School-based strategies may reduce disparities in anaphylaxis caused by food allergies
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Programs that increase access to epinephrine autoinjectors to treat anaphylaxis caused by food allergies, along with training in using them, need to be expanded, according to a review published in Annals of Allergy, Asthma & Immunology.
Expanding access and training would minimize the disparities in care experienced by underrepresented groups and by those who come from a lower socioeconomic background, Ellen W. Daily Stephen, MD, a first year allergy and immunology fellow in the department of internal medicine at Rush University Medical Center in Chicago, and colleagues wrote in the review.
For example, 17.5% of children in private schools in New York City had been diagnosed by a physician with a food allergy, compared with 7.4% of children in public schools, the researchers said.
A lack of diagnosis makes it difficult to recognize children who experience severe food reactions, the researchers wrote. Children who have not been diagnosed also do not have food allergy action plans, nor do they carry epinephrine autoinjectors.
Through their District-Issued Emergency Epinephrine Initiative, the Chicago Public Schools have stocked their facilities with undesignated epinephrine autoinjectors. These devices were used 38 times in a 1-year span between 2012 and 2013, including 21 cases involving food reactions. Also, 55% of these injections were given to children who did not have a diagnosed allergy.
Schools need to train everyone on their staff in recognizing anaphylaxis and in using epinephrine autoinjectors as well, the researchers wrote. Only 31% of schools provide such training for all their staff, the researchers continued, and only 3% allow students and staff to administer epinephrine via autoinjector.
Laws regarding epinephrine administration vary from state to state, with individual schools and districts developing their own policies. Addressing these laws and policies would improve response to food-induced anaphylaxis, the researchers wrote.
In a call to action, the researchers spotlighted strategies that could remedy these disparities.
To address the lack of access to personal epinephrine autoinjectors, the researchers called for the provision of open access to these devices, especially in school settings. They also suggested exploring options to reduce or eliminate the cost of epinephrine autoinjectors for low-income patients.
Citing inadequate education in recognizing and managing anaphylaxis, the researchers recommended standardized education for all school staff and expanded public outreach to improve awareness of the symptoms of food-induced anaphylaxis.
Finally, because there is a lack of access to allergist care for the diagnosis and management of food allergy, the researchers said providers should collaborate with school medical staff for referral to allergy specialty care when there are concerns about food allergies. Primary care providers should receive education about food allergies as well.
Perspective
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Aikaterini (Katherine) Anagnostou, MD (Hons), MSc, PhD
Food allergies affect one in 13 schoolchildren in the U.S. and carry a significant burden. Standard management consists of avoidance of the culprit food, as well as recognition and treatment of allergic reactions when they occur.
This paper highlights disparities in food allergy care for children of lower socioeconomic status and minority race, with lower rates of disease diagnosis and reduced access to emergency medication, such as epinephrine autoinjectors.
These findings are not surprising and have been supported by previous work. To address these disparities, the authors proposed school-based programs with a focus on improving access to emergency medication and providing education to school staff on how to promptly recognize and treat anaphylaxis (severe, life-threatening reaction).
Undesignated epinephrine autoinjectors were shown to be administered 38 times over a period of 1 year in Chicago public schools and were used more frequently in lower socioeconomic status schools when adjusted for the number of students with a food allergy diagnosis.
Early recognition and appropriate management of anaphylaxis is key in preventing adverse outcomes. In this area, the role of the allergist is multifaceted. It consists of raising awareness of disparities in food allergy care, educating school personnel on the appropriate management of anaphylaxis and advising schools on allergy referrals and stocking undesignated epinephrine.
On a state level, where differing legislation may affect the ability to stock and administer epinephrine in schools, allergists can be important advocates for food-allergic children, addressing relevant laws and policies with the aim to improve management and outcomes of anaphylaxis. Further research on existing and developing school-based interventions will be welcome and add to our understanding of barriers to treatment as well as efficacy of the interventions applied.
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Andrea Pappalardo, MD, FAAAAI, FACAAI
All the points that this group brings up are valid. Children are in schools most of their days, and studies show that a large portion of food-induced anaphylaxis in schools involves first-time reactions.
This stresses the need to ensure that undesignated epinephrine autoinjectors are in schools, not expired and in locations that are readily accessible and known to all staff. Also, staff need to be well trained to both recognize the need for and use autoinjectors, and proper follow-up must be in place.
Disparities exist in the diagnosis and management of food allergy as well as in referral patterns to allergist-immunologists. Although this approach to school-based food allergy management is critical, it does not replace the necessity to address multilevel concerns with food allergy management for people of color throughout the U.S.
In my experience, school nursing and health staff are desperate for knowledge and help to address food allergy and all student health concerns. They care, but they are overworked, and time is an issue. We need to be mindful of these time constraints and understanding of school resources whenever a school-based intervention is considered.
Feasibility and sustainability from the conception of a program is a necessity. Otherwise, a program, even though well-intentioned, will not be successful. Collaboration is necessary with school health administration and staff to create a multilevel intervention that addresses the needs and recognizes the resources of schools.
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