In 1906 Clemens von Pirquet coined the term "allergy" to designate a group of clinical processes (serum sickness, anaphylactic reactions, some infections) that seemed to be due to increased sensitivity to certain products. For years this term was incorrectly used to denote diverse phenomena with no apparent cause, since allergic phenomena also seemed inexplicable. The experience of Prausnitz and Kustner, in 1921, revealed that anaphylactic reactions were transmissible, possibly due to the existence of an anomalous element in individuals who showed "hypersensitivity" to particular substances. In addition to these immediate responses, cases in which the anomalous reaction was produced after hours or even days had been observed. In 1963 Gell and Coombs proposed a classification of these reactions, based on the possible immunological mechanisms through which they might be produced. Type-1, immediate or anaphylactic reactions covered most of the processes so-colled "allergic" and were mediated by an antibody, reagin, whose nature was still unknown. At the end of the 1960s Ishizaka and Ishizaka, after a laborious search, described this new antibody, which they called IgE (1-4).
Science...
Following this discovery, numerous studies have revealed the mechanisms by which allergic reactions, and consequently allergic diseases, take place. The role played by the various cells, especially mast cells, eosinophils, B and T Iymphocytes, the numerous cytokines derived from these cells and the interrelations between them, as well as the role of other elements in the pathogenesis of disease, such as adhesion molecules and chemokines, have been the subject of research in the last 30 years and much knowledge has been acquired. Knowledge of the mechanisms by which IgE is produced and its mechanism of action on target cells has equally contributed to our understanding of allergic phenomena (5). Thus, allergology as a medical science has managed to progress beyond the primitive stage in which the existence of these phenomena, which could have been psychosomatic, was questioned. Frequently, lack of knowledge or incredulity led some to label as "allergic" any clinical entity of unknown etiology.
Therapeutics has also developed considerably due to greater insight into these mechanisms: antihistamines, mastocyte membrane protectors, anti-inflammatory and anti-leukotriene agents, the recent appearance of IgE blockers and of other drugs have crucially contributed to combatting allergic diseases. Research into the nature of allergens has also made a substantial contribution, as has the development of techniques used in the preparation of allergenic extracts, which are increasingly innocuous and effective, thus guaranteeing the efficacy of immunotherapy. Recognition of the efficacy of immunotherapy is due to greater understanding of the immunological mechanisms through which this therapeutic modality acts (6, 7). The use of recombinant allergens in therapeutic extracts will undoubtedly increase the efficacy of immunotherapy (8).
...and Profession
Although insight into allergic phenomena and the diseases produced by these anomalous reactions was scarce, recognition of allergology as a specialty gradually increased. In the United States of America the Board of Allergy began to grant accreditation in allergy in 1936-1937 and in pediatric allergy in 1944. In other countries, such as Spain, recognition of the specialty took place much later although societies of allergy had been founded (e.g. Spain 1949, Argentina, 1949). However, as in Europe, in many countries the specialty has still not be recognized or is, in practice, considered a subspeciality, as a complement to other specialties (internal medicine, pediatrics, pneumology, dermatology, otorhinolaryngology). Consequently, both the contents and duration of training in this discipline vary considerably from place to place. The reason for this is clear: allergies do not affect a single organic system but take place in several places (skin, respiratory and digestive systems) or they may manifest as general reactions (anaphylactic shock).
Consequently, the specialty of allergology is related to other specialties, which feel their territory invaded. However, some aspects of our specialty are unique to allergists. These include diagnostic tests (especially skin tests and tests challenge) and therapies, above all immunotherapy which, to achieve maximum effectiveness and avoid severe adverse reactions, requires an accurate diagnosis and administration by an experienced allergist. This alone would justify the existence of the specialty but the greater experience that specialists can provide in the treatment and follow-up of allergic patients should not be undervalued. This experience ultimately benefits the patient and reduces the direct and indirect health costs. This has been shown by socio-economic studies carried out in several countries and especially by studies comparing the health care provided by specialist allergists with that provided by general practitioners or general pediatricians. The percentage of allergic patients seen by allergists is alarmingly low. In the United States of America only 16-25 % of asthmatic patients are treated by allergists while in Europe this percentage is estimated to be lower, from 10-15 %. The percentage for other diseases is equally low. In part, in several countries the responsibility lies with the Administration or with the rules of the health insurance companies, which impede patient acces to allergists and encourage health care from the general practitioner, although the public not infrequently demands specialist health care (9).
The above considerations could lead to the conclusion that the future of the specialty is none too encouraging (10). Because of the clear and widely reported increase in allergic diseases a greater number of allergology departments and allergists are needed. Allergology and related specialties should be well coordinated in order to collaborate and not compete. Acceptance of the need for other specialists to participate in the diagnosis and follow-up of particular patients, as well as recognition that general practitioners and pediatricians are qualified to oversee the day-today management of these patients, should be forthcoming. This is especially true when willingness is shown to refer first-time patients with a possible allergic disease or those with unsatisfactory evolution to an allergist (11).
Hospital Allergology departments should be given a preferential role in the health care of allergic patients and should dispose of adequate space, staff and resources. In university hospitals teaching of the subject should be entrusted to the allergology department. Moreover, at least in the most prestigious hospitals, priority should be given to research. Hence the need for allergology departments to be equipped with the necessary resources for everything from physical examination to laboratory investigations, even if for the latter, close coordination with the hospital's research laboratory is all that is required.
The appropriate health care of allergic patients can involve the practice of particular treatments, such as immunotherapy, especially in patients at high risk; consequently, immunotherapy units should be established within allergology departments.
In this edition of Allergologia et Immunopathologia (12) the regulations passed by the Spanish Society of Clinical Immunology and Pediatric Allergology for hospital allergology departments as well as immunotherapy units are published.
F. Muñoz López
REFERENCES
1. Craps L. The birth of Immunology. Sandoz Pharma Ltd. Basle, 1993.
2. Wassermann SI. The allergist in the new millenium. J Allergy Clin Immunol 2000; 105/1/1: 3-8.
3. Gell PGH, Coombs RRA. Clinical aspects of Immunology. Blackwell Sc. Pub. Oxford, 1963.
4. Ishizaka K, Ishizaka T. Human reaginic antibodies and Immunoglobulin E. J Allergy 1968; 42: 330-63.
5. Bacharier LB, Geha RS. Molecular mechanisms of IgE regulatation. J Allergy Clin Immunol 2000; 105/2/2: S547-58.
6. Liebers V, Sander I, Van Kampen V, Raulf-Heimsoth M, Rozynek P, Baur X. Overview on denominated allergens. Cl Exp Allergy 1996; 26: 494-16.
7. Akdis CA, Blasé K. Mechanisms of allergens-specific immunotherapy. Allergy 2000; 55: 522-30.
8. Chapman MD, Smith AM, Vailes LD, Arruda LK, Dhanaraj V, Pomés A. Recombinant allergens for diagnosis and therapy of allergic diseases. J Allergy Clin Immunol 2000; 106/3: 409-18.
9. European Allergy White Paper. Allergic diseases as a public health problem. The UCB Institute of Allergy. Braine-l'Alleud. Belgum, 1997.
10. Muñoz López F. Alergología en crisis. ¿Sólo en España? (Carta al Director). Rev Esp Alergol Inmunol Clin 1995; 10/4: 211-2.
11. Libro Blanco sobre el futuro de la Alergología e Inmunología Clínica en España en el horizonte del año 2005. SEAIC y Gabinete de Estudios Sociológicos Bernard Krief. Publ. C.B.F. Leti, S. A. Madrid, 1998.
12. SEICAP. Necesidades mínimas para el ejercicio en el ámbito hospitalario de la Especialidad de Inmunología y Alergología Pediátrica/Unidades de Inmunoterapia. Allergol et Immunopathol 2001; 29(1): 35-40.
