The practice of allergology

The allergist is especially competent in appropriately providing the following treatments:

• Antihistamines 

• Mast cell stabilizers

 • Bronchodilators

• Nasal, oral, ocular, topical, and inhaled glucocorticosteroids 

• Decongestants 

• Leukotriene modifiers 

• Phosphodiesterase modifiers, including theophylline 

• Adrenergic agonists 

• Anticholinergics (oral, topical and inhaled) 

• Mucolytics 

• Antibiotics 

• Adrenaline, epinephrine 

• All other pharmacologic and immunologic agents used to treat allergic and immunologic diseases The allergist is uniquely aware of the pharmacologic properties of the treatments, their limitations and side effects. He/she is also keenly aware of how other medications may affect allergic processes and cause allergic conditions, for example, coughing and angioedema (ACE inhibitors).

Allergists treat a variety of skin conditions and are expert in the use of: 

• Emollients 

• Antibiotics 

• Topical glucocorticosteroids 

• Immune modulators and all other agents and techniques used to manage eczema and other allergic skin disorders

Part of the current therapeutic arsenal includes: 

• Use of immune modulators, such as specific allergen immunotherapy (oral and injective) 

• Immunoglobulin replacement used to treat allergic and immunologic disorders 

• Monoclonal antibodies, including anti-IgE

Part of the education of patients involves: 

• Instruction on the methods and value of allergen avoidance techniques 

• Avoidance diets and nutritional implications of dietary modification 

In particular for pediatric patients the allergist should be able to educate the parents, relatives and teachers about ways to optimize the prevention and treatment of allergies in children. 

In order to apply all these treatments properly, the allergist must have current and ongoing knowledge of national and international guidelines for the management of allergic and immunologic disorders in adults and children, with particular emphasis on safety and efficacy of all therapies. 

The membership of WAO is approximately 35,000 allergists worldwide representing the bulk of the trained allergists globally. In some developed countries such as Japan, Germany and the US, there are 4,000-8,000 trained allergists per country, representing about 1 allergist per 25,000 to 75,000 patients. It is estimated that ideal care would be provided by about 1 allergist per 20,000-50,000 patients, provided that the medical community was trained and competent to provide first and second level care by primary care physicians and other organrelated specialists. On the other hand, there are countries such as Costa Rica with less than 10 allergists and others with even fewer. Thus, the huge number, diversity and importance of patients with allergic diseases is overwhelmed by the inadequacy of the training of the medical community to provide care to these sick and needy patients. It is in part from this pressing need that this White Book on allergy was developed.

The practice of allergology

The practice of allergy involves the diagnosis and care of patients with:

• Rhino-conjunctivitis, along with nonallergic rhinopathy

• Sinusitis, both acute and chronic, alone or complicated with nasal polyps 

• Otitis and Eustachian tube disorders 

• Asthma and all its forms including cough-variant asthma and exercise-induced asthma 

• Cough from all causes 

• Bronchitis, chronic obstructive pulmonary disease (COPD) and emphysema 

• Hypersensitivity pneumonitis 

• Alveolitis 

• Atopic dermatitis/eczema 

• Contact dermatitis 

• Urticaria and angioedema 

• Drug allergy 

• Food allergy 

• Latex allergy 

• Insect allergy and stinging-insect hypersensitivity 

• Gastrointestinal reactions resulting from allergy, including eosinophilic esophagitis and gastroenteritis 

• Anaphylactic shock

• Immunodeficencies, both congenital and acquired 

• Occupational allergic diseases 

• Identifying and managing risk factors for progression of allergic diseases — the «allergic march» 

• Other specific organ reactions resulting from allergy

• Conditions that may mimic or overlap with allergic disease 

• An expert knowledge of the epidemiology and genetics of allergic diseases Immunodeficencies and autoimmune diseases, with special knowledge of regional and local allergens

As part of the practice of allergy, the allergist should be capable of ordering and interpreting allergy-and immunology-related laboratory tests:

• Evaluating total IgE and allergen specific IgE measurements

• Carrying out appropriate provocation testing for allergic and immunologic disease 

• Providing analysis and advice regarding local environmental/airborne allergens and irritants, as well as the analysis and advice regarding ingested allergens/ irritants

• Conducting and/or evaluating tests of pulmonary function and tests of inflammatory markers

• Conducting and/or evaluating tests of nasal function; this may include examination of nose and throat via fiberoptic rhinoscopy and nasal endoscopy 

• Specific allergen and venom immunotherapy 

• Providing pharmacotherapy of allergic disorders and related diseases including aero-allergens, drugs, venoms, occupational allergens, and food allergens 

Because of the highly specialized training, the allergist can advise both patients and other members of the medical community on:

 The role of effector cells involved in allergic disease (stem cells, • lymphocytes, mast cells, basophils, eosinophils, neutrophils, • monocytes, macrophages, dendritic cells) 

• The molecules involved in the immunological response (both innate and acquired) including chemical mediators; immunoglobulins; antibodies; complement; cytokines;interleukins; chemokines and their receptors; human leukocyte antigen/major histocompatibility complex (HLA/MHC) antigens • The main hypersensitivity reactions 

• Cell-to-cell interactions 

• The scientific in vitro laboratory diagnostic tests for allergy and 

• their selection and interpretation, including allergenspecific in vitro assays; enzyme-linked immunosorbent assays (ELISAs); Western blotting; tests for inflammatory markers, protein and cellular antigen stimulation tests; histamine release assays

The allergist is especially competent in performing/interpreting the following: 

• Allergic history and physical examination 

• Skin testing 

• Where necessary, investigating alternative diagnoses 

• Environmental modification strategies to reduce allergen exposure 

• Specific immunotherapy (allergen vaccines; both oral and injective)

• Immunomodulatory therapy 

• Drug desensitization 

• Evaluation and treatment of allergic and immunologic competence 

• Management and treatment of anaphylactic shock 

• Education for patients, caregivers and primary care physicians 

Undergraduate And Postgraduate Education For Primary Care Physicians And Pediatricians

Identified Need: 

There is a need for undergraduate and postgraduate training in allergy, asthma and clinical immunology for general practitioners and pediatricians such that primary care physicians and pediatricians may appropriately assist patients with allergic diseases. 

Recommendation: Allergic diseases are a major cause of morbidity and mortality. Suitable undergraduate and postgraduate training for medical students, physicians, pediatricians and other healthcare professionals will prepare them to recognize allergy as the underlying cause of many common diseases. It will also enable them to manage mild, uncomplicated allergic disorders by targeting the underlying inflammatory mechanisms associated with these diseases. They will learn when and how to refer the more complicated cases for a specialist consultation. Such education at the general practice level is of paramount importance since the vast majority of patients with allergic diseases are cared for by primary care physicians and pediatricians. These clinicians will also be required to comanage such patients with an allergy specialist and should be aware of the role of the allergist/clinical immunologist in investigating, managing and caring for patients with complex allergic problems.

Recognition Of The Specialty And Training Programs

Identified Need: Globally, medical education providers need to recognize allergy / clinical immunology as a specialty or sub-specialty, resulting in adequate training programs for optimal patient care. 

Recommendation: Expertise in allergy and clinical immunology should be an integral part of the care provided by all specialty clinics. Where allergy/clinical immunology training is not presently available or recognized as a specialty, training and national accreditation programs should be instituted to enable selected physicians to receive formal training and the qualifications required to become certified allergists/clinical immunologists. Such programs will also enable general practitioners, including pediatricians, to enhance their capacity to provide for the routine care for patients with allergic diseases.

Public Awareness Of Allergy, Asthma And Clinical Immunology

Identified Need: In most populations around the world, there is a lack of adequate education about, and awareness of, the morbidity and mortality associated with allergic diseases; the often chronic nature of these diseases; the importance of consulting a physician trained in allergy, asthma and clinical immunology; and the medications and treatments available to appropriately treat and prevent these diseases. 

Recommendation: Public health authorities should target allergic diseases as a major cause of morbidity and potential mortality. They should collaborate with national allergy, asthma and clinical immunology societies and patient support groups to publicize the necessity for general awareness and appropriate care for these diseases. 

The practice of allergology

Allergy is a very common ailment, affecting more than 20% of the populations of most developed countries. The major allergic diseases, allergic rhinitis, asthma, food allergies and urticaria, are chronic, cause major disability, and are costly both to the individual and to their society. Despite the obvious importance of allergic diseases, in general allergy is poorly taught in medical schools and during post-graduate medical education, and many countries do not even recognize the specialties of Allergy or Allergy and Clinical Immunology. As a consequence, many or most allergic patients receive less than optimal care from non-allergists. The World Allergy Organization has recognized these needs and developed worldwide guidelines defining What is an Allergist?1 , Requirements for Physician Competencies in Allergy: Key Clinical Competencies Appropriate for the Care of Patients with Allergic or Immunologic Diseases2 , and Recommendations for Competency in Allergy Training for Undergraduates Qualifying as Medical Practitioners3 . These important position papers have been published worldwide over the past few years, but it is far too soon to see whether they will influence the need for more, better and improved training in allergy worldwide.

An allergist is a physician who, after training in internal medicine or pediatrics, has successfully completed a specialized training period in allergy and immunology. As part of allergy training, all allergists are trained in the relevant aspects of dermatology, pneumonology, otorhinolaryngology, rheumatology and/or pediatrics. Subject to national training requirements, allergists may be also partially or fully trained as clinical immunologists, because of the immune basis of the diseases that they diagnose and treat. In most countries where the allergy, or allergy and clinical immunology, is acknowledged as a full specialty, the duration of the training is four/five years (including the common trunk in internal medicine and/or other disciplines, and two/three years of allergy and clinical immunology); where it is a subspecialty the approved period of training in allergy and clinical immunology will be two/three years after completion of the main specialty. Depending on national accreditation systems, completion of this training will be recognized by a Certificate of Specialized Training in Allergy, in Allergy and Immunology, or in Allergy and Clinical Immunology, awarded bya governing board. In some countries this will follow successful completion of a certification test or a final exam and in other countries by competencies being signed-off by a training supervisor. In some countries the allergist treats both adults and children while in some others, pediatricians, with specialty or sub-specialty in allergy, are competent to treat children