environmental disorders. BH uses the
technique of provocation/neutralisation, a form of low dose immunotherapy originally
developed in the United States to treat allergy, intolerance and sensitivity.
The
procedure employs intradermal skin tests of sequentially lower concentrations of
antigens until a wheal like response that does not increase in size, is obtained. This
antigen concentration is then used to manufacture neutralising vaccines. 2
PATIENT GROUP
Environmental medicine/clinical ecology practitioners advocate various forms of
treatment for patients with ill defined multi-symptomatic conditions including MCS,
electromagnetic field sensitivity or fatigue syndromes including those meeting the
diagnostic criteria for chronic fatigue syndrome or myalgic encephalomyelitis. 3
RESEARCH EVIDENCE
1.
NPHS review of evidence submitted by BH
The citations provided by BH concern provocation/neutralisation techniques and other
forms of immunotherapy for several allergic conditions, such as milk allergy and
rhinitis; there were no references specific for the treatment of MCS. Critical appraisal
of these references indicates that the evidence consisted of small randomised
controlled trials (RCT) with methodological problems and observational studies.
Conclusion: The references submitted by BH do not provide good quality
evidence for the clinical effectiveness of provocation/neutralisation methods for
the treatment of MCS.
2.
NPHS review of other evidence
Dr M Webb, version 1, March 2008
The NPHS performed a rapid review of the evidence using previously described
methodology. 4 5
2.1
Evidence for the existence of MCS as a clinical entity
Many theories both immunological and non-immunological have been proposed for
the aetiology of MCS. These theories are all hampered by the absence of a consistent
dose response to proposed causative substances and consistent objective evidence of
systemic inflammation, cytokine excess, or immune system activation in relation to
symptoms is lacking. 1 6 Examination of the evidence for the existence of MCS
revealed that high quality evidence is lacking 6 7 8, although some countries such as
Denmark and the United States do have position statements on MCS. Furthermore it
has been reported that MCS cannot be explained by allergy and/or immunological
mechanisms and there is convincing evidence that the ‘condition’ can be explained by
psychological conditioning and the presence of psychiatric disorders. 9 10 11 12 13 It
should be acknowledged however, that this group of patients do present with
considerable symptomology and should therefore receive appropriate care through
NHS services. Such services have been the subject of reports detailing improvements
required to deliver comprehensive allergy services. 14 15
Conclusion: There is a lack of good quality evidence to support the existence of
MCS as a clinically distinct syndrome or disease.
2.2
Provocation/neutralisation techniques
Three comprehensive reviews for the provocation/neutralisation treatment of MCS
and related disorders provided at BH in 2004 concluded that there is a lack of good
quality scientific evidence to support the use of provocation/neutralisation methods. 16
17 18
A 2006 update of the review of the evidence indicated that despite repeated
searches the results have confirmed an absence of RCT evidence on the use of this
therapy for MCS, multiple allergy syndrome and chronic fatigue syndrome. 19
A review of 37 provocation studies in MCS concluded that persons with MCS do
react to chemical challenges, but these responses occur when they can detect
differences between active and sham substances, suggesting that the mechanism of
action is not chemical specific but is related to prior beliefs and expectations. 9
There are RCTs on provocation/ neutralisation techniques in conditions like asthma,
eczema and hay-fever but it is debatable whether findings from these studies can be
reasonably used to underpin treatment in more complex and ill-defined disorders. A
systematic review for the use of provocation/neutralisation testing and therapy for
food allergy and other sensitivities indicated that there was no evidence to suggest that
provocation/neutralisation techniques are useful. 20 It should be noted that Dr Monro,
the Director of BH, provided information to and commented on the draft of the latter
report. Dr Monro also gave evidence to the House of Lords Select Committee on
Science and Technology in 2007 whose report on allergy was published in 2007.
With regard to immunotherapy the Committee suggested that immunotherapy may be
cost effective for some conditions such as allergic rhinitis and recommended that
large well controlled trials are required to validate this. No recommendations were
made on provocation/neutralisation techniques. 15
Dr M Webb, version 1, March 2008
Conclusion: There is a lack of good quality evidence to support the use of
provocation testing and neutralising vaccines in the treatment of MCS.
COST EFFECTIVENESS
The search did not reveal any evidence on cost effectiveness of
provocation/neutralisation treatment for MCS. One cohort study from Canada studied
the impact of a multidisciplinary approach to the management of patients with MCS
on health care utilisation costs. There was a relative decrease in the years following
the initial consultation at the treatment centre of visits to general practitioners and
secondary care.
ONGOING RESEARCH
No relevant trials were identified
REFERENCES
1
The Merck Manuals. Multiple Chemical Sensitivity Syndrome(Idiopathic Environmental
Intolerance). Merck Manual 2005. Available at:
http://www.merck.com/mmpe/sec22/ch334/ch334c.html. Accessed 12th March 2008.
2
Breakspear Hospital. National Public Health Service 2004, unpublished.
3
Breakspear Medical Group Ltd. Multiple chemical sensitivity. Available at:
http://www.breakspearmedical.com/files/multiple_chemical_sensitivity.html. Accessed 11th March
2008.
4
National Public Health Service. Evidence Checklist. Available at: http://www.nphs.wales.nhs.uk.
Accessed 10th March 2008.
5
National Public Health Service for Wales. Overview of the evidence on effective service models in
chronic disease management. Cardiff: NPHS; 2005. Available at
http://wales.gov.uk/topics/health/publications/health/reports/internatoverviewchronicdisease?lang=en.
Accessed 10th March.
6
Corabian P; Harstall C. Multiple chemical sensitivity: etiology, epidemiology, diagnosis, and
treatment (Structured abstract). Health Technology Assessment Database 2008; Issue 1.
7
Somerville M. Effects of desensitisation treatments and clinical ecology for multiple chemical
sensitivity and related disorders (Structured abstract). Health Technology Assessment Database
2008;:Issue 1.
8
Health Council of the Netherlands. Multiple Chemical Sensitivity. The Hague. Health Council of
the Netherlands. 1999; Publication Number 1999/01. Available at:
http://www.gr.nl/samenvatting.php?ID=381&highlight=multiple%20chemical%20sensitivity.
Accessed 20th March 2008.
9
Das-Munshi J; Rubin GJ; Wessely S. Multiple chemical sensitivities: A systematic review of
provocation studies. Journal of Allergy & Clinical Immunology 2006 ;118:1257-64.
10
Bornschein S; Hausteiner C; Zilker T et al. Psychiatric and somatic disorders and multiple chemical
sensitivity (MCS) in 264 ‘environmental patients’. Psychological Medicine; 2002; 32: 1387-1394
11
Forsthovel C; Kaspers FA; Bailer J. Psychological correlates of multiple chemical sensitivity (MCS)
and possible psychological causes. [German]. Zeitschrift fur Klinische Psychologie und Psychotherapie
2007;36(3):198-206.
12
Eis D, Muhlinghaus T, Birkner N, Dietel A, Eikmann T, Gieler U, et al. The German multicenterstudy on multiple chemical sensitivity (MCS) - Results from phase II. [German]. Umweltmedizin in
Forschung und Praxis 2005;10:359-76.
13
Dietel A; Jordan L; Muhlinghaus T et al. Psychiatric disorders of environmental outpatients results of
the standardized psychiatric interview (CIDI) from the German Multi-Center Study on Multiple
Chemical Sensitivity (MCS). [German]. Psychotherapie Psychosomatik Medizinische Psychologie
2006 ;56:162-71.
14
Royal College of Physicians. Allergy: the unmet need. A blueprint for better patient care. A report
of the Royal College of Physicians Working Party on the provision of allergy services in the UK.
Royal College Physicians 2003.
Dr M Webb, version 1, March 2008
15
House of Lords Health Select Committee on Science and Technology. Sixth Report 2007. Available
at: http://www.publications.parliament.uk/pa/ld200607/ldselect/ldsctech/166/16602.htm. Accessed 16th
March 2008.
16
Aggressive Research Intelligence Facility. The Breakspear Hospital. University of Birmingham
2003. Available at: http://www.arif.bham.ac.uk/pdfs/REP-report-breakspear.pdf. Accessed 14th march
2008.
17
Aggressive Research Intelligence Facility. Provocation- neutralisation Technique; Miller Technique;
Multiple Allergy Syndrome; Multiple Chemical Sensitivity; Chronic Fatigue Syndrome; Candidal
Hypersensitivity; Post-chemotherapy Fatigue. ARIF, University of Birmingham 2003. Available at:
http://www.arif.bham.ac.uk/requests/p/provocation-neutralisation-miller-technique.htm. Accessed 14th
March 2008
18
Forbes L. Update report: Effects of desensitisation treatments and clinical ecology for multiple
chemical sensitivity and related disorders. In Bazian Ltd (Ed) STEER: Succinct and Timely Evaluated
Evidence Reviews 2003; 3(8). Wessex Institute for Health Research & Development, University of
Southampton. Available at: http://www.signpoststeer.org. Accessed 10th March 2008.
19
Aggressive Research Intelligence Facility. The Breakspear Hospital. University of Birmingham
2006. Available at: http://www.arif.bham.ac.uk/pdfs/REP-report-breakspear.pdf. Accessed 14th march
2008.
20
Dretzke J; Song F. Provocation-neutralisation testing and therapy for food allergy. West Midlands
Health Technology Assessment Collaboration Report. University of Birmingham 2003. Available at:
http://rep.bham.ac.uk/pdfs/2004/food_allergy.pdf. Accessed 18th March 2008.
Dr M Webb, version 1, March 2008