Q:

9/10/2014
I am hoping that you can provide further recommendations regarding peanut/tree nut allergy in the school setting, and prevention of reactions. I have a 7yo patient with severe peanut and tree nut allergy; he had an anaphylactic reaction during allergy testing 3 years ago, and has strictly avoided these allergens since. This school year, despite sitting at a peanut/tree nut free table and eating a lunch packed from home, he developed a mild anaphylactic reaction after playing on the playground after lunch. The other children had not washed their hands, and we believe that the reaction was due to cross-contamination on playground equipment. I have reviewed previous Ask the Expert responses on this subject as well as the current CDC guidelines published last year. Given the severity of his allergy, I have strongly recommended hand washing by all children prior to leaving the cafeteria. The school would like to use hand wipes instead. I am aware that in one very small study that these were shown to remove allergen to a similar degree as hand washing- but I am also aware that reactions on the playground due solely to contamination such as this are quite rare. This seems to me to represent a special case- and one that would warrant hand washing as opposed to utilization of wipes. Do you agree?

A:

Thank you for your inquiry.

I can well understand your concern with a child so sensitive. Unfortunately, in my opinion there is no definitive answer to your question, but the small amount of literature that we have dealing with the issue indicates that, as you mentioned, hand wipes are as effective as hand washing. I assume the reference you were referring to is the one by Dr. Robert Wood and Associates published in The Journal of Allergy and Clinical Immunology. For the sake of our readers, I have copied below the abstract along with both the Methods section and Results sections from this well done article. I am not aware of nor could I find any other article in the literature dealing with this issue.

Based upon these results, it has always been my impression that hand wipes were sufficient. However, I have no particular expertise in this area and therefore I am going to ask Dr. Wood, who is the senior author on this study, to weigh in on this problem. When I hear from Dr. Wood, I will forward his response to you.

Thank you again for your inquiry.

Journal of Allergy and Clinical Immunology
Volume 113, Issue 5, Pages 973–976, May 2004
Peanut allergy is an enormous clinical problem. It is the third most common food allergy in young children11 and the most common food allergy in older children, adolescents, and adults.22 In addition to its substantial prevalence, it is the food allergen most capable of causing severe, life-threatening, and even fatal allergic reactions.3., 4. The diagnosis of peanut allergy therefore carries tremendous medical and emotional significance.

Because avoidance is the only available treatment for food allergy at this time, patients with peanut allergy must take extraordinary care to eliminate all peanut-containing foods from the diet. This is far more difficult than it sounds, especially because of the cross-contamination of foods that may occur in the manufacturing process. In addition to the obvious goal of avoiding peanuts in the diet, another key issue facing patients with peanut allergy and their families involves other potential sources of accidental exposure. Inadvertent exposure has been reported to occur in environmental settings such as restaurants,55 schools,6., 7. and other public places—for instance, sporting events and commercial airline flights.88 Although these reactions are presumed to occur by exposure through skin contact or inhalation of airborne allergen, in most of these reports, accidental ingestion of peanut could not be entirely ruled out. A recent study by Simonte et al 99 reported that casual contact or inhalation of peanut butter does not pose a significant risk for severe reactions, suggesting that many of the reports of casual contact or inhalation reactions may in fact be caused by inadvertent ingestion.

The purpose of the current study was to determine the prevalence and levels of exposure that may be encountered in home and school settings and under several simulated environmental conditions. We included environments such as those present in homes and public eating areas as well as those that may be present at sporting events or during commercial airline flights.

Hand wipe samples (METHODS)
Approximately 5 mL peanut butter was applied to the hands of volunteers, and some samples were taken before hand washing. Persons were then asked to wash their hands by using their normal hand washing techniques with various cleaning agents or plain water. Participants were also asked to clean their hands with a nonsoap antibacterial hand sanitizer after the application of 1 mL peanut butter. Participants were not instructed on specific hand washing techniques but were told to wipe or wash their hands as they normally would to remove the peanut butter. After hand washing, a 37-mm glass fiber filter was moistened with extract solution, and wipe samples were taken from the hands of participants.

Hand wipe samples (RESULTS)
Nine hand samples were taken before cleaning, and the range of Ara h 1 was 480 to 5.6 × 104 ng/mL. Hand wipe samples were taken after each of the following cleaning methods: plain water, antibacterial hand sanitizer, Tidy Tykes wipes (Pampers, Procter and Gamble), Wet Ones antibacterial wipes (Playtex Products, Dover, Del), liquid soap, and bar soap (Table IITable II). Water and hand sanitizer left residual Ara h 1 on 3 of 12 and 6 of 12 hands each (range, 164-8274 ng/mL and 132-1711 ng/mL, respectively). Ara h 1 was undetectable with all other hand cleaning techniques.

Sincerely,
Phil Lieberman, M.D.

We received the response from Dr. Robert Wood. Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

Response from Dr. Robert Wood:
In reality, most of these reactions are so sporadic that none of this is likely to be needed (i.e. he is most likely to go through the rest of the year without further reactions). However, assuming we need to do something, I would be confident that wipes work as well as hand washing, and in all likelihood better since hand washing is often so rushed - in an effort to get the kids through the process at 1-2 sinks.
 
Bob Wood

Close-up of pine tree branches in Winter Close-up of pine tree branches in Winter