Current situation of allergy education in Mexico and other parts of Latin America☆

Allergic diseases are one of the most frequent chronic diseases in the world. It has been established that there is a worldwide epidemic of allergic diseases; therefore, the treatment of allergies should be acknowledged as a worldwide priority and the specialty of allergy should be considered an important field in medicine. Due to the fact that allergic diseases involve many organs, and Allergy and Clinical Immunology is one of the specialties in which physicians may be trained to treat patients of all ages, the subject in medical schools is not always taught as an individual specialty but often as part of another subject such as internal medicine or pediatrics. Certified allergists are an important contribution to health systems, providing the necessary care for patients who have allergic diseases. Undergraduate programs in many universities do not include allergy as a subject, contributing to a lack of knowledge regarding the correct management of allergic diseases. World Health Organization (WHO) recommends 1 allergist per 50,000 people; however, there is an uneven distribution of allergy and clinical immunology specialists. Most practitioners are localized mainly in larger cities and state capitals, while in other regions, specialists are still greatly needed. Support and training systems are required for allergy and clinical immunology specialists to promote continuing education and keep their clinical competence up to date, which will lead to better care for their patients. Increased exposure to the concepts of allergy and clinical immunology diagnosis and treatment in undergraduate education may also potentially lead to an increase in interest in the field of allergy and clinical immunology among physicians in training. This review will approach allergy education in Mexico and other parts of Latin America.


INTRODUCTION
Allergic disease is one of the most frequent chronic diseases in the world. It has been established that there is a worldwide epidemic of allergic diseases due in great part to modern urban lifestyle and a wide range of epigenetic modifications. 1 Therefore, the treatment of allergies should be acknowledged as a worldwide priority, and the specialty of allergy should be considered an important field in medicine. This review will approach allergy education in Mexico and Latin America. The authors are experts in the field of Allergy and Clinical Immunology from Mexico and various areas of Latin America and have provided detailed information, according to each country that is included in this manuscript.
According to World Health Organization (WHO), there are 400 million people with allergic rhinitis and over 330 million people with asthma worldwide. In Mexico, there are 8.5 million people with asthma. In 2013, the Mexican General Health Information Committee, which coordinates and analyzes budgeting of public health and service provision, registered that 20% of hospital expenditures due to chronic respiratory diseases were because of asthma, finding an underdiagnosis and inadequate treatment for patients. 2 This issue is not limited to Mexico, a recent European paper notes that allergic diseases are still not well recognized in all groups of ages by other specialties and government agencies. 3 Petitions have been made to the Mexican Senate by the Global Alliance Against Chronic Respiratory Diseases (GARD) in Mexico, the Mexican College of Pediatricians Specialized in Clinical Immunology and Allergy (COMPEDIA), the Mexican College of Clinical Immunology and Allergy (CMICA) and the Latin American Society of Allergy and Immunology (SLaai), requesting that asthma and other chronic respiratory diseases be considered as an important health issue in Mexico. This recognition would create awareness and obtain greater funding for prevention and treatment. In February 2005, the Mexican Federal Journal published the first initiative to recognize asthma as a public health issue. 4 On March 28, 2006, the second initiative presented the idea that the diagnosis and treatment of allergic diseases should be managed only by boardcertified specialists in Allergy and Clinical Immunology.
Given the high prevalence of allergic diseases and the different health systems all over the world, patients might be treated by General Practitioners (GP), internal medicine specialists, pediatricians, or by professionals who have received additional training in allergy or by certified allergists. In an attempt to ensure these patients receive appropriate care, World Allergy Organization (WAO) recommendations for acceptable competence required for any physician who takes care of patients with allergy have been published. 5 Physicians who care for patients should obtain and maintain certain medical competencies including: recognition of the essential elements of the medical profession, ethical principles and legal responsibilities; comprehension of the importance of the benefit of the patient, society and the profession, with special attention to professional confidentiality, knowledge in applying the principle of social justice to professional practice and the development of professional practice with respect to the patient's autonomy, beliefs and culture. 6 Due to the fact that allergic diseases involve many organs and Allergy and Clinical Immunology is one of the specialties in which physicians may be trained to treat patients of all ages, the subject in medical schools is not always taught as an individual specialty but often as part of another subject such as internal medicine or pediatrics. 5,7 It may also be taught in part, within organ based classes, where it is considered a part of Dermatology, Otolaryngology, Ophthalmology, Pulmonology and/or Gastroenterology.
It is also a relatively new discipline, and there are not yet many allergists available to teach this multidisciplinary subject. WAO describes this as the "knowledge/practice gap". 8 Many physicians will not qualify with adequate competency to manage the diagnosis and treatment of allergic diseases at the primary care level, unless allergy training is considered as an essential part of undergraduate medical education at the clinical level. 8

ALLERGY EDUCATION
An Allergy and Clinical Immunology physician is a sub-specialist who has completed training in the area of allergy and clinical immunology after receiving education in Pediatrics or Internal Medicine. Due to the nature of allergic diseases, with a dysregulated immune response as a key feature, the study of clinical immunology is essential to understand allergy. Certified allergists are an important contribution to the health systems, providing the necessary care for patients who have allergic diseases. 9

Undergraduate allergy education in Mexico and other countries in Latin America
Although there are 66 medical schools in Colombia, Ramírez-Zuluaga et al found that undergraduate programs in many universities do not include allergy as a subject, but only as topics, contributing to a lack of knowledge regarding the correct management of allergic diseases. 9 Brazil has the second largest number of medical schools in the world, with 345 schools, while Uruguay has 2 schools of Medicine, one private facility and another public one with 350 graduates every year. In Argentina there are 20 faculties of Medicine; Paraguay has 15 validated careers in Medicine; Venezuela has 8 schools of Medicine; and Chile has 20, while in Panama, there are 5 (Table 1). In Mexico, there are over 140 public and private medical schools of which only 8 states include allergy in their programs (Aguascalientes, Baja California, Chihuahua, Mexico City, Guanajuato, Jalisco, and two in Nuevo León) 10 (Table 2).
In the rest of the world, teaching of allergy as a subject is not always homologous and is taught in academic postgraduate programs as follows: in 16 countries as respiratory medicine, 15 as part of pediatrics, 12 countries include it as part of dermatology, 14 in otolaryngology, 14 as part of internal medicine, 1 country includes it in gastroenterology, and only in 1 country is allergy part of the training of the General Practitioner. 11 It is important that undergraduate students are exposed to the specialty in order to promote their interest and enthusiasm towards becoming specialists in the future. In the same way, this may happen with pediatric residents since the time period spent in allergy training is often not long. 3,12 Postgraduate allergy education in Mexico and other countries in Latin America In Latin American countries, allergy training is available in Argentina, Brazil, Chile, Colombia, Mexico, Paraguay, Peru, Dominican Republic, Uruguay, and Venezuela. Allergology is considered a third-level patient care specialty or subspecialty in 56% of Latin American countries. 13 Specialized referral hospitals include third level care specialties, where allergy and immunology centers provide patient care. In the case of subspecialties, 2-3 years of training is needed in internal medicine or pediatrics before physicians can access allergology. 13 Allergology training is found as second-level medical care in some countries. No basic specialization is needed and training is accessible for a general physician. General Practitioners in Brazil can start a residency after practicing allergology for at least 8 years, and result with a university degree. Children and adult care is included in most training centers. The Brazilian Association of Allergy and Immunopathology has training programs in 17 accredited centers, associated mainly with medical schools. A 2-year residency in Allergy and Clinical Immunology requires 2 years of previous training in Internal Medicine. Fellowship programs are offered for pediatricians, which require at least 2-years of training in pediatrics. The Brazilian Group of Primary Immunodeficiencies (BRAGID) was created in 2001 aiming to improve primary immunodeficiencies (PID) diagnosis through educational activities and to stimulate research in PID. This group established educational activities and stimulated research in PID. BRAGID has been linked to the Latin American Group of Primary Immunodeficiencies (www.lasid.org) which in turn became a society in 2009. The BRAGID website has more than 4200 members; among them 41% are pediatricians. The educational task on early suspicion of PID is a challenge with targets such as the warning signs, for medical students and all health professionals. 14 Brazil and Mexico have a special training program with a university title for pediatric allergists. Colombia and Venezuela each have 2 training Generally, no new examinations take place; however, recertification is required every 2-5 years. In countries such as Paraguay, certification is achieved by attending courses and congresses from the start, and physicians are not required to be certified through examination. Postgraduate schools of national universities as well as the Ministry of Health and Social Welfare in Paraguay authorize medicine and allergy practice before physicians start evaluating patients. 13 For the most part, the basic curricula in pediatric or internal medicine as well as third level allergology training has a duration of 4-6 years. Three years is the duration in places where no primary training is required before second-level allergology completion. 13 Recently, postgraduate courses have been designed for all levels of healthcare professionals who encounter patients with allergic conditions, including doctors, specialist nurses, and dietitians. Some faculties have distance learning options available. The courses may be run by leading world experts and incorporate up-to-the-minute information on new research and clinical practice.
In Mexico there are currently 15 training centers (Table 2) with the purpose to educate specialists in Allergy and Clinical immunology to be capable of providing medical care for patients with allergic and immunologic diseases; they have abilities, skills, and aptitude in diagnosis, treatment, and prevention. The subspecialty is 2 years long and in order to apply the physician must have his or her degree in Pediatrics or Internal Medicine.

Skills of the allergist 16
Understanding the development and mechanism of allergic and immunologic diseases Comprehension of the concept "one airway, one disease" as well as the "atopic march" In Mexico, there is an uneven distribution of allergy and clinical immunology specialists. Most practitioners are localized mainly in larger cities 10 Gonzalez-Diaz et al.   In the last decades, the Mexican and Latin American Allergy communities have been greatly involved in WAO, becoming leaders in allergy and immunology education. Their high standards in research, education, and community assistance have made them eligible to be included as WAO Centers of Excellence.

World Allergy Organization Centers of Excellence
A WAO Center of Excellence is identified as a multidisciplinary group, based in an academic institution, encompassing 3 or more subspecialties with the following components: graduate programs with academics and students, peerreviewed publications in the field of allergy and immunology, well-established organization with good governance, infrastructure, recognized mentors in allergy, asthma, and clinical immunology, and a research department.
A WAO Center of Excellence should be proficient in the following areas: research, basic and clinical science, and recognized education and training program (Fig. 1) Undergraduate and postgraduate training center providing prevention-oriented health care services in the outpatient clinic and research center with high-quality standards, in benefit of the general community of Monterrey and other surrounding states in northeastern Mexico. CRAIC is located in a total area of 1000 m 2 on the fourth floor of the outpatient clinic building in the UANL's University Hospital. Medical services are primarily focused on prevention, treatment, and rehabilitation of immuno-allergic diseases through comprehensive patient care for adults and children specializing in respiratory, skin, drugs, food, and hymenoptera allergy as well in immunodeficiency disorders.
Since 2000, Sandra Nora Gonzalez-Diaz, MD PhD, has led CRAIC and encouraged a culture of international collaboration in teaching, clinical medicine, and research, alongside the staff of professors.

Centro Medico Nacional Siglo XXI-Instituto
Mexicano del Seguro Social (Mexico City, Mexico): 2016 Center of Excellence The Allergy and Clinical Immunology service of the Hospital de Especialidades, Centro Medico Nacional Siglo XXI, in Mexico City, belongs to the largest public social security institution in the country. It is a national reference center for diagnosis and specialized treatment in allergic diseases and immunodeficiencies. Their mission is to be a service equipped with high technology, resolutive capacity, and constant training, which meets the needs and expectations of the right-holders, contributing with quality scientific research and high-level educational training for our resident doctors, forging the best Allergy and Clinical Immunology service in the country.
Since 2015, it has been led by Nora Hilda Segura Méndez MD, who also serves as editor-inchief of the Revista Alergia México, which is recognized as the most important scientific journal of the specialty in Latin America. She is the head professor of the graduate course in Allergy and Clinical Immunology. The center has national and international publications, and the main lines of  The Allergy, Asthma and Clinical Immunology service is a regional Comprehensive Care Center for the evaluation, diagnosis and treatment of patients with suspected allergic diseases, difficult asthma and immunodeficiency disorders. The mission of the Center is to give medical attention of high specialty on pediatric allergy and clinical immunology, giving safe attention and a high quality by sub-specialist on pediatrics, and doctors in training, and also to carry out excellence scientific research on allergic and immunologic diseases and their comorbidities. 20 They have an excellent team lead by Dr. Blanca E. Del Rio Navarro composed of teachers and researchers, professionals, graduate and undergraduate students. 19  Caraballo MD, PhD and has a high quality scientific and academic staff. As a joint effort among national and foreign colleagues, well trained technicians, PhD and MSc students as well as specialty trainees and undergraduate students, the work of the Institute for Immunological Research of the University of Cartagena covers several fields of Basic Immunology, Molecular Genetics, Biotechnology, Experimental Allergy, Clinical Allergy, Epidemiology, Pediatrics and ENT.

CONCLUSIONS
Allergic diseases are a major global health problem, also considered one of the epidemics of the XXI century. Despite the growing number of patients suffering from atopic disorders, there is still a deficiency of specialists trained in the diagnosis, treatment and prevention of this group of diseases. The undergraduate programs of a large number of universities in Mexico and other Latin American countries do not include an adequate curriculum in allergy, which contributes to the lack of information and the incorrect management of patients with increasingly common atopic diseases.
The standards in which it is determined that a physician specializes in allergy and clinical immunology are important because allergic diseases are very common. The availability of services and training for allergists is disproportionate, with a great need not yet covered. Support and training systems are also required for allergists and clinical immunologists to promote continuing education and keep their clinical competence up to date, which will lead to better care for their patients. Increased exposure to the concepts of allergy and clinical immunology diagnosis and treatment in undergraduate education may also potentially lead to an increase in interest in the field of allergy and immunology among physicians in training.