Need for more specialized care

Speech made by Technology and Research Minister Prof. Tissa Vitarana at the 5th Biennial Scientific Sessions of the Allergy and Immunology Society of Sri Lanka (AISSL) on July 29

The Allergy and Immunology Society of Sri Lanka (AISSL) is a relatively new organization. Since its beginning ten years ago with a few medically trained scientists with an interest in immunology and allergy, it has now expanded to a membership of over 250 drawn from a wide variety of disciplines including many fields of medicine like physicians, paediatricians, surgeons, rheumatologist, dermatologists and others such as veterinarians.

I am sure now that a dentist, Dr. Rajitha Senaratne, is our Chief Guest, there will be member dentists too joining our ranks. During the past two years we have had an active program which helped stimulate interest and update knowledge in this field.

Minister Prof. Tissa Vitarana

One of the key tasks that the AISSL has targeted is the establishment of a National Centre for Immunology and Allergy. I am glad to say that the plans have been drawn up for the centre, a potential site located and a project proposal prepared to seek government support. Now that the expenditure of the war is not a major constraint, we are hopeful that the project can go ahead. The death due to anaphylaxis following rubella vaccination and the unfortunate infant suffering from severe combined immune deficiency, who needs a stem cell transplant to survive infancy are two recent tragic events that have brought the field of immunology to the notice of the public. These two events are the extreme manifestations of the immune system in disarray, namely allergy and immune deficiency.

Prevalence

The international Study of Asthma and Allergies in Childhood (ISAAC) has conclusively shown that there has been a dramatic increase in the overall prevalence of atopic diseases such as atopic dermatitis, asthma, allergic rhinitis and food allergy in all regions of the world. We have seen a similar trend in Sri Lanka and although we do not have exact data regarding the prevalence of these diseases, it is evident that they are on the rise. Data from the National Hospital and the other hospitals, indicate that in the last 10 years the single disease that has shown the greatest increase both with regard to OPD and indoor treatment and deaths is Bronchial Asthma. Physicians, paediatricians, dermatologists, ENT surgeons etc... are now treating more and more patients with such atopic diseases.

Adrenaline injection

Therefore, there is an urgent need to diagnose and identify allergens in such individuals for better management.

A number of deaths due to anaphylaxis have been reported. While most patients recover, regrettably a few have succumbed. A major drawback in this country is the lack of a self injectable adrenaline injection (‘epipen’) which is a life saving device for patients prone to anaphylaxis. The available device is expensive. I hope the Society and the Health authorities, consider the possibility of producing a similar device at an affordable price, perhaps in collaboration with India.

Primary immune deficiency is being diagnosed with increasing frequency in Sri Lanka, probably due to heightened awareness among clinicians. This is seen very clearly by the neonate with SCID, delivered two weeks ago. Three generations and 15 deaths among male infants went unnoticed; today, this child was diagnosed as having x linked SCID in utero, due to a mutation in the common gamma chain, using state of the art technology. However, while diagnostic methodology has improved, treatment has become a problem. Many children with antibody deficiencies are treated with intra venous immune globulin in State hospitals; however, stem cell transplantation seems to be a distant dream in Sri Lanka. This, despite the steady increase in the number of solid organ transplants performed in this country.

Specialized care

I call upon the society to initiate, in conjunction with other colleges, a stem cell transplantation program for the people of Sri Lanka. This will help not only those with primary immune deficiencies, but many patients with malignancies, who have to travel abroad for this therapeutic option.

There is a huge need to educate and train more individuals to manage patients with immunological disorders so that ‘specialized’ care is given to those who need it. In addition to training more individuals and creating awareness regarding allergy and immunological diseases, it is also important that laboratory services are also developed in order to provide diagnostic tests at an affordable price. However, sadly such diagnostic tests are not available in most government hospitals in Sri Lanka and some tests are available in private hospitals at a greatly inflated price.

Improvement

Apart from the improvement in immunology services in the country, there is a great need to improve research. The research that needs to be done varies from simple epidemiological research to complex laboratory based research. Considering two major infectious diseases with immunological basis, HIV/AIDS and Dengue, this becomes very evident. While the data on Dengue and Dengue Haemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS) is reasonably reliable, that for HIV/AIDS, like in most countries, is a guesstimate. The Dengue epidemic which occurred last year (38,000 hospitalized cases and 342 deaths) is continuing this year (22,758 cases with 164 deaths). With regard to HIV/AIDS, based on marker group studies, Sri Lanka appears to be a relatively low incidence country, but this is uncertain.

A recent tragic incident highlights the nature of the problem. A 15 year old girl who developed DHF/DSS was hospitalized and received plasma and platelet transfusions. She recovered, but it was discovered two years later that she had contacted HIV infection. It would appear that one of the donors had been in the window period when antibody detection was not possible.

Compensation

The family was ostracised and had to leave their village and suffer greatly in economic and mental terms. They are now seeking compensation from the government.

The programs to develop vaccines against both these dreadful diseases have not succeeded so far. Clearly the immunological aspects are adding to the problems. The pathogenesis of DHF/DSS still remains an enigma. While I was the Director of the Medical Research Institute besides epidemiological studies and the isolation of the local Dengue viruses, I investigated the possible role of cytokines like Tumour Necrosis Factor (TNF).

Still not clear

I found that TNF levels in cases of DHF were much higher than in cases of ordinary dengue (DF). Going through the current literature one regrets to learn that though some headway has been made the picture is still not clear.

There is no doubt that the enhancement effect on severity with successive infections holds true. But here is evidence that genetic differences within the four Dengue virus serotypes also plays a part. The mechanisms leading to initiation and aggravation of the plasma leakage are still a subject of discussion. The contribution of the lowered platelet count to the pathogenesis is also not certain.

In this context the worries regarding the involvement of the immune system in “increased disease severity and vascular damage has raised concerns about every vaccine design strategy proposed so far” (Stephenson, John R. Bulletin of the World Health Organization 2005;83:308-314). The task is basically to produce neutralizing antibodies against each of the four Dengue serotypes using the specific epitomes, without including any of the other epitomes that might lead to the enhancing effects. I hope that Sri Lankan scientists, possibly in partnership with colleagues overseas, will address this problem and eventually join the efforts going on worldwide to develop a successful and safe vaccine.