Celebrating 75 years of <scp>BSACI</scp>

The British Association of Allergists (later named the British Allergy Society, then the British Society for Allergy and Clinical Immunology (BSACI)) was formed in 1948. Dr Vera Walker, an ophthalmologist, wrote to Dr John Freeman, St Mary's Hospital, London suggesting this. She became the new society's first president, and the first secretary was Dr William (Bill) Frankland. The first meeting had about 30 delegates and 2 speakers, both eminent, Sir Henry Dale, a distinguished pharmacologist, Nobel Prize winner 1936, and John Freeman, an early proponent and innovator of immunotherapy. At that time, the diseases were mainly asthma and hay fever, and there were few treatments—classical antihistamines and immunotherapy mainly with pollen, bacteria and whole-body extracts of bee or wasp (the latter two, subsequently shown to be ineffective). Fast forward to 2023, the 75th anniversary of the Society, and there are 1053 members and almost 800 delegates at the Annual Conference, a myriad of disorders, detailed understanding of mechanisms and molecular pathways, awareness of the importance of the environment, and vast numbers of treatments. In 1948, there were no non-sedative antihistamines, no inhaled or topical steroids, and no β2 agonists. The metered dose inhaler was not introduced until 1956 and IgE not discovered until 1967 (Photo 1). This editorial describes some of the changes over the first 75 years of the Society, based on an armchair discussion with reminiscences of four past presidents at the 2023 Annual Conference. The Society's highly regarded official journal began in 1971 as ‘Clinical Allergy’ with Prof Jack Pepys as editor and was renamed ‘Clinical and Experimental Allergy’ in 1989, Barry Kay and Stephen Holgate being editors for 25 years. With the increase in membership and explosion in allergy, both numbers of patients affected and the knowledge base, the BSACI had to deliver more. Council decided a full-time secretariat was needed. Until 2001, this was provided by the wonderful Sue Duff, working part time, from her bedroom; and there were no headquarters, far less an office. Council meetings were held in various rented rooms, the nicest of which were at the British Dental Association. Jack Barnes, a retired Department of Health senior civil servant, was appointed as Executive Officer during Pam Ewan's presidency. Jack brought expertise and strategic vision, rented space, then hired and trained an assistant, Fiona Rayner, who took over when Jack retired in 2005 and became our excellent Chief Executive. BSACI purchased offices in Battersea, London, in 2011 and now employs 10 staff. In the 1980s, 1990s and early 2000s, there were only a few major allergy centres, most of which were academic (e.g. Prof Maurice Lessof then Prof Tak Lee at Guy's, Prof Barry Kay then Prof Stephen Durham at the Brompton Hospital, Prof Stephen Holgate in Southampton, Prof Andrew Wardlaw in Leicester, Dr Pamela Ewan in Cambridge). Thus there was little or no NHS funding for their allergy services, which were vulnerable if the academic lead retired. Other small services across United Kingdom were delivered by specialists in other fields with an interest in allergy, again not underpinned by funding specific for allergy. Waiting lists were long and services patchy or non-existent. Large areas had no specialist allergy services. Paediatric allergy services were few, for example Professors John Warner at St Mary's, London, then Southampton and later Gideon Lack at St Mary's and Adnan Custovic in Manchester. In response to rising concerns, Stephen Holgate and Pamela Ewan led a Royal College of Physicians (RCP) Working Party and produced the RCP Report ‘Allergy the unmet need’ in 2003.1 There followed a series of Reports, including those from the House of Commons Health Committee, the House of Lords Science & Technology Committee and from the Department of Health itself. All had the same message: allergy was common (1 in 3 adults and more in children) but the specialist workforce was tiny and general practitioners had little knowledge or awareness of allergy. Stephen and Pam set up the National Allergy Strategy Group (NASG) in 2003, bringing together BSACI and the patient charities, Allergy UK and the Anaphylaxis Campaign (now Anaphylaxis UK). The first priority of NASG was to improve allergy services across the NHS from primary to specialist care, and for adults and children; it first documented the size of the problem, followed by the service need. Today, there have been improvements and services are mainly NHS funded. Allergy is now in the mainstream of the NHS. But large deficiencies remain, highlighted in a recent parliamentary and NASG Report.2 Workforce constraints, in particular the limited number of training posts in allergy, mean that too few consultants in allergy are trained, restricting development so services are overstretched and serve large populations, though paediatric allergy has been able to expand more. Shockingly, adult allergy was the specialty with the smallest number of trainees nationally (11). Two separate specialties, Allergy and Clinical Immunology, each with their own training programme, have recently been combined, but the total number of trainees is unchanged, meaning that each speciality is underserved. (Photo 2) Barry Kay, Stephen Holgate and Tak Lee, following post-doctoral fellowships in K Frank Austen's laboratory in Harvard during the late 1970s and early 1980s, returned to the United Kingdom and transformed the landscape of research in bronchial asthma. They initially focussed on the role of mast cells, eosinophils and their autacoid mediators. Tim Williams at Imperial College London, and Andy Wardlaw in Leicester uncovered the importance of chemotaxis and adhesion for the recruitment and activation of eosinophils in allergic asthma. Stephen Holgate highlighted the importance of the epithelial mesenchymal unit as pivotal in asthma development from an early age.3 With Sebastian Johnston he demonstrated a fundamental defect in epithelial innate immunity in asthma with an attendant increased susceptibility to virus infections that underly most asthma exacerbations. Barry Kay was the first to translate the ground-breaking work of Mossman and Coffman in the 1980s into man. With others, he established the importance of Th2 T lymphocytes in asthma,4 an observation that laid the foundation for modern monoclonal antibodies that target the Th2 pathway and have transformed the modern management of severe eosinophilic asthma, preventing exacerbations and reducing dependency on oral corticosteroids. The Society, in tandem with St Mary's, Royal Brompton, Guy's and Southampton university hospitals, have made major contributions to the field of allergen immunotherapy. William Frankland used to record daily pollen counts on the roof of St Mary's hospital. He performed the first double-blind trial of immunotherapy in the 1950s.5 He not only showed that a grass pollen subcutaneous extract was effective for seasonal asthma, but that only the high molecular weight protein-containing fraction was efficacious. Over 4 decades, Stephen Durham and others explored the underlying mechanisms of immunotherapy6 and showed that both subcutaneous and sublingual immunotherapy are disease modifying and that 3 years treatment using vaccines of proven value may induce long-term disease remission. Following initial mechanistic studies on bee venom anaphylaxis by Maurice Lessof, Lawrence Youlten and Pamela Ewan, pure venom immunotherapy also proved to be efficacious with long-term remission. Tony Frew, Chris Corrigan, Stephen Durham and others led a multi-centre BSACI initiative to perform the first large double-blind trial of grass pollen subcutaneous immunotherapy to modern standards, resulting in approval of an alum-based vaccine for hay fever throughout Europe, but sadly not United Kingdom, still lingering over concerns following the 1986 Committee on Safety of Medicines Report on Immunotherapy. Through the BSACI, Glenis Scadding has led the development of guidelines for management of rhinitis and for allergen immunotherapy that are widely quoted internationally.7 A major change since the 1990s has been the modern epidemic of food allergy, and this was accompanied by a welcome explosion of membership of paediatric clinicians, nurses and dieticians within BSACI. Hasan Arshad performed pioneering work on the Isle of Wight on preventive strategies for allergy in infancy and childhood. Pam Ewan and Andrew Clark in Cambridge flagged the importance of peanut allergy in adults and children, including the importance of co-factors in triggering life-threatening attacks. They devised an easy and effective regime for peanut oral immunotherapy and gained extensive real-world experience.8 A major development has been the findings of the LEAP study from Gideon Lack and his team at the Evelina Children's Hospital.9 The observation that early introduction of peanut, ideally before 6 months of age, may prevent the onset of peanut allergy until 5 years and beyond has major implications for infant feeding strategies. Only a few can be mentioned. The Standards of Care Committee, formed in 2004, initially chaired by Andrew Clark, has been invaluable in producing high quality much needed guidelines. Primary care training days delivered by the major allergy centres, in 1 day provide considerable knowledge. After work by NASG with the Royal College of General Practitioners, allergy was included in the GP curriculum. Of other initiatives, many relate to education. An Allergy Clinic Handbook produced from 2001, showed where UK allergy services were and what was provided (now online, BSACI ‘Find a clinic’). PWE conceived the project; PWE and SRD drafted the paper and all contributed. None.

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