Anaphylaxis and Adrenaline use in Public Schools in NSW, Australia 2017-2019

The NSW Anaphylaxis Education Program (NSWAEP) was established in 2004 to improve and support state-wide anaphylaxis education in response to the growing need in the community.

Briony Tyquin, Clinical Nurse Consultant for Allergy & Anaphylaxis Education at The Children’s Hospital at Westmead and the Manager of the NSW Anaphylaxis Education Program (NSWAEP), had a poster accepted for presentation at AAAAI (the American Allergy conference in March 2020). Unfortunately, due to COVID-19 the conference was cancelled but she has agreed to share her work with Allergy & Anaphylaxis Australia (A&AA).

Training in the recognition and management of anaphylaxis, including timely use of adrenaline, are important strategies for reducing poor outcomes from anaphylaxis. The public education system in New South Wales (NSW), Australia, educates 810,000 school students. All staff receive regular training to recognise and manage anaphylaxis. Since 2017, NSWAEP has collected data on all episodes of anaphylaxis and/or adrenaline autoinjector (AAI) use in NSW public schools. Although the abstract was only for two and a half years, the final presentation reflected three years of data.

The only AAI available in Australia is the EpiPen®. Every public (Government) school in NSW has at least 1 General Use (GU) AAI.

341 episodes where an AAI was administered for anaphylaxis over three years

• Primary and high schools accounted for most of the episodes, with almost the same numbers in both.
• Schools for Specific Purposes, also known as special schools for students with high needs who are often nonverbal and have intellectual and/or physical disabilities, accounted for about 6% of all cases.
• 12% of all episodes of anaphylaxis and/or AAI use occurred in students with intellectual or physical disabilities who attend special schools or are supported in mainstream schools in support classes.
• When signs and symptoms were investigated and reviewed by the CNC, 56 (16.5%) students didn’t have anaphylaxis but were given the AAI. The main reason for this was anxiety, but other reasons included postural orthostatic tachycardia syndrome and seizures. This data hasn’t been looked at closely for this study, but will be for future studies.

13 episodes of anaphylaxis occurred on school camp – the majority of reactions were due to food being shared in the cabins.

AAI/Adrenaline Given

51% received their own AAI as an initial dose

38% received a General Use AAI.

6% had mild/moderate symptoms and an ambulance was called but no AAI was given

1.5% got their first dose from the ambulance or hospital

In less than 4% of cases, no adrenaline was given by anyone despite symptoms of anaphylaxis and all students recovered

15% required a second dose of adrenaline

9% had a second dose of adrenaline given by a paramedic or hospital

6% had a second dose of adrenaline at school before the ambulance arrived – almost all were General Use AAI

Less than 1% required more than 2 doses of adrenaline

Why was the General Use (GU) AAI used?

• The most common reason why a GU AAI was given was where the student had no previous known allergies and had their initial anaphylaxis at school (77 students)In NSW, school staff are trained to recognise the signs and symptoms of anaphylaxis and can give a GU AAI to any student who shows signs of anaphylaxis
• The next largest group was students who should have had their AAI at school but for some reason did not (17 students)

What caused the allergic reaction?

• Food or likely food caused over 50% of all reactions (163)
• Insects 8% (27)
• A trigger was not identifiable in 122 episodes (although in 56 of these, anaphylaxis was very unlikely given the clinical picture reviewed by the Clinical Nurse Consultant conducting the study)
• On four occasions an AAI was administered for severe and life threatening asthma
• Medications were thought to be responsible for anaphylaxis on three occasions
• Majority of food triggers (87) were peanut or tree nuts – usually in another form including pesto, chocolate, protein balls and occasionally whole nuts
• Milk or milk/egg (in a cake or muffin) accounted for 17% (22) of all anaphylaxis, often hidden in a food including cake/muffin or chocolate but sometimes in the form of butter or cheese or a milk based ice-cream
• Students with a known food allergy ate something and proceeded to have anaphylaxis in 18.5% of reactions to food, but the food was unable to be identified. The author believes that many of these students actually shared a food containing their allergen but were too scared to tell someone that they did, as no new allergens were identified in most students
• No student had anaphylaxis from casual contact (smell/touch) with a food
• In the majority of food allergic reactions, the student shared food or was given food by another student or a casual staff member
• Sting anaphylaxis remains an uncommon cause of anaphylaxis in schools, with about 8% (27) of students experiencing anaphylaxis to a sting or bite. The most common insect sting was bees (over 50%)

Summary

Anaphylaxis and AAI use in the NSW school setting is common.

The most common trigger identified was food, with almost half of food-triggered anaphylaxis triggered by nuts, although milk or milk/egg were responsible for 17% of all food anaphylaxis.

More research is needed into looking at the events where no trigger for anaphylaxis could be identified and exactly how the student came to eat the food they had an allergic reaction to.

https://www.jacionline.org/article/S0091-6749(19)32368-1/fulltext
Anaphylaxis and Epinephrine Use in Public- Schools in NSW, Australia 2017-2019
Briony Tyquin, Kylie Hollinshead, Kathryn Mulligan, Margot Treloar, Dianne Campbell, MBBS FRACP PhD, Lara Ford, MD FAAAAI

Content created July 2020