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Allergy and Clinical Immunology Services in Europe*

Allergology and Clinical Immunology (ACI) is an area of clinical medicine witha precise identity, relevant recent scientific achievements and well-defined 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 amongcountries according to their health policies and priorities.In the firm belief of the role of ACI specialists in addressing clinical issues

related to the involvement of the immune system in health and diseases—such asvaccination, immunodeficiencies, susceptibility and response to microbial agents,autoimmune and allergic diseases, immune aspects of transplantation andmalignancies, in vivo and in vitro immunological tests, vaccinations,immuno-modifiers—the European Academy of Allergology and ClinicalImmunology appointed an ad hoc Task Force to produce standards for ACIServices 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 topatients and health care professionals.

S. Bonini1, I.J. Ansotegui2,S. Durham3, A.J. Frew4, J. Lçtvall5,K. Nekam6, T. Popov7, R. Dahl8,J. Gayraud9, R. Gerth van Wijk10,K. Kontou-Fili11, M. Kowalski12,A. Todo-Bon13, U. Wahn14

1Second University of Naples amd INMM-CNR,Rome, Italy; 2Department of Allergy andImmunology, Santiago Ap�stol Hospital, Santiago,Spain; 3Department of Allergy and ClinicalImmunology, Imperial College, National Heart andLung Institute, London, UK; 4Inflammation andRepair Division, School of Medicine, University ofSouthampton, Southampton General HospitalInfection, Southampton, UK; 5Department ofRespiratory Medicine and Allergology, GçteborgUniversity, Gothenberg, Sweden; 6Department ofAllergy and Clinical Immunology, Polyclinic of theHospitaller Brothers of St. John of God, Budapest,Hungray; 7Clinical Center of Allergology, MedicalUniversity of Sofia, Sofia, Bulgaria; 8Department ofRespiratory Diseases and Allergology, AarhusUniversity Hospital, Aarhus, Denmark; 9UEMSAllergology and Clinial Immunology Section, Tarbes,France; 10Department of Allergology, UniversityHospital Rotterdam, Rotterdam, the Netherlands;11Dept of Allergology and Clinical Immunology,Division of Internal Medicine, LGD Hospital ofAthens, Athens, Greece; 12Department of ClinicalImmunology and Allergy, Medical university of Lodz,Lodz, Polond; 13Servicio Immunoalergia, Centro dePneumologia, University de Coimbra, Coimbra,Portugal; 14Department of Dermatology and Allergy,Allergy Centre Charit�, Universit�tsmedizin Berlin,Berlin, Germany.

*This article represents the position paper of the adhoc Task Force of the European Academy ofAllergology and Clinical Immunology (EAACI),produced in collaboration with GA2LEN; a networkof excellence founded by the European Union.

Drafting group: S. Bonini (Chairman), I.J. Ansotegui;S. Durham; A.J. Frew; J. Lçtvall; K. Nekam; T. Popov

Task Force members: R. Dahl; J. Gayraud; R. Gerthvan Wijk; K. Kontou-Fili; M. Kowalski; A. Todo-Bon;U. Wahn.

Prof. Sergio BoniniInternal MedicineSecond University of NaplesINMM-CNR 100 Via Fosso del Cavaliere00133 RomeItaly

Accepted for publication 18 January 2006

Allergy 2006: 61: 1191–1196 � 2006 The AuthorsJournal compilation � 2006 Blackwell Munksgaard

DOI: 10.1111/j.1398-9995.2006.01081.x

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History and background

Allergology and Clinical Immunology (ACI) is an area ofclinical medicine with a precise identity which deals withmaintenance of the healthy state as well as with diagnosis,prevention and treatment of several diseases caused byover or under – activity of the immune system that havehigh individual and socio-economic impact.Allergology and Clinical Immunology – which found

its origins in the first half of the twentieth century – wasrevolutionized in the 1960s by the fundamental discover-ies on the structure and functions of the immune system,immunodeficiencies and allergic hypersensitivity reactionsresponsible for clinical diseases (1). At present, ACIrepresents one of the areas of medicine which underwentmost significant scientific development, as documented bythe number of discoveries, scientific publications andNobel Prizes awarded.Allergology and Clinical Immunology is not an organ

specialty (such as Respiratory Medicine, Gastroenterol-ogy, etc.) and does not refer to specific diseases but toindividuals (2). Certainly, several diseases that mayinvolve the immune system such as diabetes, asthma orglomenulonephritis, are treated competently by organ-based specialists. However, only ACI specialists have theprofessional education required for facing the clinicalissues related to the involvement of the immune systemin health and disease, such as vaccination, immunode-ficiencies, susceptibility and response to microbialagents, autoimmune and allergic diseases, immuneaspects of transplantation and malignancies. Moreover,a large number of diagnostic in vivo and in vitrotechniques are based on the interaction between antigensand antibodies (such as skin tests with tuberculin,microbial agents, professional and environmental aller-gens; immunoassays for hormones and infectious agents;flow-cytometry, etc.). This requires specific methodolo-gical competences for their performance and interpret-ation. Finally, several treatments (vaccines, immune-modifiers, cancer therapies, etc.) require a good under-standing of the function and manipulation of theimmune system.Accordingly, ACI is a broad clinical specialty which

relates to 100% of European citizens, from birth toelderly, 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 corecurriculum of undergraduate students in Medicine in allEuropean Countries. At postgraduate level, there is aconsensus on having specific professional education inACI. However, in some countries ACI represents a fullspecialty, in others a subspecialty and in others aprofessional competence (Table 1).

In each European Country there is a scientific societydealing with ACI. All National European Societies referto the European Academy of Allergology and ClinicalImmunology (EAACI, http://www.eaaci.net) which ispart of the International Association of Allergology andClinical Immunology – World Allergy Organization(IAACI-WAO, www.worldallergy.org). ACI Societieshave been working in a very close collaboration withnational and international regulatory bodies to producestandards for health care such as disease guidelines,measures of environmental control, socio-economicissues, etc. Moreover, patients suffering from allergicand 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 consideredto be a health and scientific priority and a large number ofprojects and networks of excellence have been recentlyfunded with massive investments by the European Unionwithin the fifth and sixth Framework Programmes (4). Onthe other hand, at the level of health care, the organiza-tion of ACI is imperfect and there is an ongoing debateabout which areas should be covered by the specialty (5–7). Although ACI Services exist in all European countries,their area of competence, structuring, autonomy andrecognition by the National Health System is heteroge-neous among countries and sometimes even within thesame country (Table 1).

The current situation has some inconveniences:

1 The large amount of new scientific information andprogress in ACI produced by the scientific environmenthas not so far translated into better clinical care. ACIrepresents one of the best clinical examples of what hasbeen referred to as �Lost in Translation� (8).

2 The lack of a well-defined professional specialtytraining and career structure has reduced the attractive-ness of the specialization and, therefore, the number ofspecialists in ACI.

3 As a consequence, important issues relating to themaintenance of the healthy state (vaccination, environ-mental control, etc.) as well as the management of theextremely large and increasing number of patients withallergic and immunologic diseases are referred todifferent area specialists. For example whereas it ishighly appropriate that pneumologists are responsiblefor the pharmacotherapy and acute hospital manage-ment of acute life-threatening asthma, the global inputfrom a consultant allergist is valuable for the identifi-cation and treatment of underlying causes of asthma.Similarly ENT doctors may evaluate rhinitis whereasthe allergist should be responsible for instigating allergydiagnosis environmental control measures and whereappropriate, allergen immunotherapy. The same princi-ples apply to the dual role of allergists and dermatol-ogists in the management of atopic eczema.

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Furthermore these diseases frequently co-exist and theabsence of the global expertise offered by an allergist,which complements the individual specialty approach, isdetrimental for individuals and increases the costs forthe community, not least because multiple consultationsare otherwise required.

The objective of the EAACI Task Force on Allergy Services

On the basis of the above considerations, the EAACIfelt the need to appoint a Task Force aimed atproducing standards for ACI Services to be used as aunique consulting reference for National Health Ser-vices (NHS) in their autonomous planning of healthorganization. This should result in a more homogen-eous structure of ACI Services in Europe, a necessaryprerequisite for the free circulation of patients andhealthcare professionals.

General principles for structuring of ACI Services

The organization of health services in each EuropeanCountry varies according to the health policy andpriorities of individual States as well as on resources,epidemiological and socio-economic issues, and theexisting organization of other areas of medicine.Accordingly, no rigid criteria should be defined buta flexible framework, to be adapted by individualNHSs.

This document will address the Areas to be covered byACI Services, the different levels at which ACI issuesshould be addressed, indicate the minimal requirementsfor each organizational level. Individual Health Serviceswill adapt the number and type of ACI Services for eachlevel and depending on regional differences. An exampleof national documents which should stem from thegeneral guidelines provided by EAACI are representedby 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)

CountryDo services

exist?

Are theyAutonomous?Linked to?1 Area covered (or suggested as to be covered)

Cl L A AD ID T C I EH

Albania X X X XAustria X X X X X XBelgium X X X X X X X XBulgaria X X X X X XCroatia X X X X X X X X XCzechia X X X X X XDenmark X X X X X X XFinland X X X X X X X X X X XFrance X X X X X X X X XGreece X X X X X X X XGermany X X X X X XHolland X X X X X X X X X XHungary X X X X X X X X XIceland X X X X X X X X X XItaly X X X X X X X X X X X XMacedonia X X X X X X XNorway X X X X X X X XPoland X X XPortugal X X X X X XRomania X X X X X X X X XRussia X X X X X X X XSerbia & MN X X X X X X XSlovenia X X X X X X XSpain X X X X X XSweden X X X X XSwitzerland X X X X X XTurkey X X X XUK X X X X XUkraine 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

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Areas to be covered by ACI Services

The following areas are considered within the competenceof ACI specialist although there is no consensus amongCountries and other specialists will also be involved insome of these areas, depending on the organization ofNHSs:

Diseases

Allergic diseases

Allergic asthma; allergic rhinitis; allergic eye diseases;urticaria, eczema, allergic skin diseases and anaphylaxisrepresent the most frequent conditions which affect c.25% of the general population. These conditions areoften present together or subsequently in the sameindividual, thus requiring a comprehensive approach fordiagnosis and treatment. Within allergic diseases, food,drug, insect venom and occupational allergy representareas requiring the specific competences of an ACIspecialist.

Autoimmune diseases

Nonorgan specific autoimmunity (Rheumatoid arthritis,Systemic Lupus erythematosus, Scleroderma, etc.). Or-gan-specific autoimmunity (Type I diabetes, autoimmunethyroiditis, other autoimmune endocrine diseases, etc.).

Immunodeficiencies

Whilst primary immunodeficiencies mainly refer to thepaediatric field, secondary immunodeficiencies – such asAIDS 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 significantly affectthe immune system and increase susceptibility toinfections.

Transplantation

Selection of patients for organ transplantation as well asmonitoring of transplanted patients involve issues ofprimary competence for ACI specialists.

Diagnostic techniques

Both in vivo and in vitro diagnostic techniques are basedon the antigen–antibody reaction and/or phenotypic andfunctional studies of cells of the immune system.

The most commonly used in vivo tests include:

• Skin tests (allergy prick tests, patch test for contactand professional dermatitis, tuberculin tests, tests forimmunodeficiencies).

• 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-specific provocation, etc.)

Laboratory techniques that request expertise in theirinterpretation by ACI specialists include:

– Immunoassays for detection of antigens and anti-bodies; flow cytometry; cytology (immunohisto-chemistry, immunofluorescence, etc.); functionalstudies of immune cells.

Treatments

The following treatments have primary or profoundeffects (1) on the immune system:

• Vaccines-Allergen immunotherapy (desensitisation)in patients with IgE-mediated disease-Microbialproducts (such as CpG, M. Vaccae, etc.)-Anti-allergicdrugs-Immune-response modifiers-Immunoglobulintreatment -Cytokines and Growth Factors-Anti-neoplastic drugs.

Adverse reactions to drugs often have an immunologicalbasis.

Additional tasks

Additional tasks for ACI Services should include:

1 Educational activities ACI should be taught to allundergraduate and post-graduate medical students aswell as biologists, pharmacists, nurses and laboratorytechnicians 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 entirepopulation, General Practitioners need to haveContinuing Medical Education in ACI. The task ofthe ACI specialist is to ensure that this happens and,where appropriate, to inform and/or deliver sucheducational activities. The provision of accurateinformation to the public is best addressed by thepatient-oriented charitable organization with strongprofessional input and advice from ACI Services.

2 Monitoring of environment Allergic and immunologicdiseases are not only influenced by occupationalenvironment, but also by diet, exercise, life style andoutdoor and indoor pollution. ACI Services should

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ensure that relevant factors influencing health anddisease are monitored and should contribute to thepromotion of healthy lifestyles and environments.

3 Consulting and Advisory Role ACI specialists shouldprovide consulting and advisory services for decisionsrelated to environmental measures and socio-econo-mic choices affecting allergic and immunologic dis-eases.

Levels of organization and minimal requirements

Many patients with mild allergic disease will self medicateor seek advice from the internet, from pharmacies or GPsand other community-based medical information services.We recognize that the boundaries between community

and specialist services vary in different countries and weare not going to discuss community based provisionfurther within this document.

Level I

Level I refers to services offered at peripheral level andincludes both Specialist Units for outpatients referred tothem by GPs and peripheral hospitals with divisions ofInternal Medicine and/or Paediatrics.Allergology and Clinical Immunology Specialist Units

should handle patients with allergic and immunologicdiseases having a high prevalence in the populationproviding all tests needed for basic diagnosis or clearindications on referral places for further diagnosticevaluation. They should be able to anticipate all ACIdisease, request and interpret the results of all diagnostictests needed and guide the treatment and follow-up ofpatients by the general practitioner.The number and location on the territory of ACI

Specialists Units should be based on the local prevalenceof ACI diseases as well as on other organizing andregional considerations.All Divisions of Medicine and Paediatrics of Peripheral

Hospitals (1) should have a specialist in ACI acting as aconsultant for both inpatient and outpatient care.All diagnostic and therapeutic services not provided by

the peripheral hospital should be referred to a well-defined Level II centre.

Level II

Level II refers to ACI Services of Central Hospitals withmultiple divisions and centralized laboratory facilities.All Central Hospitals should have an ACI Service,

provided in collaboration with other hospital services,offering all diagnostic and therapeutic options forpatients with allergic and immunologic diseases. Thecentralized laboratory should provide all diagnostic testsrequired for each area of ACI diseases.

Level III

In addition to services provided at Level II ACI Servicesof Regional Hospitals assigned to Level III should:

• Have a data bank of all Level I and Level II ACIServices with documentation of the personnel andservices available;

• Provide quality control of ACI Services of Level Iand II;

• Represent a source of epidemiological data of ACIdiseases;

• Offer referral service for special techniques or treat-ment not possible at Central Hospitals; Provide orcoordinate environmental monitoring of the territory;

• Give advice to local authorities about environmentalmeasures to be taken, drug and diagnostic testreimbursement policies, etc.; Provide CME to healthprofessionals in ACI;

• Coordinate epidemiological surveys, clinical trials,drug surveillance.

Level IV

Centres of excellence for ACI should be established atNational Level in academic centres or research hospitals.They should have research facilities and coordinatenational networking of regional centres.

Undergraduate and Postgraduate teaching as well asCME is assured by Level IV ACI Centres of Excellencethat should also offer an advisory support for nationalhealth policy in ordinary matters (research and medicalpractice priorities, reimbursement policy, etc.) as well asin occasional emergencies (AIDS, SARS, bioterrorism,etc.).

All European Level IV ACI Excellence Centres shouldbe part of a permanent Network aimed at achievingharmonized guidelines and standard parameters of ser-vice throughout Europe.

Acknowledgments

The EAACI Task Force is grateful to the following colleagues whoprovided information for the countries not represented in the TaskForce:

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) isgrateful acknowledged.

We thank Elisabetta Rea for her kind assistance in editing themanuscript.

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