Q&A: Missouri legislation allows trained school personnel to administer epinephrine

Gov. Mike Parson of Missouri has signed SB 710, which authorizes all school personnel in the state trained by a nurse to administer epinephrine via autoinjector to any student experiencing anaphylaxis without any civil liability.

This legislation was drafted to expand the level of care accessible to children who have life-threatening food allergies including young students who are unable to administer the medication themselves, students who cannot afford their own autoinjectors and students who might not even know they have allergies.

Healio spoke with Jason Linde, MA, senior vice president of government and community affairs at Food Allergy Research & Education (FARE), to find out more about the legislation and the need for access to epinephrine for children across the nation.

Healio: Why is there a need to expand access to epinephrine in schools?

Jason Linde

Linde: In 2016, an NIH study found that 25% of all anaphylactic attacks that happen in schools occur in children with no known food allergies. In 2020, an eye-opening study showed that children who are on Medicaid are one-tenth as likely as children with private health insurance to be diagnosed with food allergies.

So regardless of whether it’s Missouri or Montana or any state in the country, the fact is that in schools, there is a great number of children walking around who are unaware that they have life-threatening food allergies and that there are just not enough precautions in place, frankly, to help them. This is certainly true among those who are the most economically vulnerable. The massive underdiagnosis there is cause for concern.

Our feeling is that the people in Missouri are working very hard in their schools to help their children and that this just makes their job just a little bit easier.

Healio: How does this legislation address those dangers?

Linde: It gives the power to administer epinephrine to a larger group of people. By doing so, you create a larger safety net. For example, the school bus driver, who previously couldn’t administer epinephrine for a whole host of reasons, now has permission once he or she is trained to do so.

There are about 70,000 children who have life-threatening food allergies, but not all of them have been diagnosed. Every year, we see with schools where unfortunately a student passes because epinephrine wasn’t administered in a timely manner.

In Nebraska earlier this year, an eighth grader unfortunately passed after consuming a granola bar that included an allergen that he wasn't aware of. Unfortunately, the school personnel did not administer epinephrine first.

It’s a horrible reminder for people with this disease and these life-threatening food allergies that epinephrine is the only solution. We just need to put it in more people’s hands who can administer it and who can step in during a time of need. That’s why this is so important.

Healio: The legislation specifies that training would be required before school personnel would be allowed to administer epinephrine. What might that training be like?

Linde: Schools probably will use any of the different available epinephrine trainer pens so personnel feel comfortable with them and understand that these pens need to go in the thigh. We want to make sure that people who are going to act know how to act properly — how the pen works, how to hold it and that sort of thing. It’s like a fire. You don’t want to be reading the directions on the fire extinguisher when your oven is blazing. Training probably could be handled during a single in-service day. I was a lifeguard growing up. This is not CPR training. This does not take that long, whatsoever.

Healio: What are some potential situations where school personnel would need to step in and use an autoinjector?

Linde: In some cases, the anaphylaxis is so overwhelming that the child might not be able to use their autoinjector themselves. In other cases, children aren’t even carrying these pens. Even with health insurance, copays can be extremely expensive. A lot of people leave their pens at the pharmacy. We want to make sure that the school bus driver or other personnel can step in at a time of need and hopefully have access to autoinjectors. Different programs exist where schools can get discounted autoinjectors at a very low cost.

Healio: When it comes to stocking autoinjectors for emergency use, is expiration an issue for schools?

Linde: It is and it isn’t. We’re working on a federal bill — HR 7669 in the House; it already has passed in the Senate — that would give the FDA power to extend the expiration date on epinephrine. Studies show that epinephrine is effective in years 2 and 3, with an efficacy rate of 90% in year 3.

Clearly, we think one way to lower the cost of epinephrine is to extend the expiration date. We would love to see the FDA have the power to take that action. If schools have an epinephrine pen that is 18 months old, they should not hesitate to use it if there is an emergency. It’s better than nothing.

Healio: Now that this legislation is in place, do you have any outreach planned to educate school communities?

Linde: FARE has nationwide support groups, about 120 across the country. We have an active one in St. Louis and one in the greater Kansas City area. We hope through our social media outreach, and through our work with these support groups and others, that word gets spread. We’re also hoping that local news in Missouri will help get the message out to schools. I’m sure that schools will be informed by their state medical associations as well, and by their folks in the capital, and we hope they take advantage of this law.

Healio: How can doctors and other stakeholders get more involved in advocacy for this and other issues pertaining to food allergy?

Linde: The easiest and probably the most effective way would be to reach out to their state medical associations. If we’re talking about doctors and health care professionals specifically, they all have very solid and well-regarded state lobbying associations. These are folks who are advocating on behalf of doctors at their statehouse.

The easiest and probably the most effective way is to raise concerns with their state association about these issues and to encourage the state association to take up bills like this one to improve the quality of life for the more than 32 million Americans suffering from life-threatening food allergies. That’s the most effective and easiest way because it’s coming from within. It’s coming from a well-wired professional community. These state lobbying associations know the players at the statehouse.

For others, they can always join our advocacy list and reach out to me or send us an email if they’re interested. They can join our group of grassroots advocates who are working on state and federal issues. We are happy to have the help of others as we move forward.

Healio: Are there any resources to help doctors, teachers or other stakeholders better educate themselves about these issues and prepare for these emergencies?

Linde: FARE has an extensive amount of information on its website about back-to-school preparation. It’s mostly written for parents, but teachers can probably pick up and absorb quite a bit of information there as well. Teachers already are required to understand 504 plans, which are the accommodation plans for children with life-threatening food allergies and other health care issues. So, we welcome them to learn more specifically about our community and look at our website. We also do dozens and dozens of webinars every year, touching on a whole host of issues. Occasionally we will touch upon accommodations in the classroom. There’s a lot of information on the website that teachers can access and utilize.

Healio: Is there anything else you would like to add?

Linde: We are grateful for our advocates at the state and local level. They are the real drivers of change. We want to support them in every way possible, and we look forward to doing that in Missouri. We’re very appreciative of the work done in Missouri, and we look forward to doing it in other states as well.

References:

Bilaver LA, et al. Am Pediatr. 2020;doi:10.1016/j.acap.2020/03.005.

Cantrell FL, et al. Ann Intern Med. 2017;doi:10.7326/L16-0612.

Kassel L, et al. J Allergy Clin Immunol Pract. 2019;doi:10.1016/j.jaip.2019.04.028.

White MV, et al. Pediatr Allergy Immunol Pulmonol. 2016;doi:10.1089/ped.2016.0675.

For more information:

Jason Linde, MA, can be reached at Jlinde@foodallergy.org.