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!

Emergency! Epinephrine in Anaphylaxis: under-use and inappropriate use by EMS

Despite a decline in anaphylaxis deaths over the past 25 years, lack of epinephrine and incorrect administration of epinephrine still play a significant role in mortality.

According to a retrospective case study by researchers from McMaster University in Hamilton, Ontario only a quarter of patients received epinephrine prior to cardiac arrest, including those treated by emergency medicine personnel.

Of the 80 deaths recorded in Ontario from 1986 – 2011, 47 had a known or suspected allergy to the fatal allergen, but only 18 had been prescribed an epinephrine auto-injector and only 9 had their auto-injector at the time of the reaction. And at least 8 of these people received epinephrine that was either expired or administered incorrectly.

“The low proportion of patients who received epinephrine correctly may indicate that more information is needed by both patients and first responders regarding indications and techniques for administering epinephrine and auto-injectors,” said lead investigator, Ya Sophia Xu, MD

Most of the fatalities were caused by food allergy (n = 37), insect sting (n = 27), or medication (n = 11).  But in 5 patients, death occurred with no known allergen.

More than half (59%) of the food-related fatalities involved food eaten away from home – at public places including school, camp, or another person’s home.

“Patients with food allergies should be especially vigilant when eating outside of the home,” added Dr. Xu “restaurants need to improve the labeling and disclosure of potential allergens to the public.”

The study also revealed that Coroners’ reports are sometimes lacking information about the severity of previous allergic reactions, level of asthma control, time of administration of the first epinephrine dose, body mass index of patients, and anatomical location of the epinephrine injection.

Ryan Jacobsen, MD, EMT who is associate emergency medical services director for the Kansas City Fire Department in Missouri commented “there seems a perception among pre-hospital personnel that the administration of epinephrine is dangerous.”  He and his colleagues recently published a study with very similar results.

Dr. Jacobsen’s team surveyed 3,500 nationally registered paramedics in the United States and found that 36.2% of responders felt there were contraindications to the administration of epinephrine for a patient in anaphylactic shock. And 40% of paramedics (incorrectly) believed that diphenhydramine was the first-line medication for a patient suffering from anaphylactic shock.

“They also had challenges in the recognition of atypical presentations of anaphylaxis and determining the correct location and route of epinephrine administration,” he said.

Only 2.9% correctly identified atypical presentation of anaphylaxis, while less than half (46.2%) identified epinephrine as the initial drug of choice. Equally concerning, only 38.9% correctly chose the intramuscular route of administration, while 60.6% incorrectly identified the deltoid, rather than the anterolateral thigh as the preferred injection site location.

As an EMS educator I spend much of my time, discussing the 5 Rights of Administration: right patient, right time, right drug, right route, right dose.

Yet, according to this study, it seems as if emergency medical personnel are routinely failing on all 5 when it comes to anaphylaxis.

“Basically, we have the same issues in the United States that were found in the Canadian study,” says Jacobsen. “There needs to be an aggressive educational campaign geared toward emergency personnel in both the safety of epinephrine and its importance as the first-line therapy for anaphylaxis.  The benefits of epinephrine almost always outweigh the risks, but there’s a reluctance to use it. Patients get palpitations, they might get a headache, their heart rate goes up, but it’s a potentially life-saving treatment.

Amen to that.

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.”

Modern Family’s Emmy winning actress takes on the most important role of her life

Actress Julie Bowen, recently awarded her second Emmy for her role in the hit TV comedy “Modern Family,” started a more serious role last week: raising awareness about life-threatening childhood allergies and anaphylaxis.

The two-time best supporting actress in a comedy series and mother of three knows firsthand about potentially fatal allergic reactions. Her oldest son, Oliver, was 2 years old when he developed anaphylaxis as a result of a double-whammy exposure to a bee sting coupled with a bit of peanut butter.

“We had no reason to suspect we might have a problem. He had had peanuts before. And he had always been fine,” explained Bowen. “But then one day we found out that, no, he’s not.”

Almost immediately, Oliver’s face swelled dramatically. Other symptoms of anaphylaxis include chest pain; hives; breathing difficulties; tightening of the throat; lip and tongue swelling; nausea; dizziness and fainting.

Bowen’s husband, who was at home with the toddler, was terrified. “He knew it was bad.” Oliver was rushed to the hospital and immediately given an injection of epinephrine – the drug used for the emergency treatment of anaphylactic reactions that can follow exposure to allergens such as peanuts, walnuts, shellfish, bee stings, medications and/or latex.

Although any child can develop an allergy, or abnormal immune response, they are more likely to occur in people whose family members also have allergies.

Bowen now is spearheading the nationwide awareness campaign with the help of Mylan Specialty L.P., the pharmaceutical company that makes EpiPen^®.

“The goal is education,” said Bowen. “We, as parents, can’t always be with our children all day, every day. So we want the people around them to be educated.”

Thankfully, Oliver made a full and quick recovery. “Once he had the proper medicine, it was a very quick process,” she noted. “But today we always carry epinephrine with us wherever we go.”

Food allergies are the leading cause of anaphylaxis. The U.S. Centers for Disease Control and Prevention (CDC) estimates that food allergies in children have increased 18% since 1997. More than 9,000 children are hospitalized because of severe food allergies each year.

Many allergic reactions occur when children accidentally consume foods they’re allergic to at school. According to the CDC as many as one-quarter of anaphylaxis happens in students with no history of food allergies.

Parents and school employees shouldn’t dismiss a child’s complaints, Bowen says, “We want parents and teachers to know the signs, so that if you see them coughing, scratching at their throat some, or that they’ve got some rash, that you go ahead and look into it further.”

If you suspect your child may have an allergic reaction to anything, get it checked out. Call 911 and get medical attention immediately because there’s no way to guarantee that your child is never going to have an anaphylactic reaction.

The odds are not insignificant. “One to two children in each classroom could potentially be at risk for a serious food allergy,” says Dr. Carla Davis, an assistant professor of pediatrics in the section of immunology, allergy and rheumatology at Texas Children’s Hospital in Houston.  Of those, 30-40% would be at risk for life-threatening anaphylaxis.

Epinephrine is the first-line treatment, and caregivers must act quickly in order to treat effectively.  How quickly? Ideally, within minutes of the child developing a reaction.

For more information on anaphylaxis, visit the Food Allergy & Anaphylaxis Network.

Back-to-school lesson on food allergies

According to the Food Allergy & Anaphylaxis Network (FAAN), nearly six million children across the United States suffer from food allergies. Of those, more than 300,000 were admitted to hospital in the last year alone. To help ensure your food allergic child doesn’t suffer the same fate, SRxA’s Word on Health offers some simple Back-to-School tips for parents. The key to preventing allergic reactions and anaphylaxisis preparation:

• Contact the school well in advance of the first day of class and let your child’s teachers, coaches and school nurse know about their allergies
• Provider the school with a copy of your Child’s Anaphylaxis Action Plan
• Find out about field trips, parties, and special events such as Halloween or Valentine’s to ensure that allergens don’t sneak in along with other treats
• Meet with key personnel that will take care of your child if a reaction occurs
• Find out what plans are already in place for children with food allergies and what steps will be taken if an allergic reaction occurs at school
• Ensure that any medication, such as an EpiPen, on that plan has a physician’s order to cover it at school and that medication is readily available to personnel if it needs to be administered
• Teach your child what foods are off limits
• Teach your child to recognize symptoms and let an adult know immediately if they think they might be suffering an allergic reaction.
• Make sure your child understands not to trade food with others or eat anything with unknown ingredients.

Schools and teachers can also prepare themselves for the food allergic children in their class.  FAAN produces some excellent resources as part of its Safe@School campaign. For example, they offer expert in-service training to school districts to prepare staff to confidently CARE™ for students with food allergies by teaching them how to: In addition, FAAN provides training presentations, suitable for elementary and secondary schools as well as colleges and universities. So whether you’re a child, parent or teacher dealing with food allergies, be prepared, be safe and CARE this back-to-school season.

Be S.A.F.E.

SRxA’s Word on Health was deeply saddened to hear of the seven-year-old girl from Chesterfield County, Virginia who died this week after suffering an allergic reaction at school.  According to news reports she was given a peanut from another child who was unaware of her allergy.

Our heartfelt condolences go out to her family and friends. We dedicate this blog as a tribute to her and all the other children who have lost their lives to anaphylaxis.

Although there’s no cure for food allergies, as we’ve reported in the past, such deaths are almost entirely preventable with proper education and immediate treatment with epinephrine.   And even though we don’t know all the details of this case, what we do know is that food allergies are on the rise. 8% of children under age 18 in the United States have at least one food allergy.

Now, we’d like your help to prevent a similar tragedy from happening in the future.

The American Academy of Allergy, Asthma and Immunology’s  Be S.A.F.E. campaign is dedicated to educating patients and healthcare professionals on the steps needed to save lives. We urge you to read the campain’s action guide and share it with your colleagues, friends, and relatives. If you have kids in school, make sure the teachers are aware of it. If you use a gym, make sure the trainers know. Tell your favorite restaurant, share with your employer…the list goes on and on.

Seek immediate medical help. Call 911 and get to the nearest emergency facility at the first sign of anaphylaxis, even if you have already administered epinephrine.

Identify the Allergen. Think about what you might have eaten or come in contact with – food, insect sting, medication, latex – to trigger an allergic reaction. It is particularly important to identify the cause because the best way to prevent anaphylaxis is to avoid its trigger.

Follow up with a Specialist. Ask your doctor for a referral to an allergist/immunologist, a physician who specializes in treating asthma and allergies. It is important that you consult an allergist for testing, diagnosis and ongoing management of your allergic disease.

Carry Epinephrine for emergencies. If you are at risk for anaphylaxis, make sure that you carry an epinephrine kit with you at all times, and that family and friends know of your condition, your triggers and how to use epinephrine. Consider wearing an emergency medical bracelet or necklace identifying yourself as a person at risk of anaphylaxis. Teachers and other caregivers should be informed of children who are at risk for anaphylaxis and know what to do in an allergic emergency.

So there you have it. 4 simple steps that could save lives. Go share them!

Emergency Epinephrine Act

SRxA’s Word on Health is pleased to start the week with some good news.  Last Friday a new federal bill known as the School Access to Emergency Epinephrine Act was introduced in the Senate.  The Bill encourages schools to prevent allergy-related deaths by allowing trained, qualified staff to give an injection of epinephrine to a student suffering from a severe allergic reaction.

The tragic deaths of teenagers in Georgia and Illinois, who did not have immediate access to epinephrine, underscores the importance of immediate treatment and the passage of this legislation. One, a 13-year-old student from Albany Park, IL who had previously suffered from only minor allergies died at her school because of a severe allergic reaction.

Following this, Illinois passed a law that allowed school nurses to administer epinephrine shots to any student suffering from a severe allergic reaction. The new legislation proposed by Illinois Senators Mark Kirk and Dick Durbin would expand the law by allowing all trained and authorized school personnel — not just school nurses — to administer the shot.

U.S. Senator Mark Kirk (R-IL) said, “For the millions of children suffering from serious, potentially fatal allergies, the safe and expedient administration of epinephrine can mean the difference between life and death. Something as seemingly harmless as a bee sting during recess or a peanut butter and jelly sandwich during lunch can quickly become a tragedy.”

For about 1 in every 13 children, school lunchtime or a classmate’s school birthday party can risk exposure to foods that can cause a severe and life-threatening reaction. For these children, the consequences of exposure to the wrong food can be fatal.  However, if epinephrine is available such consequences are preventable.

The legislation would reward states that require schools to maintain a supply of epinephrine auto-injectors, such as EpiPen, and train authorized school personnel to administer an epinephrine injection if a student experiences an anaphylactic reaction. The bill also contains a provision that requires those states to have Good Samaritan laws in place to protect school employees who administer an epinephrine injector to any student believed to be experiencing anaphylaxis.

Although students with severe allergies are allowed to self-administer epinephrine if they have a serious allergic reaction, a quarter of anaphylaxis cases at schools involve young people with no previous allergy who are unlikely to carry a personal epinephrine injector.

Attorney General Lisa Madigan applauded Durbin and Kirk on their push for federal legislation. “Growing numbers of children suffer from life-threatening food allergies,” Madigan said. “In Illinois, we were able to eliminate bureaucratic barriers that previously prevented schools from acting when a child could be suffering from a severe allergic reaction but whose medical records didn’t reflect an allergy diagnosis.”

Word on Health also applauds the introduction of a law that could save children’s lives and raise awareness that in anaphylaxis every second counts. We also hope it will stimulate a wider dialog that could eventually lead to epinephrine autoinjectors becoming available in airports and on airplanes, in restaurants, sports stadiums and other public places…much as automated external defibrillators (AED’s) are today.

New Guidelines may help Food-Allergic Children Feel Safer

Food allergy affects up to 6% of children and results in an estimated 150-200 fatalities each year in the U.S. Accidental exposures are common and occur in homes, restaurants and schools.

Now a new study has shown that children who have experienced life-threatening anaphylactic shock from food have significantly different views of the risks associated with their allergies.

As these children mature into teenagers they become even more afraid of their food allergies, feel less confident about their surroundings and the level of information possessed by school personnel and even their parents.

High schools were perceived as less safe because of the lack of homerooms and unsupervised lunch areas. Elementary schools were considered safer because of the stronger presence of parents and consistent routines involving supervised lunch rooms, trained personnel, and communication strategies.

The study involved 20 children with severe food allergies.  They were interviewed about their experiences living with and managing a chronic medical condition that requires them to carry an EpiPen and remain keenly alert to their surroundings.

Both age groups identified environmental and social barriers that contributed to feelings of isolation, exclusion or being teased. Missing out on school activities, camps, or time with friends was common.

Young children relied more on parents and teachers to cope, whereas adolescents often anxiously fended for themselves by avoiding risky foods, educating others, navigating confusing food labels and quickly escaping from unsafe places. Some felt disempowered and overburdened and even developed symptoms like constant hand washing or waiting to eat until an adult was present who was available to drive them to the hospital.

SRxA‘s Word on Health is hopeful that new guidelines produced by the National Institute of Allergy and Infectious Diseases for both clinicians and patients will help.

They include a definition of food allergy, discuss co-morbid conditions associated with food allergy, and focus on reactions to food. Topics addressed include the epidemiology, diagnosis, and management of food allergy, as well as the management of severe symptoms and anaphylaxis.  In addition they provide 43 concise clinical recommendations and guidance on points of current controversy in patient management.