Published Online: June 5, 2015
One in 13 students have a food allergy requiring individualized health care plans, emergency action plans, and training for school personnel. Reactions in schools are common: 16-18% percent of school-age children with food allergies experienced a reaction in the school, and onset of symptoms in the school setting is a risk factor for fatal reactions. Given the prevalence and severity of this issue, the State of Illinois enacted “Guidelines for Managing Life-threatening Food Allergies in Illinois Schools” and the “School Access to Emergency Epinephrine Act.” These laws stipulated food allergy training and anaphylaxis drills in school and allowed undesignated epinephrine for any child with a severe allergic reaction. The assessment of current practices is important in the planning for appropriate resources for school emergency preparedness, including food allergy education and anaphylaxis drills for staff. This is particularly important as similar food allergy legislation is applied nationally. Learning from the Illinois experience is important to optimize national implementation.
An article recently published in The Journal of Allergy and Clinical Immunology: In Practice by Szychlinski et al characterized school nurse response to food allergy emergencies in school and the impact recent Illinois State legislation has had on emergency preparedness to manage severe food allergy reactions. A cross-sectional online survey was administered to school nurses and aides throughout Illinois between October 1, 2012, and January 20, 2013. Survey questions were designed to assess school experience with food allergy reactions and school response to recent food allergy legislation in the State of Illinois. A chi-squared test of independence was used to compare answers by school community type (eg, rural, suburban, and urban) and school level (preschool/elementary school, middle/junior high, high school).
Four-hundred-sixty personnel (72% of the Illinois Association of School Nurses membership) completed the survey, representing over one thousand (1,012) Illinois schools. Nurses covered 2.4 schools on average. Schools were described as suburban (n=662 schools, 65.8%), rural (n=225 schools, 22.2%) and urban (n=125 schools, 12.4%), and all school levels from preschool to high school were represented. Over one-third (35.2%) of respondents reported an experience with a severe allergic reaction, although nurses from rural communities were least likely to report this experience (n=161 emergencies, 18.9% rural vs 38.5% suburban vs 46% urban, p=0.001). Importantly, 21.6% (n=35/161) of the severe reactions were from a previously unknown. Epinephrine was administered a total of 120 times (79.5%) but was not given in 28 of 161 severe reactions (17.4%). When epinephrine was not given, unavailability of the drug was the most frequently cited reason, and this was most common in rural schools (85.7% vs 50% vs 47%, p=0.037). Despite stipulations in the State Guidelines, rural schools were least likely to have a written plan or protocol to outline staff procedure in the event of a severe allergic reaction (59.4% of respondents working at rural schools were aware of a written plan or protocol vs 81.7% for suburban vs 71.9% for urban, p=0.0019). This did not differ between school levels. Additionally, rural schools were least likely to report undesignated epinephrine policies (35.6% of rural, 47.5% of suburban, and 64.0% of urban schools, p=0.005). Among those schools with undesignated epinephrine autoinjectors, nearly all nurses and aides supported the new policy (92.4% nurses, 92.3% aides) and the majority of nurses (83.2%) and aides (92.3%) indicated that they felt children with food allergy were now safer in school.
Together, these data emphasize that all school personnel are called upon to administer injectable epinephrine, and that school nurses support expanded legislation regarding food allergy education, training, and availability of injectable epinephrine. Previously unrecognized, this study illustrates an important health disparity and an opportunity for improved implementation and advocacy in implementation of food allergy legislation. This study demonstrates positive effects of recent state legislation mandating food allergy education and the allowance of undesignated epinephrine in schools and highlight the need for school-wide food allergy preparedness and training. The findings also reveal opportunities for improvement in food allergy policy implementation, including securing additional time and resources for food allergy training and anaphylaxis drills, and addressing geographic health disparities by increasing efforts in rural communities.
The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.