Anaphylaxis Legislation gets Presidential Seal of Approval

SRxA is delighted to announce that earlier this week President Obama signed into law the School Access to Emergency Epinephrine Act.  During a week in which Obama and his new healthcare.gov website have made headlines for all the wrong reasons, we thought it only fair to commend him on this important anaphylaxis initiative.

The School Access to Emergency Epinephrine Act is legislation that will help to protect schoolchildren who experience life-threatening anaphylaxis.

“This legislation is a significant milestone for food, venom and latex allergy safety in our nation’s schools,” says Tonya Winders, chief operating officer of Allergy & Asthma Network Mothers of Asthmatics (AANMA). “It will help save lives of children who experience an anaphylactic reaction for the first time or don’t have epinephrine auto-injectors readily available when anaphylaxis occurs.”

The measure provides a funding incentive to states that enact laws allowing school personnel to stock and administer emergency supplies of epinephrine auto-injectors. Epinephrine is the first line of treatment for anaphylaxis.

The School Access to Emergency Epinephrine Act was bipartisan legislation, first passing the U.S. House of Representatives on July 30, 2013, and then the U.S. Senate on Oct. 31, 2013, before heading to the President’s desk.

Allergic reactions to foods are the most common cause of anaphylaxis in community settings, according to the U.S. Centers for Disease Control and Prevention (CDC). Studies show that 16-18% of schoolchildren with food allergies have had a reaction from accidentally ingesting food allergens. In addition, 25% of anaphylaxis cases reported at schools happened in children with no prior history of food allergy.

As of today, 28 states have passed emergency stock epinephrine legislation and six have bills pending.  Let’s hope this legislation will spur the remaining states to follow as soon as possible.

Green states that have passed stock epinephrine laws or regulations:

Alaska, Arkansas, Arizona, California, Colorado, Florida, Georgia, Illinois, Kansas, Kentucky, Louisiana,Maryland, Massachusetts, Minnesota, Missouri, Montana, Nebraska, Nevada, North Dakota, Oklahoma,Oregon, South Carolina, Tennessee, Utah, Virginia, Vermont, Washington, and West Virginia

Yellow states have pending stock epinephrine bills:
Michigan, New Jersey, New York, North Carolina, Ohio and Pennsylvania

Red states that have no stock epinephrine bills: 
Alabama, Connecticut, Delaware, Hawaii, Idaho, Indiana, Iowa, Maine, Mississippi, New Hampshire, New Mexico, Rhode Island, South Dakota, Texas, Wisconsin, and Wyoming

To find out more about anaphylaxis in schools please visit http://www.epipen4schools.com/ and https://www.anaphylaxis101.com/Resource-Library/Anaphylaxis-in-Schools.asp

Kudos to Canada

This morning, SRxA’s Word on Health salutes the Canadian city of Hamilton, Ontario, for its pioneering lead in anaphylaxis safety. Hamilton is destined to become the first city in the world to require all food service outlets to have life-saving epinephrine auto-injectors on hand for people with severe food allergies.

The move is being led by Hamilton Councillor  – Lloyd Ferguson, in hopes of avoiding sudden and tragic deaths like one this past spring of a Stoney Creek girl.

Twelve-year-old Maia Santarelli-Gallo had what her doctor said was a mild allergy to eggs and milk that had only ever caused her a runny nose. But last March, while eating an ice cream cone at a Hamilton-area mall with her father and older sister, Maia experienced a sudden, severe allergic reaction.

Her sister found someone with an epinephrine injector, but by the time it was administered, it was too late. Emergency crews took Maia to hospital but she was pronounced dead.

When Councillor Ferguson heard about Maia’s death, he decided to draft a ground-breaking motion to get epinephrine auto-injectors in every restaurant and mall in the city.

He says it’s high time that food providers have access to medicines that could help their customers who develop allergic reactions. He says if automated external defibrillator (AEDs) are now being installed in arenas and other community centers, it makes sense to have epinephrine injectors in areas where food allergy reactions are most likely to occur.

“It took us about 40 years to get defibrillators into public facilities and they have been a great success. This is the next step,” he says.

Allergy specialist Dr. Mark Greenwald, Allergist, and Chief Medical Officer of EpiCenter Medical would like to go further and see public awareness campaigns that would train the public on how to use epinephrine injectors, just as there have been campaigns encouraging people to learn CPR.

Greenwald has developed an online course called EpiPenTraining.com, to offer training on how to recognize allergic reactions, and how to use the injectors. He says such training is vital because during anaphylaxis, seconds count.

And anaphylaxis isn’t rare.  Allergic disease is the 5th most prevalent chronic disease among all ages, and the 3rd most prevalent among children. Every 3 minutes in North America, a food allergic reaction sends someone to the Emergency Room. Every 6 minutes, that Emergency Room visit is for anaphylaxis, that’s 10 patients per hour!

In 25% of people requiring treatment, the reaction is their first episode, and they are completely unprepared.  And for 50% of the people who die from anaphylaxis, the victims had life-saving epinephrine, but it wasn’t used or it wasn’t used in time. The other 50% didn’t carry epinephrine despite their previous allergic episodes.

Participants in the online course become SAVE certified – Save Anaphylaxis Victims in an Emergency.

Debbie Bruce of the Canadian Anaphylaxis Initiative was part of a program this past spring to get epinephrine injectors on all fire trucks in Mississauga. She says that like Maia, up to one-third of people who have allergic reactions outside the home did not realize they had a severe allergy and didn’t carry an epinephrine injector. She is now petitioning politicians  to come up with a national allergy plan.

“I think it is a new reality,” she says. “Reactions happen and we need to be prepared.”

Maia’s mother, Leah Santarelli, backs all efforts to make the public more aware of anaphylaxis and hopes the Hamilton city council passes Ferguson’s motion.

“There’s no guarantee that an EpiPen will save your life 100 per cent of the time, just like a defibrillator won’t save you 100 per cent of the time, but it is there as a safety measure,” she says.

The motion is currently being reviewed by the city’s health team; if approved, it should go before Hamilton city council in October.

We certainly hope that it does and that this trend will rapidly spread across the borders.  As Greenwald says – every second counts!

Protecting Kids with temporary tattoos

Parents of the three million or so kids in the US who have been diagnosed with food allergies whose kids have severe food allergies know they can’t be too careful. One bite of the food they are allergic to could be deadly. Indeed, according to the CDS, more than 200 people with food allergies die every year as a result of anaphylaxis.

Now, Michele Walsh, a mother of three from Baltimore, has created SafetyTat  to help remind teachers, classmates and babysitters to be extra careful.

The safety tats are brightly colored temporary tattoos or long-lasting write-on stickers that can be placed prominently on a child’s arm, with information such as “ALERT: NUT ALLERGY” or other critical information.

When you leave a child in someone else’s care at school or camp, “no matter how many times you fill out the forms, you’re still taking a leap of faith,” Walsh says. “This is like my voice with my son when I’m not there. It’s almost like teaching them ‘stop, drop and roll…’ They know exactly what to do.”

Another company –  Allermates offers allergy education tools, stickers, alert bracelets and other products for kids. Allermates was created by Iris Shamus, inspired by her son’s multiple allergies and an incident at school. “When you have a child with a food allergy, you’re always worried. It’s just part of your life,” she says. “I wanted to have something a little more personalized for him to remind teachers and babysitters.”

It began with a fun necklace, then a wristband and a large selection of products accompanied by cartoon characters such as Nutso, a charming peanut, to help her son understand, remember and confidently discuss his allergies.

“It makes me feel so much more secure,” she says. “I know you can’t be there all the time when you’re a mom, and this gives you peace of mind.”

“Anything that can help educate the patient about their problem and continue to make them aware about it is helpful whether it’s a temporary tattoo or a warning bracelet,” says Stan Fineman MD, immediate past president of the American College of Allergy, Asthma and Immunology.  “The important thing is for people to accurately find out what they’re allergic to and then make sure to take the appropriate precautions,” Fineman says. He says parents of kids with severe allergies should keep EpiPens on hand, check school policies, talk to school officials and bring in treats their kids can eat for special events.

Betsy Shea of Chicago says both of her boys, 4-year-old Colin and 2-year-old Emmet, have nut allergies, and Colin wears Allermates’ green snap-on wristband featuring Nutso. She’s thinking about trying temporary tattoos for Emmet.

Having allergies herself, she remembers having to wear the traditional metal medical alert band, which made her feel different and self-conscious. But Colin “loves that band. He wears it with pride and thinks it’s just so cool. We couldn’t get him to take it off for a while,” she says.

We thinks it’s pretty cool too!

Adrenaline Junkie

Although we repeatedly hear about the negative health effects of stress, today we’re here to tell you that stress isn’t necessarily all bad. Like food, sex, and shoes, it’s quality, not quantity, that determines whether stress helps or hurts!

Beneficial stress comes in the form of an acute, stimulating surge, like when your raft starts to overturn in some seriously churning rapids. The resulting single adrenaline (epinephrine) burst that comes and goes very quickly is a good thing because it gives you energy and gets you ready to mobilize for immediate action.

Physiologically, the adrenaline created by an abrupt blast of stress sends a flood of oxygen-rich red blood cells through your body, boosts your immune system, and signals your brain to start releasing painkilling endorphins.

Bad stress, on the other hand, is intense and drags on and on. This constant grind causes your adrenal glands to leak a slow, steady stream of another stress hormone: cortisol. And unlike adrenaline, which tends to hit your system in a flash and then dissipate, cortisol often wears out its welcome by hanging around in your bloodstream, driving up blood pressure, suppressing your immune system, and making you more susceptible to a slew of stress-related ailments, including colds, irritable bowel syndrome, migraines, and even heart disease and stroke.

So how do good stressors battle the bad ones? It all comes back to the positive power of adrenaline. In addition to all of its performance-enhancing effects, it triggers the release of dopamine and endorphins, two neurotransmitters that make you feel good – really, really good.

It also makes me feel good – really, really good, given the activities I have planned this weekend. But more of that later…

For now, let’s return to our favorite stress hormone – epinephrine. If you’ve ever tried skydiving, bungee jumping or heli-skiing, you’ll probably remember literally flipping out during your first attempt. But once you landed safely you probably experienced a euphoric, fist-pumping high thanks to dopamine flooding your brain’s pleasure center, giving you. During the next jump, you may still have felt all the same physiological stress responses such as a pounding heart and sweaty palms but instead of being terrifying, it’s exhilarating, because your mind’s already anticipating the thrill of that dopamine reward.

And the more times you do it, the less anxiety you’re likely to feel and the more fun you’ll have. That’s because your brain’s tagging the experience as a positive one.

And the benefits persist.  Before long, your body can start to develop an almost Pavlovian response to stressful situations. If your nerves are tingling, your stomach is clenching, and you can barely breathe, then it’s tricked into thinking something really awesome is about to happen!

That’s what researchers at Texas A&M University found when they put a small sample of men and women through a series of purposely stressful outdoor adventure tasks. Some subjects – the fittest ones who were already comfortable with physical challenges fared better than others. The researchers discovered that those participants had a reduced stress response (including lower blood levels of cortisol) when facing demanding activities like whitewater canoeing or rock climbing. Essentially, they were more confident and less stressed out, even though the tasks were potentially hazardous. This may be because their past experience blazing through strenuous situations made them less likely to perceive new challenges as stressful or difficult. And according to the researchers, it’s possible to transfer that oh-so-cool-and-collected response to life’s other nerve-racking events.

Better still, you don’t have to scuba dive with great whites or BASE jump off the Empire State Building to reap the stress-busting perks of adrenaline. Whether you hit the bunny slope or the double-black-diamond mogul fields, as long as you’re taking a giant step outside your comfort zone, you’ll give your body that adrenaline kick and when you do it regularly and keep testing your edge, you’ll change your relationship with stress for the better.

So next time that little voice inside your head starts clamoring, no freaking way, just go for it and be prepared to reap the rewards.

Which brings me back to my weekend. Keen to test the above theory for myself and readers of SRxA’s Word on Health, I will be spending tomorrow riding some of the longest, highest, fastest most insane rollercoasters in the country…and the following day I will be running with the bulls. If being pursued by twenty-four 1,000-pound bulls doesn’t set my adrenaline firing on all cylinders, then I guess nothing will.

I”ll let you know (hopefully) on Monday!

COPD & asthma linked to poor anaphylaxis outcomes

Researchers have found that patients with chronic lung diseases, including asthma and chronic obstructive pulmonary disease (COPD), are significantly more likely to have poor outcomes when hospitalized for anaphylaxis and other allergic conditions compared with other patients.

Zuber Mulla, MSPH, PhD, Associate Professor and Director of Epidemiologic Research at the University of Texas School of Public Health and Estelle Simons, MD, FRCP from the University of Manitoba, Winnipeg, Canada identified 30,390 patients who were hospitalized in Texas for allergic conditions between 2004 and 2007. Of these, 2,410 had a primary or secondary diagnosis of anaphylaxis at discharge.

The 2,772 (9.1%) patients in the overall cohort who had asthma were 67% more likely to receive mechanical ventilation than patients without asthma, while the 1,818 (6.0%) patients with COPD were 35% more likely to be admitted to the intensive care unit (ICU), 41% more likely to experience a prolonged stay in hospital (over 3 days), and 98% more likely to receive mechanical ventilation than those without the condition.

In the sub-cohort of patients with anaphylaxis, patients with asthma (n=334; 13.9%) did not have an increased risk for mortality compared with other patients, but they were over two-times more likely to be mechanically ventilated than patients without asthma).

Meanwhile, COPD patients with anaphylaxis (n=149; 6.2%) were 86% more likely to experience a prolonged hospital stay and 61% more likely to receive mechanical ventilation than patients without COPD.

Other lung conditions associated with poor outcomes included pulmonary eosinophilia, which increased the odds for ICU admission in patients with allergic conditions, while chronic bronchitis, emphysema, and interstitial lung diseases were linked to an increased risk for hospital mortality.

In particular, in the sub-cohort of patients with anaphylaxis, interstitial lung disease was linked to an 8.71-fold increased odds for mortality and a 5.16-fold increased odds for mechanical ventilation.

Writing in BMJ Open, Mulla and Simons say that their “unique exploratory analysis of a large database offers new insight into the effects of chronic pulmonary disease on anaphylaxis, an area for which there has previously been a dearth of information.”

Welcome to World Allergy Week

Today marks the start of the World Allergy Organization’s (WAO) annual World Allergy Week.

During the 2013 event, WAO together with its 93 national Member Societies, will be addressing the topic of “Food Allergy – A Rising Global Health Problem,” and its growing burden on children.

Globally, it’s estimated that as many as 220-250 million people suffer from food allergy.  And the incidence is on the rise in both developed and developing countries, especially in children.

During World Allergy Week WAO plans to highlight the need for greater awareness and understanding of food allergy as well as the exchange of ideas and collaboration in order to address a variety of safety and quality-of-life issues related to the care of patients with food sensitivity.

According to Professor Ruby Pawankar, President of the World Allergy Organization, “There are problems that need to be addressed in many countries throughout the world such as the lack of awareness of food allergies, lack of standardized national anaphylaxis action plans for food allergy, limited or no access to epinephrine auto-injectors, and the lack of food labeling laws. Moreover, some countries have standardized action plans but no ready access to auto-injectors; while others have auto-injectors but no standardized action plans.”

An important part of the initiative of World Allergy Week 2013 is to advocate for the safety and quality of life of patients who suffer from food hypersensitivity. WAO has also produced a list of online food allergy resources for healthcare professionals and patients / caregivers, which we have reproduced below.

HEALTHCARE RESOURCES

Kids Teased about Food Allergies No Laughing Matter

Access the article

WAO White Book on Allergy

Access the book

Food Allergy: Pathogenesis and Prevention
World Allergy Forum, December 2012, Orlando, Florida, USA
Access the presentations

Food Allergy
Cassim Motala, Joaquín Sastre, Dolores Ibáñez
WAO Global Resources in Allergy (GLORIA™), 2009, updated 2011
Access slide deck

Cow’s Milk Allergy in Children
Access the summary

Anaphylaxis
Richard F. Lockey, September 2012, updated Disease Summary

Access the summary

WAO Diagnosis and Rationale for Action against Cow’s Milk Allergy (DRACMA) Guidelines
Access the article

ICON: Food Allergy
The Journal of Allergy and Clinical Immunology, 2012; 129(4): 906-920
Access the article

World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis
World Allergy Organization Journal, 4:13-37, February 2011
Access the article

PATIENT / CAREGIVER RESOURCES

Food Allergy Research & Education (FARE)

The FARE website has an abundant source of valuable resources specifically for patients suffering from food allergies and the people who care for them, including:

• Resources for the Newly Diagnosed
• Resources for Parents of Children with Food Allergies
• Resources for Schools
• Resources for Healthcare Providers
• For Investigators Conducting Food Allergy Research

Anaphylaxis Campaign

The Anaphylaxis Campaign is a UK charity catering exclusively to the needs of people at risk from anaphylaxis by providing information and support relating to foods and other triggers such as latex, drugs and insect stings.
The AllergyWise online programs provide training for families, carers and individuals as well as health professionals. General information on Anaphylaxis and Severe Allergy

• Living With Anaphylaxis
• Knowledgebase
• Common Allergens
• Helpline Information

Avoiding Anaphylaxis this Advent

Christmas parties, meals out with friends and family, stockings full of candy, chestnuts roasting on the open fire…

While all this sounds like great fun, there’s a risk that more people than usual will be accidentally exposed to foods they are allergic too. Food allergies are common. An estimated 9 million, or 4%, of adults and nearly 6 million or 8% of children have food allergies with young children being those most affected.

Although childhood allergies to milk, egg, wheat and soy generally resolve in childhood, they appear to be resolving more slowly than in previous decades, with many children still allergic beyond age 5 years. And allergies to peanuts, tree nuts, fish, or shellfish are generally lifelong.

If you’re one of those affected by food allergy, what can you do to avoid accidental exposure this holiday season?

Remind people! Sure you might once have told your hosts that you have an allergy, but a gentle reminder is always helpful, especially at Christmas when things get busy and the alcohol starts flowing!

Just say ‘no’ – if you don’t know what’s in it, don’t eat it. And even if you do, can you really be sure there was no cross-contamination in the kitchen.

Bring snacks, rather than rely on your hosts to have food you can eat…or

Stay home. Host the party yourself – then you know it’s safe.

Bring your epinephrine auto-injector with you –and keep it close to hand! Make sure somebody else at the party knows you have food allergies, where your auto-injector is and how to use it.

Know the Symptoms – within minutes, an allergic reaction may turn into a life-threatening severe allergic reaction. Sometimes the reaction can occur in two phases, with another reaction occurring up to 48 hours after the initial reaction.

Use epinephrine immediately after you have been exposed to your allergy trigger – it may prove to be life-saving.  If you are even thinking should I give myself epinephrine, the answer is almost certainly yes!

After giving epinephrine, seek emergency medical attention – call or have someone else call 9-1-1 or your local emergency medical services.  In most individuals, epinephrine is effective after one injection. However, symptoms may recur and further injections may be required to control the reaction. Epinephrine can be re-injected every 5 to 15 minutes until the severe allergic reaction stops completely.

Do you have your anaphylaxis Action Plan ready?  If not, make it part of your holiday preparations. It could be the best Christmas present you give yourself this year.

Doctors Deficient in Anaphylaxis Care

Having just returned from the American College of Allergy, Asthma and Immunology (ACAAI) annual meeting, we’re spoiled for choice of news. But among all the science there was one stand out shocker.  In a session on Sunday, physicians presented the results of a survey, sponsored by the Asthma and Allergy Foundation of America (AAFA). During this, they revealed that a disturbingly high proportion of primary care and emergency physicians don’t know how to treat anaphylaxis.

Interviews with 318 physicians indicated that:

• substantial numbers do not always provide epinephrine to patients – even those  they believe are having anaphylactic reactions
• they often fail to refer anaphylaxis patients for follow-up care
• they believe incorrectly that some patients should not receive epinephrine auto-injectors

Myron Zitt, MD, says the results reveal “likely deficiencies in physician knowledge,” and corroborate results from earlier chart review studies.

In the telephone-based survey, researchers conducted interviews lasting an average of 19 minutes with approximately 100 emergency room physicians, 100 allergists, 50 adult primary care physicians, and 50 pediatricians.

82% to 99% of respondents in each group said they had treated at least one anaphylaxis case.

Although epinephrine is supposed to be given to all patients having such reactions, about 10% of emergency room physicians and 20% of primary care and pediatric physicians said they had done something else.  These “something else’s” included prescribed another drug, sending the patient to a hospital, or an “other” action.

Prescribing of auto-injectors for patients to take home also was far from universal. Barely 60% of emergency room physicians said they did. In fact, emergency physicians were generally bad at all phases of follow-up care. They rarely referred patients for diagnostic tests, they almost never demonstrated use of an auto-injector, and seldom explained that auto-injectors have an expiration date.

Another disturbing finding from the survey, Zitt said, was that many physicians of all types – even the allergists – mistakenly believed that some patients should never receive epinephrine.

In the same session, Akhil Chouksey, MD, reported that anaphylaxis care in a major teaching hospital usually failed to meet guidelines established by a consortium of allergy societies including the ACAAI.  In a 10-year review of anaphylaxis cases only 15% met the standards of care recommendations i.e. that epinephrine be administered within 30 minutes of triage, that auto-injectors be prescribed at discharge, and that patients be referred to an allergist or immunologist for follow-up investigations and treatment.

The review also found that in 26% of cases in which anaphylaxis was definitively confirmed, the patients never received epinephrine.  Antihistamines, such as benadryl (diphenhydramine), were given in nearly all cases but epinephrine was omitted in one-quarter. In fact, epinephrine was only the third most commonly administered medication, with corticosteroids such as methylprednisolone, taking the second spot after antihistamines.

During the question-and-answer period, an audience member suggested that, when patients present with relatively mild symptoms, the treating physicians may decide that epinephrine isn’t needed at that point.  Zitt countered, that this was a very dangerous approach.

The national guidelines state explicitly that there are no absolute contraindications to epinephrine. Nevertheless, 16% of the pediatric allergists and 32% of the other allergists said there were such contraindications, as did 38% of adult primary care and emergency physicians.

Also common were beliefs that schools, restaurants, and ambulances always stock epinephrine. In fact, Zitt said, there are no general requirements for schools or restaurants to do so, and approximately half of all ambulances do not have epinephrine on hand.

Clearly there is much work still to be done in terms of education.  SRxA’s Word on Health suggests a first step would be to instill a healthy fear of anaphylaxis into doctors and the general public while simultaneously removing the fear of epinephrine.

Or as Dr Zitt says, “Give epinephrine first, ask questions later.”