Global disparities in availability of epinephrine auto-injectors

Background

Anaphylaxis is the most severe clinical presentation of acute systemic allergic reactions and can cause death. Given the prevalence of anaphylaxis within healthcare systems, it is a high priority public health issue. However, management of anaphylaxis - both acute and preventative - varies by region.

Methods

The World Allergy Organization (WAO) Anaphylaxis Committee and the WAO Junior Members Steering Group undertook a global online survey to evaluate local practice in the diagnosis and management of anaphylaxis across regions.

Results

Responses were received from WAO members in 66 countries. While intramuscular epinephrine (adrenaline) is first-line treatment for anaphylaxis, some countries continue to recommend alternative routes in contrast to guidelines. Epinephrine auto-injector (EAI) devices, prescribed to individuals at ongoing risk of anaphylaxis in the community setting, are only available in 60% of countries surveyed, mainly in high-income countries. Many countries in South America, Africa/Middle-East and Asian-Pacific regions do not have EAI available, or depend on individual importation. In countries where EAIs are commercially available, national policies regarding the availability of EAIs in public settings are limited to few countries (16%). There is no consensus regarding the time patients should be observed following emergency treatment of anaphylaxis.

Conclusion

This survey provides a global snapshot view of the current management of anaphylaxis, and highlights key unmet needs including the global availability of epinephrine for self-injection as a key component of anaphylaxis management.

[Food allergy at school: Personalized healthcare project and adrenaline]

In Europe, the prevalence of food allergy is estimated at 6-8% of children. Ten to 20% of pediatric food-induced anaphylaxis reactions occur at school. Individual healthcare plans (IHP) for food allergy aim at: identifying children at risk of allergic reactions; reducing the risk of allergen exposure; providing emergency kits containing adrenaline auto-injectors (AAI) if needed with emergency action plans and instructions about when and how to use AAI. In France, IHP were introduced into law in 2003 and was updated in 2021. The number of IHP for allergy is increasing since 10 years (50,000 IHP for allergy/year). While the recommendations of the learned societies have resulted in the national harmonization of criteria for the implementation of IHP for allergy and for the prescription of emergency kits with AAI, adrenaline remains underused. In 2019, a national policy stated that all high schools must have a provision of spare AAI in case of anaphylaxis and the promotion of school staff training about food allergy and anaphylaxis was encouraged. These recommendations should be assessed widely and allergy training should be widespread. Pharmacists play an important role to take care of food-allergic children: provision of AAI prescribed for the most at-risk food allergic patients, advice and information on AAI. The pharmacist is therefore a key player in the therapeutic education of the patient to reinforce the key messages on the efficacy and safety of adrenaline used for anaphylaxis.

Anaphylaxis at school. Are we prepared? Could we improve?

INTRODUCTION AND OBJECTIVES

Food allergy is a highly prevalent disorder. Anaphylaxis is the most serious consequence, and reactions often occur in schools. In the event of anaphylactic reaction prompt treatment is key and should be initiated by school personnel. The aim of this study was to assess the level of knowledge of the management of anaphylaxis, and to determine if it improves after a training session among school staff.

MATERIALS AND METHODS

Descriptive study carried out by means of a pre-and post-training questionnaire completed by participants before and after a training session held at the school. Data from the same participants before and after the educational session were compared using McNemar's test.

RESULTS

Three schools were enrolled (with a total of 38 children with food allergy) and 53 participants (85% teachers, 15% canteen staff) were trained. In the pre-training surveys, 83% said they had a Student's Allergic Reaction Management Plan, 56% had met with parents, 83% recognised some symptoms of allergic reaction but only 41% recognised anaphylaxis, 16% knew when to use adrenaline, 15% knew how to use it and 19% knew how to act after administering it. In the post-training questionnaires, 100% were satisfied and believed they had improved their knowledge, 93% recognised anaphylaxis and 95% the treatment of choice.

CONCLUSIONS

Prior to the intervention their knowledge was insufficient, but it improved considerably after simple training. It also increased the confidence of the staff, which will be decisive when responding to an anaphylactic reaction. We believe that a compulsory training programme should be implemented universally in all schools.

Adherence to adrenaline autoinjector prescriptions in patients with anaphylaxis

This study evaluates adherence to adrenaline autoinjector prescriptions in a cohort of well-characterized anaphylaxis patients. The overall retrieval rate was 76% with the highest rate in patients with severe anaphylaxis. Special attention is needed in patients with unknown elicitors and in young adults, comprising the largest proportion of non-adherent patients.

Trial registration No intervention performed. Retrospective data used with permission from the Danish Data Protection Agency and Regional Committees on Health Research Ethics

Identifying the factors and root causes associated with the unintentional usage of an adrenaline auto-injector in Japanese children and their caregivers

BACKGROUND

The unintentional usage of adrenaline auto-injectors may cause injury to caregivers or patients. To prevent such incidents, we assessed the causative factors of these incidents.

METHODS

The Anaphylaxis Working Group of the Japanese Society of Pediatric Allergy and Clinical Immunology requested that society members register cases in which adrenaline auto-injectors were unintentionally used. One hundred cases were reported from June 2015 to March 2016. We identified the root causes of 70 child and 25 adult cases, separately.

RESULTS

The incidents occurred with repeated prescriptions as well as the first prescription. Three cases resulted in a failure to administer an adrenaline auto-injector to children with anaphylaxis. Four caregivers used it with improper application (epilepsy or enteritis). Among the child cases, the median age at the time of the incident was 5.5 years (range, 2-14 years). Five children injected the adrenaline auto-injector on their own body trunk. Twenty children were not the allergic patients themselves. Improper management protocol of the device and the child's development were concomitantly involved in most of the cases. A variety of human behaviors were identified as the root causes in the adult cases. At least 34 cases were associated with mix-ups between the actual and training device.

CONCLUSIONS

Health workers should provide sufficient education regarding safety use of adrenaline auto-injector for caregivers tailored to their experience levels at both first and repeated prescriptions. Such education must cover anticipatory behavior based on normal child development. Devices should also be further improved to prevent such incidents.

Surveillance of the use of adrenaline auto-injectors in Japanese children

BACKGROUND

The appropriate usage of an adrenaline auto-injector (AAI, Epipen^®) is a key aspect of patient and social education in the management of anaphylaxis. However, although AAIs are being prescribed increasingly frequently, there are few reports on their actual use.

METHODS

The Anaphylaxis Working Group of the Japanese Society of Pediatric Allergy and Clinical Immunology requested that society members register cases in which AAIs were used. Two hundred and sixty-six cases were collected from March 2014 to March 2016.

RESULTS

The cases included 240 events of immediate-type food allergies caused by cow's milk (n = 100), hen's egg (n = 42), wheat (n = 40), and peanuts (n = 11). Exercise-related events were reported in 19 cases; however, the diagnosis of food-dependent exercise-induced anaphylaxis with a specific causative food was only made in 4 cases (wheat, n = 2; fish, n = 1; squid, n = 1). The frequent reasons for the causative intake included programmed intake (n = 48), failure to check the food labeling (n = 43), and consuming an inappropriate food (n = 26). AAIs were used at schools or nurseries in 67 cases, with school or nursery staff members administering the AAI in 39 cases (58%). On arriving at the hospital, the symptom grade was improved in 71% of the cases, while grade 4 symptoms remained in 20% of the cases. No lethal cases or sequelae were reported.

CONCLUSIONS

AAIs were used effectively, even by school teachers. The need to visit a hospital after the use of an AAI should be emphasized because additional treatment might be required.

Administration of the adrenaline auto-injector at the nursery/kindergarten/school in Western Japan

Background

In view of the increasing prevalence of food allergies, there has been an associated increase in frequency of situations requiring an emergency response for anaphylaxis at the home, childcare facilities and educational institutions.

Objective

To clarify the situation of adrenaline auto-injector administration in nursery/kindergarten/school, we carried out a questionnaire survey on pediatric physicians in Western Japan.

Methods

In 2015, self-reported questionnaires were mailed to 421 physicians who are members of the West Japan Research Society Pediatric Clinical Allergy and Shikoku Research Society Pediatric Clinical Allergy.

Results

The response rate was 44% (185 physicians) where 160 physicians had a prescription registration for the adrenaline auto-injector. In the past year, 1,330 patients were prescribed the adrenaline auto-injector where 83 patients (6% of the prescribed patients) actually administered the adrenaline auto-injector, of which 14 patients (17% of the administered patients) self-administered the adrenaline auto-injector. “Guardians” at the nursery/kindergarten and elementary school were found to have administered the adrenaline auto-injector the most. Among 117 adrenaline auto-injector prescription-registered physicians, 79% had experienced nonadministration of adrenaline auto-injector at nursery/kindergarten/school when anaphylaxis has occurred. The most frequent reason cited for not administering the adrenaline auto-injector was “hesitation about the timing of administration.”

Conclusion

If the adrenaline auto-injector was administered after the guardian arrived at the nursery/kindergarten/school, it may lead to delayed treatment of anaphylaxis in which symptoms develop in minutes. Education and cooperation among physicians and nursery/kindergarten/school staff will reduce the number of children suffering unfortunate outcomes due to anaphylaxis.

A workshop with practical training for anaphylaxis management improves the self-efficacy of school personnel

BACKGROUND

School personnel are required to guarantee a secure school environment for children suffering from severe food allergies. We organized a workshop for school personnel to learn the appropriate management of anaphylaxis that included practical training with an adrenaline auto-injector (AAI). The objective of this study was to evaluate the workshop in terms of the improvement of self-efficacy (SE) of participants to deal with anaphylaxis.

METHODS

All 93 school nurses, 73 schoolteachers and 110 childcare workers participating in the study completed a questionnaire before and after the workshop. The SE of the participants was evaluated using an original 15-item questionnaire.

RESULTS

Before the workshop, the SE of school nurses was the highest among the profession groups, and being involved with children prescribed an AAI was a common factor associated with a high SE. After the workshop, the SE increased in all groups, but most apparently in school nurses and those involved with children prescribed an AAI. The presence of an emergency plan was positively associated with the SE of schoolteachers only after the workshop, even though no such association existed beforehand.

CONCLUSIONS

Practical instruction of school nurses and school personnel involved with children prescribed an AAI resulted in dramatic improvement of the SE. These people are expected to play a central role in the development of an anaphylaxis management plan in their schools.