Allergy and Clinical Immunology Services in Europe

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Allergy and Clinical Immunology Services in Europe*


Allergology and Clinical Immunology (ACI) is an area of clinical medicine with
a precise identity, relevant recent scientic achievements and well-dened edu-
cational and professional needs.
In spite of the high individual and socio-economic impact of allergic diseases
in Europe, the organization of ACI services is imperfect and varies among
countries according to their health policies and priorities.
In the rm belief of the role of ACI specialists in addressing clinical issues
related to the involvement of the immune system in health and diseasessuch as
vaccination, immunodeciencies, susceptibility and response to microbial agents,
autoimmune and allergic diseases, immune aspects of transplantation and
malignancies, in vivo and in vitro immunological tests, vaccinations,
immuno-modiersthe European Academy of Allergology and Clinical
Immunology appointed an ad hoc Task Force to produce standards for ACI
Services in Europe.
The resulting position paper should be used as a consulting reference for
National Health Services as a necessary pre-requisite for the free circulation to
patients and health care professionals.
S. Bonini
1
, I.J. Ansotegui
2
,
S. Durham
3
, A.J. Frew
4
, J. Ltvall
5
,
K. Nekam
6
, T. Popov
7
, R. Dahl
8
,
J. Gayraud
9
, R. Gerth van Wijk
10
,
K. Kontou-Fili
11
, M. Kowalski
12
,
A. Todo-Bon
13
, U. Wahn
14
1
Second University of Naples amd INMM-CNR,
Rome, Italy;
2
Department of Allergy and
Immunology, Santiago Apstol Hospital, Santiago,
Spain;
3
Department of Allergy and Clinical
Immunology, Imperial College, National Heart and
Lung Institute, London, UK;
4
Inflammation and
Repair Division, School of Medicine, University of
Southampton, Southampton General Hospital
Infection, Southampton, UK;
5
Department of
Respiratory Medicine and Allergology, Gteborg
University, Gothenberg, Sweden;
6
Department of
Allergy and Clinical Immunology, Polyclinic of the
Hospitaller Brothers of St. John of God, Budapest,
Hungray;
7
Clinical Center of Allergology, Medical
University of Sofia, Sofia, Bulgaria;
8
Department of
Respiratory Diseases and Allergology, Aarhus
University Hospital, Aarhus, Denmark;
9
UEMS
Allergology and Clinial Immunology Section, Tarbes,
France;
10
Department of Allergology, University
Hospital Rotterdam, Rotterdam, the Netherlands;
11
Dept of Allergology and Clinical Immunology,
Division of Internal Medicine, LGD Hospital of
Athens, Athens, Greece;
12
Department of Clinical
Immunology and Allergy, Medical university of Lodz,
Lodz, Polond;
13
Servicio Immunoalergia, Centro de
Pneumologia, University de Coimbra, Coimbra,
Portugal;
14
Department of Dermatology and Allergy,
Allergy Centre Charit, Universittsmedizin Berlin,
Berlin, Germany.
*This article represents the position paper of the ad
hoc Task Force of the European Academy of
Allergology and Clinical Immunology (EAACI),
produced in collaboration with GA
2
LEN; a network
of excellence founded by the European Union.
Drafting group: S. Bonini (Chairman), I.J. Ansotegui;
S. Durham; A.J. Frew; J. Ltvall; K. Nekam; T. Popov
Task Force members: R. Dahl; J. Gayraud; R. Gerth
van Wijk; K. Kontou-Fili; M. Kowalski; A. Todo-Bon;
U. Wahn.
Prof. Sergio Bonini
Internal Medicine
Second University of Naples
INMM-CNR 100 Via Fosso del Cavaliere
00133 Rome
Italy
Accepted for publication 18 January 2006
Allergy 2006: 61: 11911196 2006 The Authors
Journal compilation 2006 Blackwell Munksgaard
DOI: 10.1111/j.1398-9995.2006.01081.x
1191
History and background
Allergology and Clinical Immunology (ACI) is an area of
clinical medicine with a precise identity which deals with
maintenance of the healthy state as well as with diagnosis,
prevention and treatment of several diseases caused by
over or under activity of the immune system that have
high individual and socio-economic impact.
Allergology and Clinical Immunology which found
its origins in the rst half of the twentieth century was
revolutionized in the 1960s by the fundamental discover-
ies on the structure and functions of the immune system,
immunodeciencies and allergic hypersensitivity reactions
responsible for clinical diseases (1). At present, ACI
represents one of the areas of medicine which underwent
most signicant scientic development, as documented by
the number of discoveries, scientic publications and
Nobel Prizes awarded.
Allergology and Clinical Immunology is not an organ
specialty (such as Respiratory Medicine, Gastroenterol-
ogy, etc.) and does not refer to specic diseases but to
individuals (2). Certainly, several diseases that may
involve the immune system such as diabetes, asthma or
glomenulonephritis, are treated competently by organ-
based specialists. However, only ACI specialists have the
professional education required for facing the clinical
issues related to the involvement of the immune system
in health and disease, such as vaccination, immunode-
ciencies, susceptibility and response to microbial
agents, autoimmune and allergic diseases, immune
aspects of transplantation and malignancies. Moreover,
a large number of diagnostic in vivo and in vitro
techniques are based on the interaction between antigens
and antibodies (such as skin tests with tuberculin,
microbial agents, professional and environmental aller-
gens; immunoassays for hormones and infectious agents;
ow-cytometry, etc.). This requires specic methodolo-
gical competences for their performance and interpret-
ation. Finally, several treatments (vaccines, immune-
modiers, cancer therapies, etc.) require a good under-
standing of the function and manipulation of the
immune system.
Accordingly, ACI is a broad clinical specialty which
relates to 100% of European citizens, from birth to
elderly, as well as to relevant environmental and socio-
economic issues of our Society (3).
The present situation in Europe
Allergology and Clinical Immunology is part of the core
curriculum of undergraduate students in Medicine in all
European Countries. At postgraduate level, there is a
consensus on having specic professional education in
ACI. However, in some countries ACI represents a full
specialty, in others a subspecialty and in others a
professional competence (Table 1).
In each European Country there is a scientic society
dealing with ACI. All National European Societies refer
to the European Academy of Allergology and Clinical
Immunology (EAACI, http://www.eaaci.net) which is
part of the International Association of Allergology and
Clinical Immunology World Allergy Organization
(IAACI-WAO, www.worldallergy.org). ACI Societies
have been working in a very close collaboration with
national and international regulatory bodies to produce
standards for health care such as disease guidelines,
measures of environmental control, socio-economic
issues, etc. Moreover, patients suering from allergic
and immunologic diseases have gathered in well-estab-
lished societies harmonized and coordinated by supra-
national grouping such as EFA.
For all the above reasons, ACI is currently considered
to be a health and scientic priority and a large number of
projects and networks of excellence have been recently
funded with massive investments by the European Union
within the fth and sixth Framework Programmes (4). On
the other hand, at the level of health care, the organiza-
tion of ACI is imperfect and there is an ongoing debate
about which areas should be covered by the specialty (5
7). Although ACI Services exist in all European countries,
their area of competence, structuring, autonomy and
recognition by the National Health System is heteroge-
neous among countries and sometimes even within the
same country (Table 1).
The current situation has some inconveniences:
1 The large amount of new scientic information and
progress in ACI produced by the scientic environment
has not so far translated into better clinical care. ACI
represents one of the best clinical examples of what has
been referred to as Lost in Translation (8).
2 The lack of a well-dened professional specialty
training and career structure has reduced the attractive-
ness of the specialization and, therefore, the number of
specialists in ACI.
3 As a consequence, important issues relating to the
maintenance of the healthy state (vaccination, environ-
mental control, etc.) as well as the management of the
extremely large and increasing number of patients with
allergic and immunologic diseases are referred to
dierent area specialists. For example whereas it is
highly appropriate that pneumologists are responsible
for the pharmacotherapy and acute hospital manage-
ment of acute life-threatening asthma, the global input
from a consultant allergist is valuable for the identi-
cation and treatment of underlying causes of asthma.
Similarly ENT doctors may evaluate rhinitis whereas
the allergist should be responsible for instigating allergy
diagnosis environmental control measures and where
appropriate, allergen immunotherapy. The same princi-
ples apply to the dual role of allergists and dermatol-
ogists in the management of atopic eczema.
Bonini et al.
1192
Furthermore these diseases frequently co-exist and the
absence of the global expertise oered by an allergist,
which complements the individual specialty approach, is
detrimental for individuals and increases the costs for
the community, not least because multiple consultations
are otherwise required.
The objective of the EAACI Task Force on Allergy Services
On the basis of the above considerations, the EAACI
felt the need to appoint a Task Force aimed at
producing standards for ACI Services to be used as a
unique consulting reference for National Health Ser-
vices (NHS) in their autonomous planning of health
organization. This should result in a more homogen-
eous structure of ACI Services in Europe, a necessary
prerequisite for the free circulation of patients and
healthcare professionals.
General principles for structuring of ACI Services
The organization of health services in each European
Country varies according to the health policy and
priorities of individual States as well as on resources,
epidemiological and socio-economic issues, and the
existing organization of other areas of medicine.
Accordingly, no rigid criteria should be dened but
a exible framework, to be adapted by individual
NHSs.
This document will address the Areas to be covered by
ACI Services, the dierent levels at which ACI issues
should be addressed, indicate the minimal requirements
for each organizational level. Individual Health Services
will adapt the number and type of ACI Services for each
level and depending on regional dierences. An example
of national documents which should stem from the
general guidelines provided by EAACI are represented
by the actions taken in UK (9).
Table 1. Clinical immunology, rheumatology, oncology, pneumology, ENT, dermatology, ophthalmology, infectious diseases, paediatrics, internal medicine, laboratory medicine,
pathology (depending on the country)
Country
Do services
exist?
Are they
Autonomous?
Linked to?1 Area covered (or suggested as to be covered)
Cl L A AD ID T C I EH
Albania X X X X
Austria X X X X X X
Belgium X X X X X X X X
Bulgaria X X X X X X
Croatia X X X X X X X X X
Czechia X X X X X X
Denmark X X X X X X X
Finland X X X X X X X X X X X
France X X X X X X X X X
Greece X X X X X X X X
Germany X X X X X X
Holland X X X X X X X X X X
Hungary X X X X X X X X X
Iceland X X X X X X X X X X
Italy X X X X X X X X X X X X
Macedonia X X X X X X X
Norway X X X X X X X X
Poland X X X
Portugal X X X X X X
Romania X X X X X X X X X
Russia X X X X X X X X
Serbia & MN X X X X X X X
Slovenia X X X X X X X
Spain X X X X X X
Sweden X X X X X
Switzerland X X X X X X
Turkey X X X X
UK X X X X X
Ukraine X X X X X X X X X
Cl, clinical activities; L, laboratory; A, allergy; AD, autoimmune diseases; ID, immunodeficiencies; T, transplantation immunology; C, cancer immunology; ID, infectious diseases;
EH, environmental health
ACI Services in Europe
1193
Areas to be covered by ACI Services
The following areas are considered within the competence
of ACI specialist although there is no consensus among
Countries and other specialists will also be involved in
some of these areas, depending on the organization of
NHSs:
Diseases
Allergic diseases
Allergic asthma; allergic rhinitis; allergic eye diseases;
urticaria, eczema, allergic skin diseases and anaphylaxis
represent the most frequent conditions which aect c.
25% of the general population. These conditions are
often present together or subsequently in the same
individual, thus requiring a comprehensive approach for
diagnosis and treatment. Within allergic diseases, food,
drug, insect venom and occupational allergy represent
areas requiring the specic competences of an ACI
specialist.
Autoimmune diseases
Nonorgan specic autoimmunity (Rheumatoid arthritis,
Systemic Lupus erythematosus, Scleroderma, etc.). Or-
gan-specic autoimmunity (Type I diabetes, autoimmune
thyroiditis, other autoimmune endocrine diseases, etc.).
Immunodeficiencies
Whilst primary immunodeciencies mainly refer to the
paediatric eld, secondary immunodeciencies such as
AIDS or drug-induced IDFs also occur in adults.
Malignancies
Apart from immunoproliferative diseases (some leu-
kaemias, myeloma, mastocytosis, etc.) some malignan-
cies as well as cytostatic treatment signicantly aect
the immune system and increase susceptibility to
infections.
Transplantation
Selection of patients for organ transplantation as well as
monitoring of transplanted patients involve issues of
primary competence for ACI specialists.
Diagnostic techniques
Both in vivo and in vitro diagnostic techniques are based
on the antigenantibody reaction and/or phenotypic and
functional studies of cells of the immune system.
The most commonly used in vivo tests include:
Skin tests (allergy prick tests, patch test for contact
and professional dermatitis, tuberculin tests, tests for
immunodeciencies).
Provocation tests with allergen (bronchial, nasal,
conjunctival).
Imaging techniques with labelled antigen or antibody.
Clinical examination as well as functional and ima-
ging studies of targets of the allergic reaction (spir-
ometry, non-specic provocation, etc.)
Laboratory techniques that request expertise in their
interpretation by ACI specialists include:
Immunoassays for detection of antigens and anti-
bodies; ow cytometry; cytology (immunohisto-
chemistry, immunouorescence, etc.); functional
studies of immune cells.
Treatments
The following treatments have primary or profound
eects (1) on the immune system:
Vaccines-Allergen immunotherapy (desensitisation)
in patients with IgE-mediated disease-Microbial
products (such as CpG, M. Vaccae, etc.)-Anti-allergic
drugs-Immune-response modiers-Immunoglobulin
treatment -Cytokines and Growth Factors-Anti-
neoplastic drugs.
Adverse reactions to drugs often have an immunological
basis.
Additional tasks
Additional tasks for ACI Services should include:
1 Educational activities ACI should be taught to all
undergraduate and post-graduate medical students as
well as biologists, pharmacists, nurses and laboratory
technicians and this should be guaranteed by ade-
quate structures in all academic and teaching hospi-
tals. Since ACI is part of the health care of the entire
population, General Practitioners need to have
Continuing Medical Education in ACI. The task of
the ACI specialist is to ensure that this happens and,
where appropriate, to inform and/or deliver such
educational activities. The provision of accurate
information to the public is best addressed by the
patient-oriented charitable organization with strong
professional input and advice from ACI Services.
2 Monitoring of environment Allergic and immunologic
diseases are not only inuenced by occupational
environment, but also by diet, exercise, life style and
outdoor and indoor pollution. ACI Services should
Bonini et al.
1194
ensure that relevant factors inuencing health and
disease are monitored and should contribute to the
promotion of healthy lifestyles and environments.
3 Consulting and Advisory Role ACI specialists should
provide consulting and advisory services for decisions
related to environmental measures and socio-econo-
mic choices aecting allergic and immunologic dis-
eases.
Levels of organization and minimal requirements
Many patients with mild allergic disease will self medicate
or seek advice from the internet, from pharmacies or GPs
and other community-based medical information services.
We recognize that the boundaries between community
and specialist services vary in dierent countries and we
are not going to discuss community based provision
further within this document.
Level I
Level I refers to services oered at peripheral level and
includes both Specialist Units for outpatients referred to
them by GPs and peripheral hospitals with divisions of
Internal Medicine and/or Paediatrics.
Allergology and Clinical Immunology Specialist Units
should handle patients with allergic and immunologic
diseases having a high prevalence in the population
providing all tests needed for basic diagnosis or clear
indications on referral places for further diagnostic
evaluation. They should be able to anticipate all ACI
disease, request and interpret the results of all diagnostic
tests needed and guide the treatment and follow-up of
patients by the general practitioner.
The number and location on the territory of ACI
Specialists Units should be based on the local prevalence
of ACI diseases as well as on other organizing and
regional considerations.
All Divisions of Medicine and Paediatrics of Peripheral
Hospitals (1) should have a specialist in ACI acting as a
consultant for both inpatient and outpatient care.
All diagnostic and therapeutic services not provided by
the peripheral hospital should be referred to a well-
dened Level II centre.
Level II
Level II refers to ACI Services of Central Hospitals with
multiple divisions and centralized laboratory facilities.
All Central Hospitals should have an ACI Service,
provided in collaboration with other hospital services,
oering all diagnostic and therapeutic options for
patients with allergic and immunologic diseases. The
centralized laboratory should provide all diagnostic tests
required for each area of ACI diseases.
Level III
In addition to services provided at Level II ACI Services
of Regional Hospitals assigned to Level III should:
Have a data bank of all Level I and Level II ACI
Services with documentation of the personnel and
services available;
Provide quality control of ACI Services of Level I
and II;
Represent a source of epidemiological data of ACI
diseases;
Oer referral service for special techniques or treat-
ment not possible at Central Hospitals; Provide or
coordinate environmental monitoring of the territory;
Give advice to local authorities about environmental
measures to be taken, drug and diagnostic test
reimbursement policies, etc.; Provide CME to health
professionals in ACI;
Coordinate epidemiological surveys, clinical trials,
drug surveillance.
Level IV
Centres of excellence for ACI should be established at
National Level in academic centres or research hospitals.
They should have research facilities and coordinate
national networking of regional centres.
Undergraduate and Postgraduate teaching as well as
CME is assured by Level IV ACI Centres of Excellence
that should also oer an advisory support for national
health policy in ordinary matters (research and medical
practice priorities, reimbursement policy, etc.) as well as
in occasional emergencies (AIDS, SARS, bioterrorism,
etc.).
All European Level IV ACI Excellence Centres should
be part of a permanent Network aimed at achieving
harmonized guidelines and standard parameters of ser-
vice throughout Europe.
Acknowledgments
The EAACI Task Force is grateful to the following colleagues who
provided information for the countries not represented in the Task
Force:
A. Priftanji, Albania; D. Plavec, Croatia; R. Dubakiene, Lithu-
ania; D. Dokic, Macedonia; D.Dumitrascu, Romania; G. Goud-
ima, Russia; V. Djuric, Serbia & Montenegro; M. Kostnic,
Slovenia; O. Kalayci, Turkey; G. Drannik, Ukraine. The contri-
bution of the EAACI Specialty Committee (G.S. Del Giacco),
Sections (M. Larche` ), and of the UEMS-UEA (J. Gayraud) is
grateful acknowledged.
We thank Elisabetta Rea for her kind assistance in editing the
manuscript.
ACI Services in Europe
1195
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Bonini et al.
1196

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