Once it was thought to be something of a joke, the affliction of posh people. Now millions suffer. Linda Gamlin explains why and offers practical advice for relieving it.
Daffodils in flower just after Christmas and volleys of sneezing in early February – what’s the connection? The answer of course is ‘climate change’, with the exceptionally mild winters bringing the flowering season of plants forward more and more. As I write this, in mid-February, the University of Worcester, a major centre for pollen monitoring and forecasting in Britain, is recording the peak of the pollen season for hazel bushes – a source of problems for some hayfever sufferers – in many parts of the country. Thirty years ago, the hazel catkins would not generally have begun expanding and opening to release pollen until late February, with the peak of their season in mid-March. There were always unusual years with very mild winters, when the hazel pollen began to appear from late January onwards. But those were exceptional years. In our changing world, this early start is ‘the new normal’.
In southern and central regions of England, the catkins of alder trees – tiny, hard and purple all through winter – have also started to swell and shed pollen by mid-February this year. Like hazel, alder can trigger hayfever for some allergy patients, and the pollen count is already rising to moderate levels on sunny days, enough to provoke symptoms.
Next in line will be the birch trees, whose pollen is a troublesome allergen for many of us, and in Scandinavia is by far the biggest single cause of hayfever. For the British Isles, the major hayfever culprits are the grasses, with roughly half of UK hayfever patients sensitised to one or more grass species. Grasses flower in late spring, but whereas formerly they hit their peak in the second week of June, now they can peak at the end of May.
What all these hayfever-causing plants have in common is that they are pollinated by the wind, rather than by insects or other animal pollinators. Pollen that travels from one plant to another on the legs of a bee or the ‘tongue’ (proboscis) of a butterfly is made up of relatively large pollen grains that are both sticky and heavy. Although some insect-pollinated plants can cause hayfever in a few people – privet does, for example – this is relatively unusual. Pollen that depends on the wind for dispersal is, by comparison, made up of small lightweight grains, and is produced in huge quantities, since for a pollen grain to make contact with a female flower of the same species – which is what pollination is all about – is the ultimate blind date. Wind pollination, in other words, is hit and miss (mostly miss). This is why there is such a massive amount of pollen from wind-pollinated plants floating about in the air, and getting into our eyes and noses. Most people are oblivious to it, but for hayfever sufferers, who account for roughly 20% of the population today, this is a source of annual misery and embarrassment. Those who have asthma as well as as hayfever may have more trouble with their breathing during the pollen season, and it can also exacerbate eczema for a few patients. Most worryingly for teenagers with hayfever and their parents, GCSE and ‘A’ level exams coincide with the grass pollen season, and anyone with severe hayfever is at risk of doing worse in their final exams than they should. Compared to the grade achieved in the mock exams in January, hayfever sufferers are 40% more likely to drop a grade than pupils without hayfever.
Hayfever is the original ‘affluenza’, appearing out of nowhere in the late 18th Century, and at first striking the upper classes only. It was thought of as something of a joke, not surprisingly, as the afflicted members of the aristocracy, snuffling and sneezing, escaped to Brighton for the summer, where the sea breezes cleared the air and gave them relief from their symptoms. The disease continued to increase gradually, but for over a century it still showed a preference for the well off, and then, as time went on, a preference for the more highly educated, and finally for those who lived in towns. It took a very long time to work its way down to the poor and to country dwellers, and to show no detectable preferences.
For a long time there were geographical variations too. In 1925, when Noel Coward changed the original name of his play Oranges and Lemons to Hayfever, the disease was obviously well known enough for London theatre-goers to understand the title. (At the same time, Coward’s choice suggests that hayfever retained something of its comical absurdity – a disease of the idle rich.) By contrast, a young medical student in Scotland in the late 1930s, John Morrison-Smith, found nobody among his learned tutors, or any other doctors he came across, who could explain his prolonged ‘summer cold’ that was always worse on the golf course or roaming around Loch Lomond. Many years passed before he found the explanation or encountered another hayfever sufferer – yet when he married and had children of his own, two of them developed hayfever.
Today, these geographic differences have vanished along with the social ones, at least in UK and most other wealthy nations: all classes and all regions are equally affected. In many African countries, however, there is still a difference in the hayfever rate between urban and rural areas, and the same may be true of some wealthy countries, such as Finland, where the contrasts in environment between city and country life are far greater.
Explaining the epidemic
As hayfever rates climbed ever faster in the 20th Century, the story became newsworthy and in the 1980s journalists collectively plumped for ‘pollution’ as the cause, undeterred by the fact that the scientific evidence suggested only a minor role at most. In particular, the peculiar early history of hayfever doesn’t fit with the idea that its sudden appearance was a result of growing air pollution. After all, it was the urban poor who endured choking industrial pollution in the 19th Century, not the landed gentry.
Over the past 15 years, those ‘Hayfever Epidemic due to Air Pollution’ headlines have faded away as the real root causes of the meteoric rise have finally become clear: a radical change in the bacterial environment that children encounter in their early years. This conclusion is based on a mass of evidence from different parts of Europe. It is worth looking at this evidence briefly because it helps to understand what is commonly, and a little misleadingly, described as ‘the hygiene hypothesis’:
- Three separate research studies on children growing up on farms with livestock showed that their rates of hayfever and/or allergen sensitisation were substantially lower than other children in the same villages.
- A British study discovered that children with several older siblings were much less likely to develop hayfever than either the oldest child in a family or an ‘only child’. The difference was huge : an ‘only child’ was four times more likely to have hayfever than the youngest child of a large family.
- Another study showed that this risk for the ‘only child’ could be much reduced by having a pet dog.
- A study of Italian boys called up for military service found that sensitisation to common allergens was much less common in those whose blood carried antibodies to three different infectious organisms, all dispersed by food or faeces. The researchers measured these antibodies because they act as indicators of cleanliness at home: if the family has a cheery disregard for habits such as washing hands before meals this will show up as particular kinds of antibodies in the blood. Whatever this grubby way of life might have entailed in terms of childhood stomach aches, it offered a powerful protection against allergies.
- Another showed that giving antibiotics (especially the broad-spectrum kinds that kill a wide range of bacteria, and have an impact on the natural gut flora) before the age of two increased the risk of allergic sensitisation in children from allergy-prone families. The more courses of antibiotics a child had taken, the greater the risk.
- A British study showed that children who washed their hands more and had frequent baths were more likely to develop asthma. (In children, asthma is generally linked to allergies, so this study is relevant here, with asthma acting as an indicator of allergen sensitisation.)
As you can see from these studies, ‘hygiene’ is only part of the story. What they all point to, in their different ways, is that babies, soon after birth, need the stimulation provided by encountering bacteria in the environment. Most of those bacteria are harmless and do not produce any disease. Some are the bacteria that naturally live in our gut or on our skin: these are mostly picked up from the mother during birth and early life. Many others are soil-living species which live by breaking down dead leaves and roots. Known as ‘saprophytic bacteria’ they are harmless to humans and animals. A few of the bacteria that a baby might encounter in the environment produce mild and transient symptoms. All of these different bacteria are capable of giving the baby’s immune system a powerful nudge in the right direction, so that it develops a profile of regulatory cells that work to combat disease. This profile doesn’t favour allergy. Without sufficient stimulation from different kinds of bacteria, the baby’s immune system remains fixed in a pattern of activity (due to a particular profile of regulatory cells that we have at birth) which is predisposed to respond with allergic sensitisation when allergens such as pollen are encountered.
Obviously this isn’t just a question of hygiene and hand-washing: antibiotics play a part too. And Professor Tari Haahtela, head of the Allergy Department at Helsinki University Central Hospital in Finland, considers that asphalt and concrete are equally important. When paths and roads were unsurfaced, he argues, the soil dust from them became airborne in dry weather and was inhaled. It did not contain live bacteria, but it contained bacterial products that can have the same stimulatory effects on the immune system of a young child. Professor Haahtela has shown how the amount of asphalt used in Finland and the rates of asthma have increased in perfect unison. In his view it is ‘distance from the soil’, brought about by many different aspects of modern life, that is responsible for the rise in hayfever and other allergies.
Professor Graham Rook of University College London broadly agrees, and has introduced the term ‘old friends hypothesis’ which he thinks is more appropriate and helpful than ‘hygiene hypothesis’. Professor Rook’s ‘old friends’ are bacteria and parasitic worms with which we evolved over the millennia. They were such a constant and familiar part of our environment that in various ways our bodies became dependent on them. The immune system, especially, came to rely on them to channel it into the right course during the first few weeks and months of life. Professor Rook believes that various other ‘diseases of civilisation’, such as inflammatory bowel disorders and Type 1 diabetes, could be caused by this lack of the right stimulation. He also argues that it is the diversity of bacterial stimulation that is needed, and that we are suffering from ‘a lack of biodiversity’ both internally and in the external environment.
All these new ideas and discoveries are fascinating, but can they help the hayfever sufferer in the here and now? One key question is whether, with the right kind of bacterial stimulation, the immune system can be pushed in the proper direction – away from the tendency to allergy – in later childhood or even adulthood. This does not seem to have been investigated, but it is possible. Certainly it works in reverse, in that people moving from remote and impoverished rural areas in developing countries and settling in towns may acquire hayfever, a disease unknown in the places they originate from.
Where the research could definitely be of practical help is in avoiding hayfever and other allergic problems in the next generation. Any family that is prone to allergies would do well to take up the decking, the paving, the gravel and all those other ‘easy maintenance’ features from the back garden and start digging the soil below to actually grow things, involving the children as much as possible. If you live in a flat, you could try to get an allotment, go and help an old person with their garden, or just acquire some windowboxes and indoor plants. Several strands of research suggest that bacterial products (the remains of their cell walls for example) are capable of tweaking the immune system, just as much as live bacteria. For example, in one study it was found that in homes where the dust contained high levels of endotoxin – a breakdown product of certain bacteria – children were less likely to develop asthma. This is encouraging news if your only gardening possibility is indoors or on a balcony because, while the potting compost you buy from a garden centre is heat-treated to eradicate plant pests and diseases, it will still contain the breakdown products of saprophytic bacteria. (If anyone in the family is allergic to mould spores as well as pollen, however, note that pot plants will increase levels of mould spores within the home unless you change the topmost layer of the compost regularly and keep it fairly dry.)
Another highly relevant piece of research here is that children who are active are less prone to developing hayfever than children who take little or no exercise. This is thought to be a direct effect of physical exertion on the immune system. So winching the children off the sofa and getting them outside for a brisk walk (preferably in the woods or somewhere wild and green – even in London such places can be reached quite easily) is all to the good. Don’t fuss if they get muddy or roll in the leaf-mould.
If you suffer from hayfever yourself this may be the last thing you want to do on a summer’s day, of course. The key here is getting your own hayfever symptoms under control as much as possible so that going outside isn’t unbearable. Here is a six-point plan for minimising your symptoms :
- Start with a determined all-out programme that tackles your hayfever on several fronts at once. (Some of the measures below will almost certainly be part of your treatment plan already; add in those that are not.) Assuming that you can get the symptoms under better control, keep all the measures going for a while to allow your eyes and nose to ‘calm down’. Then, if you wish, you can experiment with eliminating one or another of the measures to see what the response is.
- Make full use of the medications that are on offer. Ask your GP or pharmacist for advice. Nothing that is currently available for hayfever carries any risk of serious side-effects, as long as you are careful not to over-use steroid nose sprays (such as Beconase, Avamys, Rhinocort, Flixonase and Nasonex). Anti-histamines are particularly safe drugs – but check with your doctor if you are also taking antidepressants because some interact. There is no reason to feel concerned about taking anti-histamines every day during the hayfever season. The sleepiness that old-fashioned anti-histamines (such as Piriton) brought on has been overcome with the new-generation anti-histamines (such as Cetirizine and Loratadine, which are available without prescription). It is amazing how many people don’t take anti-histamines because they took them twenty years ago, found themselves nodding off in the daytime, and never tried them again. This is unfortunate because most people with hayfever have substantial benefits, especially from Cetirizine which is both cheap and safe. Anti-histamines are now available in a nose-spray form as well. Finally, if you have severe hayfever that isn’t helped by any of the usual treatments, ask your GP if it might be possible to prescribe a leukotriene receptor antagonist; this is a medicine that is taken in tablet form and can be very effective.
- Use anti-histamines as a preventive medicine. This means taking them before the season for your particular pollen begins, and keeping on with them until the season in over. Too many people only take anti-histamines when they first experience hayfever symptoms, or – even worse – they tough it out and wait until they “really need them”. To understand why this is a mistaken strategy, think of a game of musical chairs. The ‘chairs’ are the receptors in your nose and eyes where, when histamine sits down, it starts off all the watering, irritation and sneezing. When an anti-histamine molecule sits on the ‘chair’ first, the histamine can’t sit down and so nothing happens. You need to have all the ‘chairs’ (receptors) occupied by anti-histamines before any histamine appears on the scene. Since histamine is produced as soon as the offending pollen gets into your eyes and nose, it is obvious that you need to have anti-histamines deployed in advance of that, for the drug to be of maximum benefit. So remember when your symptoms began last year, or follow the pollen forecasts, and be well ahead of the game. If you don’t manage to do that, take your anti-histamines at the very first sign of a symptom, however slight. And then keep taking them at the same time every day: don’t skip doses, or delay them.
- Back up the drug regime with pollen avoidance, so that there is less histamine to cope with. If your eyes are affected, do what you can to keep pollen out of your eyes while outdoors. Wear sunglasses, preferably the ‘wrap around’ kind. If you dislike sunglasses, or want even more protection, you can wear the kind of lightweight plastic safety specs that are sold for DIY: they have a shield all the way around each lens which will really keep the pollen at bay.
- Protect your nose from pollen as much as you can. The simplest measure is to smear a little Vaseline around the inside of each nostril and renew it regularly. This works to reduce your exposure by trapping some of the pollen in the airstream entering your nose. A more radical approach is to use something that will filter out the pollen entirely, either a dust mark or a pair of tiny filters that fit inside, one in each nostril. There are a few different products of each type for sale online. The intra-nasal filters have the advantage of being inconspicuous and while they are slightly uncomfortable at first, people find they get used to them. One American design, called ‘WoodyKnows Nasal Filters’, is available in the UK and has some very good reviews although it clearly doesn’t work for everyone. Given the modest price, it would seem worth trying. If your nose is very runny you may find it difficult to use these nasal filters: ask a GP about prescribing a nasal spray that contains Ipratropium, which can reduce your nasal discharge. When buying either a nasal filter or a mask, remember that to control hayfever you only need something to take out particles, not the more expensive products that contain activated carbon for removing chemical pollutants from the air. · When you get home after a time outside, if you notice any symptoms, then change your clothes, rinse your hair through, and keep the doors and windows closed. Stay clear of pets that come in from outside as they may well have pollen on their fur. (Note that pollen settles quickly from the air in a still room, and buying an expensive air filtering machine is not going to add significant benefit.)
Turning the allergic reaction off
If the six-point plan hasn’t helped as much as you hoped, then there is a further option. This is the most radical treatment for hayfever, one that switches off the allergic reaction before it even starts by re-educating the immune system. In effect it tells your immune system that the pollen allergen it has ‘taken against’ is actually safe and harmless. This is achieved with a series of injections of the pollen extract just under the skin. The treatment is known as immunotherapy, allergic desensitisation, or – in North America – ‘allergy shots’. The story of how this treatment was devised by a British doctor in 1911 and then became virtually unavailable in Britain, uniquely among Western nations, is a long and sad one that I have told before in this magazine. The bottom line is that you are most unlikely to get allergic desensitisation on the NHS unless you have a very severe allergic response. It is generally reserved for patients with a life-threatening allergy to insect stings.
A new and very safe alternative to this injection-based therapy is one where the allergen is delivered to the body as drops or in tablet form, placed under the tongue. A simple version, called Grazax, that just treats grass pollen allergy can – in theory – be prescribed on the NHS. The first dose must be taken in hospital and after that the patient takes it at home. Although slightly less effective than the injection-based immunotherapy it usually brings some improvement, and for the luckier patients it can be a total life-changer. Unfortunately, the very high cost of Grazax (see below) means that most NHS regulatory bodies have ruled against it being used at all. There are exceptions however, and in some areas it is available to a few allergic patients. So it is worth enquiring of your GP if you could be referred to a specialist centre that can consider your need for this treatment. Expect a great deal of discouragement at every stage of your journey!
If you could afford to pay for the treatment yourself you could do this, but you would still need a referral from your GP as the first step. The cost will be about £1200 per annum for three years. Benefits tend to persist after the treatment has ended, at least for a few years, so in thinking about whether it is worth it, aportion the costs over six years. You could think of it as a prolonged ‘holiday’ from the miseries of hayfever and ask if it is a holiday you want to take at that price!
Linda Gamlin’s books THE ALLERGY BIBLE and, co-authored with Prof. Jonathan Brostoff, THE COMPLETE GUIDE TO FOOD ALLERGY AND INTOLERANCE, are available from Merton Books Ltd. 020 8892 4949, £12.50 each.
This article first appeared in Allergy Newsletter No. 116, Spring 2016.