REQUIREMENTS FOR PHYSICIAN TRAINING
KEY CLINICAL COMPETENCIES APPRO- countries, called allergology) is concerned with preven-
PRIATE FOR THE CARE OF PATIENTS tion and diagnosis of the disease and management and
rehabilitation of patients with allergic and related dis-
WITH ALLERGIC OR IMMUNOLOGIC DIS- eases.
EASES: A PROVISIONAL POSITION In some countries, the allergy specialty is combined
STATEMENT OF THE WORLD ALLERGY with clinical immunology. Immune processes are fun-
ORGANIZATION damental to host defense. Malfunction of the immune
system causes infections, reduces immune surveil-
lance, leads to autoimmune phenomena, and impacts
Michael A Kaliner, Sergio Del Giacco, Carlos D every organ system. Clinical immunology relates to
Crisci, Anthony J Frew, Guanghui Liu, Jorge immune system dysfunctions and immunologically
Maspero, Hee-Bom Moon, Takemasa mediated diseases, which by definition also include
Nakagawa, Paul C Potter, Lanny J allergic diseases. In countries other than the USA, aller-
Rosenwasser, Anand B Singh, Erkka Valovirta, gy is positioned as a component of organ-specific
Paul van Cauwenberge, John O Warner; WAO specialties such as dermatology, pulmonology,
Specialty and Training Council rheumatology, gastroenterology, and otorhinolaryngol-
ogy. This positioning results in the specialty of allergy
With special recognition of the contribution of Karen not always being recognized separately, and there is
Henley, staff liaison to Council often no defined standardization of specialty training
requirements for allergy. WAO as a global society pro-
INTRODUCTION poses that the best way to achieve a uniform quality
level of care for the many millions of patients with aller-
Allergic diseases are extraordinarily prevalent world-
gic diseases is to define the key levels of competence
wide, and the incidence of allergy is increasing every-
required for both specialists and primary care clinicians
where.1-7 Because allergic and immunologic processes
who see patients who have allergic disorders.
overlap all organ systems, allergy is not always taught
in medical schools as a separate subject. Indeed, lack Given the very high prevalence of allergic diseases and
of recognition of the specialty and of the need to teach the different medical systems throughout the world,
about allergic and immunologic diseases results in patients may be managed by primary care physicians,
allergy not being included at all in some medical curric- including internists or pediatricians (which in this docu-
ula.8 With an estimated 22% of the global population ment is defined as first-level care), by organ-based spe-
suffering from allergic and immunologic diseases, it is cialists who receive some specific training in allergy
time to recognize and strengthen education in allergy and/or immunology (defined as second-level care),
and immunology.8 and/or by fully trained specialists in allergy (third-level
care). WAO believes that an acceptable level of com-
The World Allergy Organization, an alliance of 74
petence is required for all physicians who see allergy
national and regional allergy societies, created this con-
patients but who are not allergy specialists.
sensus document to establish educational guidelines
for worldwide application, to identify and correct aller- A strong cooperative network with vertical links among
gy training deficiencies and to define appropriate train- first-level care providers, organ-based specialists, and
ing goals. In creating this consensus, it is recognized allergists is necessary for the optimal management of
that each country has its own principles and goals in allergy patients.14,15 Which physician sees which
medical education at the undergraduate and postgrad- patient and to whom the patient is referred reflects
uate levels. This document defines what a medical both the availability of physicians specifically trained in
practitioner should know in order to care for allergic allergy and immunology and the levels of competence
patients. of the referring physicians. It is essential for proper
medical management that first- and second-level physi-
cians are cognizant of the importance of an accurate
BACKGROUND diagnosis and the appropriate point at which to refer a
Diseases with an allergic etiology can affect many patient to the next level of care.
organ systems and occur in response to a wide variety This document recommends the appropriate levels of
of environmental factors. Allergic diseases are among competence necessary to manage allergic patients at
the commonest causes of chronic medical problems in each of the three defined levels and clarifies the appro-
both adults and children and are associated with a high priate time point in the disease for referral to an aller-
morbidity. They carry a large socio-economic burden9-12 gist. Once agreement upon these recommendations is
and can result in catastrophic anaphylaxis or fatal asth- achieved, WAO will develop a more specific core cur-
ma attacks. Systemic hypersensitivity diseases riculum and appropriate educational and training pro-
include, among others, asthma, rhinoconjunctivitis, oti- grams for medical students, general practitioners,
tis, rhinosinusitis, urticaria, angioedema, eczema, food pediatricians, internists, organ-based specialists, and
allergy, drug allergy, insect allergy, occupational allergic allergy specialists.
diseases, and anaphylaxis. Conventionally, allergic dis-
eases have been divided into those associated with It is proposed that the levels of competence for knowl-
IgE-mediated hypersensitivity and those involving edge and skills be divided as described in the following
other forms of hypersensitivity.13 As a medical special- paragraphs.
ty based in immunology, the allergy specialty (in some
Current Allergy & Clinical Immunology, August 2006 Vol 19, No. 3 113
I. First-level care background in allergy and immunology, an understand-
This level includes recommendations for the knowl- ing of common allergic diseases, and the knowledge
edge and skills in allergy required for general practi- and skills to perform and interpret diagnostic tests in
tioners, internal medicine providers and pediatricians. It order to competently treat uncomplicated allergic dis-
also includes the knowledge and skills recommended eases.
for family practitioners, as well as specialists in regions In most countries, background training in allergy and
where organ-based specialists are not formally trained immunology is obtained through rotations in allergy
in the allergic aspects of their specialty and where and immunology centers provided during residency in
trained allergists are not available. These recommen- internal medicine or pediatrics. Thereafter, during the
dations also will apply to nurse practitioners and physi- two to three years of training in specialties such as der-
cians’ assistants if they are part of the health care matology, pulmonology, otorhinolaryngology, gastroen-
community. terology, or rheumatology, adequate opportunities for
Knowledge at this level should include a background in instruction in allergy and immunology should be
immunology obtained during medical training and required. Organ-based specialists at this level should
should include: an understanding of hypersensitivity be required to have the knowledge base required of
mechanisms (Gell & Coombs I-IV); major mechanisms any first-level, primary care physician, plus additional
of host defence; the role of immunoglobulins in host knowledge of host defence and clinical immunology
defence; knowledge of lymphocyte function; the roles and some understanding of cytokines and chemokines,
of leukocytes, especially eosinophils; and the functions genetics and environmental factors, and allergens and
of mast cells and basophils. their relationship to human diseases.
Knowledge at the first level of care should include the The recommendations for second-level, organ-based
following areas: specialists include the following:
1. Adequate clinical knowledge about the main aller- 1. Broad clinical knowledge of major allergic and
gic diseases, including rhinoconjunctivitis, rhinosi- immune-deficiency diseases.
nusitis, otitis, asthma, urticaria, angioedema, 2. Knowledge sufficient to diagnose and treat the
eczema, food allergy, insect allergy, anaphylaxis, common, uncomplicated cases of allergic disor-
drug allergy, and immunodeficiency, so that the ders, according to national and international guide-
diagnosis and treatment of both acute and chronic lines.
diseases are possible. Where feasible, such care 3. Adequate skills to perform and interpret allergy skin
should be carried out in collaboration with or with tests, as well as the ability to interpret the other
access to an allergist or an allergy referral center. tests useful for the diagnosis, treatment, and pre-
2. Adequate knowledge in the interpretation of the vention of allergic diseases.
main diagnostic allergy tests, skin prick tests, and 4. Administration of various forms of immunotherapy
serological tests for IgE and an understanding of (in collaboration with allergy specialists and referral
pulmonary function test interpretation. Such train- centers) after adequate training, but only if such
ing generally would not include competency in per- therapy is performed in a setting where patient
forming skin tests or the more sophisticated safety is ensured.
pulmonary function tests. 5. Recognition of when and where to refer complicat-
3. Sufficient training to recognize patients with a level ed or difficult-to-manage patients.
of persistence or severity, who experience exacer- 6. In medical systems where the second-level spe-
bations that are life-affecting, or who have difficult- cialist is the only provider of expert care for allergy
to-manage allergic disease who should be referred and immunology patients, the training should
to an allergy specialist for evaluation and initiation include all of the elements detailed in the section
of treatment before the disease advances to a on third-level care.
severe or life-threatening stage.
4. Immunotherapy (injective, sublingual) is performed
by first-level providers in some countries. WAO III. Third-level care
suggests that this is only appropriate as follows: The third level of care should include full knowledge of
a. The immunotherapy has been prescribed by a allergic diseases and the skills to diagnose, treat, and,
specialist. where possible, prevent allergic diseases.16-18
b. The first-level provider has had adequate training Core training is necessary in either adult internal medi-
in allergy and the management of anaphylaxis in cine or pediatrics. In some countries (e.g. the United
order to provide this service safely. States), trainees in allergy with background training in
pediatrics or internal medicine are trained to take care
c. The location where immunotherapy is per- of patients in all age groups.
formed fulfils all the conditions for patient safety.
The recommendations for the training of a third-level,
It is recommended that immunotherapy be initiated fully certified allergist are as follows:
by an allergist or in a referral center and that a suit-
ably trained first-level provider provides mainte-
nance treatment only. A. Knowledge training objectives
1. Immune mechanisms involved in the development
II. Second-level care of immunologically mediated diseases and, in par-
Recommendations for key competencies at the sec- ticular, allergic sensitization and disease formation.
ond level of care apply to organ-based physicians such 2. Genetic and environmental factors, including infec-
as those in dermatology, pulmonology, gastroenterolo- tious diseases, involved in the genesis of allergic
gy, otorhinolaryngology and rheumatology, who see diseases.
allergy patients or act as allergy specialists, receiving 3. Pathogenesis of rhinoconjunctivitis, otitis, rhinosi-
referrals of allergy patients for diagnosis and manage- nusitis, asthma, atopic dermatitis, urticaria, and
ment. In some health care systems, second-level care angioedema; drug and food allergy; insect allergy
providers receive training specifically in allergy. and anaphylaxis; and the concept that many allergic
Knowledge at this level should include a fundamental diseases are systemic in etiology.
114 Current Allergy & Clinical Immunology, August 2006 Vol 19, No.3
4. Relationship between tissue inflammation and respiratory tract infections that affect allergic sen-
repair. sitization and disease development.
5. Mechanisms of IgE-mediated immediate- and late- 18. Diagnosis and treatment of patients with humoral
phase allergic reactions. and cellular immunodeficiencies, hereditary and
6. Mechanisms of non-IgE-mediated allergic reactions acquired complement deficiencies, and phagocytic
and other disorders in the differential diagnosis of disorders.
allergic disease. These diseases include, but are
not limited to, nonallergic rhinitis; drug-induced B. Skills training objectives
rhinitis; acute and chronic rhinosinusitis; nonallergic 1. Clinical skills
asthma; cough; bronchitis; non-IgE-mediated ana-
phylaxis; idiopathic urticaria; eczema; otitis; con- Differential diagnosis, evaluation, and management
junctivitis; eosinophilic esophagitis, gastroenteritis of the following:
and colitis; celiac-like syndromes; food induced Eczema
enteropathies leading to gastroesophageal reflux, Rhinoconjunctivitis
oesophagitis, gastritis and gut motility disorders
including constipation. Conjunctivitis
7. National and global epidemiology of allergic dis- Rhinosinusitis
eases. Atopic dermatitis
8. Local airborne, contact, and occupational allergens. Asthma, cough, dyspnea, and recurrent wheeze
9. Classification and relative importance of all relevant Acute and chronic urticaria, including physical
allergens and their biological characteristics, includ- urticarias
ing heat, digestive stability, and cross-reactivity; Angioedema, including hereditary angioedema
understanding of local pollen counts and the char- Anaphylaxis
acteristics of various aeroallergens and routes of
allergen exposure. Food allergy and intolerance
10. Therapy. Drug and vaccine allergies or intolerance
a. Use and route of administration of antihista- Insect allergy/hypersensitivity
mines; mast cell stabilizers; bronchodilators; Oral allergy syndrome
nasal, oral, topical, and inhaled glucocortico- Latex allergy
steroids; decongestants; leukotriene modifiers;
theophylline; adrenergic agonists; anticholiner- Occupational allergy, asthma, eczema
gics; mucolytics; antibiotics; adrenaline; and all Otitis
other pharmacologic and immunologic agents Common variable immunoglobulin deficiency and
used to treat allergic and immunologic diseases. related immunodeficiencies
b. Use of emollients, antibiotics, topical glucocorti- Primary immunodeficiencies
costeroids, immune modulators and all other Secondary immunodeficiencies
agents and techniques used to manage eczema
and other allergic skin disorders. Complement deficiencies
c. Use of immune modulators, such as specific Abnormalities of phagocytic cells
allergen immunotherapy, monoclonal antibod- 2. Management of patients with multiple or complex
ies, including anti-IgE, and immunoglobulin allergies.
replacement used to treat allergic and immuno- 3. Management of patients with multiple food aller-
logic disorders. Knowledge of immune modula- gies, requiring avoidance diets.
tors that are being developed for clinical use in
4. Provision of allergen avoidance advice.
allergic and immunologic disorders.
5. Safe supervision of food and drug challenges.
d. Methods and value of allergen-avoidance tech-
niques. 6. Assessment of patients for immunotherapy. Proper
administration of immunotherapy including
e. Avoidance diets and nutritional implications of
immunotherapy dose adjustment and manage-
ment of complications. Supervision of immunother-
f. Knowledge of national and international guide- apy protocols. Recognition and management of
lines for the management of allergic and allergic reactions associated with immunotherapy.
immunologic disorders in adults and children,
7. Recognition of indications for and the skills to per-
with particular emphasis on safety and efficacy
form, interpret, and understand the limitations of
of all therapies.
skin prick, intradermal, patch, and delayed type
11. Investigation and management of adverse reac- skin tests, and specific in-vitro IgE antibody tests.
tions to drugs and vaccines.
8. Interpretation of natural allergen and environmental
12. Methods to measure cells and mediators in biolog- exposures.
ical fluids and tissues.
9. Evaluation and differentiation of non-IgE mediated
13. Primary and secondary prevention of allergy, partic- hypersensitivity reactions.
ularly in children.
10. Investigation and management of behavioral prob-
14. Understanding of the social and psychological lems related to allergic and immunologic diseases.
issues associated with allergic diseases.
11. Improvement of patient compliance with pharma-
15. Diagnosis and management of occupational allergic cotherapy regimes through personalized disease
diseases. management plans.
16. Methods to monitor home or work environments 12. Knowledge of drug desensitization protocols.
for allergens associated with allergic diseases.
13. Management in the community of patients at risk
17. Understanding of environmental factors such as of anaphylactic reactions, incorporating an under-
pollutants and occupational allergens and of viral standing of integrated care pathways.
Current Allergy & Clinical Immunology, August 2006 Vol 19, No. 3 115
14. Diagnosis, treatment, and referral of primary and tests (blood, serum, microbiological, urine, fecal
secondary humoral and cellular immunodeficien- tests).
cies Such diseases include, but are not limited to * Some of these skills should be at least taught and
Bruton's agammaglobulinemia, severe combined understood by the trainee but may not be performed
immunodeficiency, thymic dysplasia, adenosine personally, in accordance with national guidelines and
deaminase deficiency, Wiskott-Aldrich syndrome, established practice parameters.
ataxia telangiectasia and various lymphocyte acti-
vation defects. D. Attitudes
15. Safe and effective administration of intravenous 1. Ability to work with colleagues in other disciplines.
2. Appreciation of the scope and limitations of allergy
16. Recognition and management of hereditary and testing.
acquired complement deficiencies.
3. Appreciation of the limitations and problems creat-
17. Knowledge about and treatment of phagocytic cell ed by so-called complementary medicine or alterna-
disorders, such as Chediak-Higashi syndrome, tive allergy practices.
chronic granulomatous disease, leukocyte adhe-
4. Understanding of the role of patient support groups
sion defects, and a variety of congenital and
and ability and willingness to work with patient sup-
5. Appreciation of all the issues relating to patient con-
C. Technical skills and knowledge training fidentiality and the ethical standards expected of all
1. Performance and interpretation of skin prick, intra- 6. Understanding of research protocols, the ethics of
dermal, patch tests, and delayed hypersensitivity experimental design, data analysis, bio-statistics,
tests. good clinical practice, and good laboratory practice,
2. Performance of diagnostic testing for suspected and a willingness to become involved in either clin-
drug, biological, or vaccine allergy. ical or basic translational research.
7. Knowledge of the country-specific legal framework
3. Safe preparation and administration of
for reporting of occupational diseases and assisting
patients in obtaining compensation for occupational
4. Performance of allergen provocation tests, such as diseases.
nasal, conjunctival, bronchial, and oral challenges,
8. An ability to be a clinical decision maker, communi-
and food and medication challenges.
cator, collaborator, manager, healthcare advocate,
5. Performance of patch testing for contact dermati- and scholar.
6. Performance or knowledge of rhinoscopy and Implementation of training
laryngoscopy, nasal endoscopy, accoustic rhinome- A minimum of 24 months of training is necessary in an
try* and rhinomanometry.* accredited clinical allergy and immunology training pro-
7. Performance of basic lung function testing, includ- gram. Depending on past training, further experience
ing spirometry and bronchial provocation tests may be desirable in chest medicine, dermatology, gas-
(methacholine or histamine challenges, measure- troenterology, otorhinolaryngology, and basic immunol-
ment of flow-volume loops and pulse oximetry, and ogy. A minimum of 6 weeks of training in an
pre- and post-bronchodilator testing). immunology laboratory is recommended. Additional
8. Knowledge of how and when to measure exhaled desirable components of training include experience in
nitric oxide, and how and when to perform whole research and teaching at either or both the undergrad-
body plethysmography and impulse oscilometry.* uate and postgraduate level.
9. Knowledge of how and when to use various tests The trainee should have training in evidence-based
to measure airway inflammation and/or constric- medicine, research study design, data analysis, biosta-
tion, including bronchodilator-induced bronchodila- tistics, and critical review of the literature.
tion, induced sputum* and/or bronchial and Cross-training in both adult and pediatric allergy is pre-
broncho-alveolar lavage.* ferred during the 24-month training program.
10. Assessment of environmental hazards in occupa- Where possible, a logbook for documentation and
tional allergy and knowledge of live insect sting proof of training should be required to qualify as an
challenges. allergy specialist. Allergy training can be altered in
11. Management of exclusion diets and provocation accordance with national guidelines. Specialized cen-
diets. ters are required in many situations for the care of
patients with primary and secondary immunodeficien-
12. Knowledge of and ability to interpret measure-
cy diseases; therefore, special training of the aller-
ments of immune function, including serum
gist/immunologist in this area of expertise is
immunoglobulin levels, IgG subclass levels, pre
necessary, and should be undertaken at institutions
and post-immunization antibody titers, isohemag-
where appropriate training is available.
glutinin titers, and other ancillary tests for use in
the differential diagnosis of congenital or acquired
humoral immunodeficiency. REFERENCES
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This Position Statement is intended to contribute generally to the professional dialogue regarding the require-
ments for physician training in allergy. It is not intended to be a substitute for the exercise of qualified profes-
sional judgment in any given situation. Hospitals, educational institutions, physicians and other health care
professionals and other providers utilizing this information are solely responsible for determining whether and
how to use this Position Statement and evaluate or apply its contents in any particular situation. This Position
Statement reflects WAO's best judgment as of the date it is posted and is subject to change.
WAO DISCLAIMS ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING WITHOUT LIMITATION ANY WAR-
RANTY AS TO MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. UNDER NO CIRCUM-
STANCES WILL THE CONTRIBUTORS TO THIS POSITION STATEMENT, WAO OR ANY OF ITS DIRECTORS,
OFFICERS, MEMBERS, EMPLOYEES OR AGENTS BE RESPONSIBLE OR LIABLE TO ANY USER OR OTHER
ENTITY FOR ANY DAMAGES OF ANY KIND OR NATURE, INCCLUDING, WITHOUT LIMITATION, DIRECT,
COMPENSATORY, INDIRECT, INCIDENTAL, CONSEQUENTIAL (INCLUDING LOST PROFITS OR LOST BUSI-
NESS OPPORTUNITIES), SPECIAL, EXEMPLARY OR PUNITIVE DAMAGES, THAT RESULT FROM OR RELATE
IN ANY MANNER WHATSOEVER TO (1) USE OF OR RELIANCE ON THIS POSITION STATEMENT, OR (2)
ERRORS, INACCURACIES, OMISSIONS OR OTHER DEFECTS IN THIS POSITION STATEMENT.
Originally published in Allergy & Clinical Immunology International – Journal of the World Allergy Organization, www.acii.net: Kaliner MA, Del Giacco
S, Crisci CD, Frew AJ, Liu G, Maspero J, Moon HB, Nakagawa T, Potter PC, Rosenwasser LJ, Singh AB, Valovirta E, van Cauwenberge P, Warner
JO; WAO Specialty and Training Council. Requirements for physician training in allergy: Key clinical competencies appropriate for the care of
patients with allergic or immunologic diseases – a provisional position statement of the World Allergy Organization. Allergy Clin Immunol Int –
J World Allergy Org 2006; 18:92-97. (c) 2006 Hogrefe & Huber Publishers. Reproduced with permission.
ATTENTION ALLSA MEMBERS
This is to inform you that the 2006 ALLSA Annual General Meeting (AGM) will be held at the Sun
City Convention Centre during the ALLSA Congress.
DATE: Friday 8th September 2006
VENUE: Sun City Convention Centre
1. Minutes of the previous meeting
2. Matters arising
3. Secretary’s report Dr Sharon Kling
4. Treasurer’s report Dr Adrian Morris
5. Portfolio Reports
Journal Professor Heather Zar
Research Professor Mohamed Jeebhay
Education/Training Dr Sharon Kling
Policy/Advocacy Dr Andrew Halkas
7. Announcement of the new Excom
Current Allergy & Clinical Immunology, August 2006 Vol 19, No. 3 117