Preventing Food Allergy Anaphylaxis Fatalities in Schools: Enhanced Epinephrine Access and School Personnel Training
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Abstract
Immediate access to epinephrine is crucial to the treatment of students who have previously experienced anaphylaxis or may experience anaphylaxis for the first time at school. The need for consistent policies, procedures and training is needed in schools across the United States to improve safety for at-risk students. In US schools, state policies and procedures vary, which can lead to delays in epinephrine administration for children experiencing anaphylaxis. This article outlines essential components of a comprehensive and equitable approach that should be standardized nationwide. Through consistent policies and procedures, training for educators, and improved access to epinephrine—including new forms such as neffy® nasal spray and AnaphylmTM dissolving epinephrine—the safety and inclusion of students in US schools will be improved.
Keywords: epinephrine access, anaphylaxis, collaboration, teacher training, policy and procedures
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References
References
Administration of stock epinephrine auto-injectors. Title 21 - Education § 21-4-316. (2024). https://wyoleg.gov/statutes/compress/title21.pdf
Asthma and Allergy Foundation of America. (2025). Modernizing epinephrine stocking laws: An advocacy toolkit. https://aafa.org/wp-content/uploads/2025/02/epinephrine-stocking-law-advocacy-toolkit-2025.pdf
Allergy & Asthma Network. (2021, July 21). School plans for students with food allergies. https://allergyasthmanetwork.org/news/school-plans-students-food-allergies/
Allergy & Asthma Network. State laws. Retrieved December 27, 2025, from https://advocacy.allergyasthmanetwork.org/state-laws/
Americans With Disabilities Act of 1990, 42 U.S.C. § 12101 et seq. (1990).
https://www.ada.gov/pubs/adastatute08.htm
Anagnostou, A., Sharma, V., Herbert, L., & Turner, P. (2022). Fatal food anaphylaxis: Distinguishing fact from fiction. The Journal of Allergy and Clinical Immunology. In Practice, 10(1), 11-17. https://doi.org/10.1016/j.jaip.2021.10.008
Aquestive Therapeutics. (2024, February 15). Aquestive therapeutics to present AnaphylmTM (epinephrine) sublingual film pharmacokinetic and pharmacodynamic data at the 2024 AAAAI annual meeting. Https://Aquestive.Com/Aquestive-Therapeutics-to-Present-Anaphylm-Epinephrine-Sublingual-Film-Pharmacokinetic-and-Pharmacodynamic-Data-at-the-2024-Aaaai-Annual-Meeting/
ARS Pharmaceuticals. (2025, March 5). ARS pharmaceuticals announces FDA approval of neffy® 1 mg (epinephrine nasal spray) for type I allergic reactions, including anaphylaxis, in pediatric patients weighing 15 to < 30 kilograms. https://ir.ars-pharma.com/news-releases/news-release-details/ars-pharmaceuticals-announces-fda-approval-neffyr-1-mg
ARS Pharmaceuticals. (2025, January 21). ARS pharmaceuticals launches neffyinschools program providing free life-saving needle-free epinephrine for emergency use to eligible K-12 schools. https://ir.ars-pharma.com/news-releases/news-release-details/ars-pharmaceuticals-launches-neffyinschools-program-providing
Atal, Z., Patrick, A., & Wang, J. (2016). Food allergy education session improves nurses' knowledge, confidence, and attitudes towards managing food allergic children in a school environment. Journal of Allergy and Clinical Immunology, 137(2), AB85. https://doi.org/10.1016/j.jaci.2015.12.40
Automated external defibrillator program. SC Section 59-17-155. (2008)
https://www.scstatehouse.gov/code/t59c017.php
Avive.Live. (2024). The importance of AEDs in schools: A life-saving strategy for campuses.
https://www.avive.life/blog/aed-for-schools
Bernstein, D., Blaiss, M., Dellon, E. & Rance, K. (2025). Benefits of epinephrine for anaphylaxis outweigh potential harm - A safety review. The Journal of Allergy and Clinical Immunology. In Practice, 13(12), 3188-3194. https://doi.org/10.1016/j.jaip.2025.04.018
Bock, S. A., Muñoz-Furlong, A., & Sampson, H. A. (2007). Further fatalities caused by anaphylactic reactions to food, 2001-2006. Journal of Allergy and Clinical Immunology, 119(4), 1016–1018. doi.org/10.1016/j.jaci.2006.12.622
Boyce, J. A., Assa’ad, A., Burks, A. W., Jones, S. M., Sampson, H. A., Wood, R. A., Plaut, M., Cooper, S. F., Fenton, M. J., Arshad, S. H., Bahna, S. L., Beck, L. A., Byrd-Bredbenner, C., Camargo, C. A., Eichenfield, L., Furuta, G. T., Hanifin, J. M., Jones, C., Kraft, M., … Schwaninger, J. M. (2010). Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report. Journal of Allergy and Clinical Immunology, 126(6), 1105–1118. https://doi.org/10.1016/j.jaci.2010.10.008
Branum, A. M., & Lukacs, S. L. (2008). Food allergy among U.S. children: Trends in prevalence and hospitalizations. National Center for Health Statistics, 10, 1-8. https://doi.org/10.1542/peds.2009-1210
Branum, A. M., & Lukacs, S. L. (2009). Food allergy among children in the United States. Pediatrics, 124(6), 1549–1555. https://doi.org/10.1542/peds.2009-1210
Brown, J., Simons, E. & Rudders, S. (2020). Epinephrine in the management of anaphylaxis. The Journal of Allergy and Clinical Immunology. In Practice, 8(4), 1186-1195. https://doi.org/10.1016/j.jaip.2019.12.015
Cardona, V., Ansotegui, I. J., Ebisawa, M., El-Gamal, Y., Fernandez Rivas, M., Fineman, S., Geller, M., Gonzalez-Estrada, A., Greenberger, P. A., Sanchez Borges, M., Senna, G., Sheikh, A., Tanno, L. K., Thong, B. Y., Turner, P. J., & Worm, M. (2020). World allergy organization anaphylaxis guidance 2020. World Allergy Organization Journal, 13(10). https://doi.org/10.1016/j.waojou.2020.100472
Centers for Disease Control and Prevention. (2013). Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs. https://www.cdc.gov/school-health-conditions/media/pdfs/20_316712-a_fa_guide_508tag.pdf
Chafen, J. J. S., Newberry, S., Riedl, M., Bravata, D. M., Maglione, M., Suttorp, M., Sundaram, V., Paige, N. M., Towfigh, A., Hulley, B. J., & Shekelle, P. G. (2010). Prevalence, Natural History, Diagnosis, and Treatment of Food Allergy: A Systematic Review of the Evidence. 303(18), 1848–1856. https://www.rand.org/pubs/working_papers/WR757-1.html
Chokshi, N.Y., Patel, D., & Davis, C.M. (2015). Long-term increase in epinephrine availability associated with school nurse training in food allergy. The Journal of Allergy and Clinical Immunology: In Practice, 3(1), 128-130. DOI: 10.1016/j.jaip.2014.09.015
Children’s asthma treatment grants program, 42 USC 280g. (2004). https://www.govinfo.gov/content/pkg/PLAW-108publ377/pdf/PLAW-108publ377.pdf#:~:text=Page%204,30%2C%202004
DuPuis, R., Kinsey, E.W., Spergel, J.M., Brown‐Whitehorn, T., Graves, A., Samuelson, K., Epstein, C., Mollen, C. & Cannuscio, C.C. (2020). Food allergy management at school. Journal of School Health, 90(5), 395-406. https://doi.org/10.1111/josh.12885
Ebisawa, M., Takahashi, K., Takahashi, K., Yanagida, N., Sato, S., Lieberman, J., Pistiner, M., Spergel, J., Lowenthal, R. & Tanimoto, S. (2025). Epinephrine nasal spray improves allergic symptoms in patients undergoing oral food challenge, phase 3 trial. The Journal of Allergy and Clinical Immunology. In Practice, 13(10), 2787-2794. https://doi.org/10.1016/j.jaip.2025.06.038
Ellis, A., Casale, T., Kaliner, M., Oppenheimer, J., Spergel, J., Fleischer, D., Bernstein, D., Camargo, C., Lowenthal, R. & Tanimoto, S. (2024). Development of neffy, an epinephrine nasal spray, for severe allergic reactions. Pharmaceutics, 16(811), 1-16. https://doi.org/10.3390/pharmaceutics16060811
Ercan, H., Ozen, A., Karatepe, H., Berber, M., & Cengizlier, R. (2012). Primary school teachers’ knowledge about and attitudes toward anaphylaxis. Pediatric Allergy and Immunology, 23(5), 428–432. https://doi.org/10.1111/j.1399-3038.2012.01307.x
Fineman, S. M. (2014). Optimal treatment of anaphylaxis: Antihistamines versus epinephrine.
Postgraduate Medicine, 126(4), 73–81. https://doi.org/10.3810/pgm.2014.07.2785
Fleischer, D. M., Perry, T. T., Atkins, D., Wood, R. A., Burks, A. W., Jones, S. M., Henning, A. K., Stablein, D., Sampson, H. A., & Sicherer, S. H. (2012). Allergic reactions to foods in preschool-aged children in a prospective observational food allergy study. Pediatrics, 130(1), e25–e32. https://doi.org/10.1542/peds.2011-1762
Fleming, J.T., Clark, S. Camargo, C. A., & Rudders, S.A. (2015). Early treatment of food-induced anaphylaxis with epinephrine is associated with a lower risk of hospitalization. The Journal of Allergy and Clinical Immunology: In Practice, 3(1), 57-62. https://doi.org/10.1016/j.jaip.2014.07.004
Food Allergy and Anaphylaxis Connection Team [FAACT]. (n.d.) Section 504 plans. https://www.foodallergyawareness.org/accommodations/accommodations-in-schools/
Food allergy and anaphylaxis management, 21 U.S.C. 2205. (2015). https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title21-section2205&num=0&edition=prelim
Food Allergy Research & Education (FARE). Keeping students safe and included. https://www.foodallergy.org/our-initiatives/education-programs-training/fare-training-food-allergy-academy/keeping-students
Glassberg, B., Nowak-Wegrzyn, A., & Wang, J. (2021). Factors contributing to underuse of epinephrine autoinjectors in pediatric patients with food allergy. Annals of Allergy, Asthma & Immunology, 126(2), 175-179. https://doi.org/10.1016/j.anai.2020.09.012
Golden, D., Greenhawt, M., Confer, N. & Kraus, C. (2025). Pharmacokinetics and pharmacodynamics of AQST-109: Phase 3 results comparing epinephrine sublingual film with intramuscular injection [Manuscript in press]. Annals of Allergy, Asthma & Immunology. https://doi.org/10.1016/j.anai.2025.11.023
Harris, A. (2023, August 15). Charleston Co. Schools equipping every school nurse with Narcan. Live 5 News. https://www.live5news.com/2023/08/15/charleston-co-schools-equipping-every-school-nurse-with-narcan/
Hay, G. H., Harper, T. B., & Moore, T. G. (2006). Assuring the safety of severely food allergic children in school. Journal of School Health, 76(9), 479–481. https://doi.org/10.1111/j.1746-1561.2006.00145.x
Hogue, S. L., Muniz, R., Herrem, C., Silvia, S., & White, M. V. (2018). Barriers to the administration of epinephrine in schools. Journal of School Health, 88(5), 396-404. https://doi.org/10.1111/josh.12620
Hopkins, A. F., & Hughes, M. (2016). Individualized health care plans: Supporting children with chronic conditions in the classroom. Young Exceptional Children, 19(2), 33–44. https://doi.org/10.1177/1096250614566538
Irwin, M. K., & Elam, M. (2011). Are we leaving children with chronic illness behind? 30(2), 67–80. https://files.eric.ed.gov/fulltext/EJ955447.pdf
Irwin, M. K., Elam, M., Merianos, A., Nabors, L., & Murphy, C. (2018). Training and preparedness to meet the needs of students with a chronic health condition in the school setting. Research, Advocacy, and Practice for Complex and Chronic Conditions, 37(2), 34–59. https://doi.org/10.14434/pders.v37i2.26254
Jackson, K. D. (2013). Trends in allergic conditions among children: United States, 1997–201. National Center for Health Statistics Data Briefs, 121, 1-8. https://stacks.cdc.gov/view/cdc/37589
Kourosh, A., Nsobundu, C. K., Khosla, R., Guffey, D., Minard, C. G., Levinson, A. J., & Davis, C. M. (2020). The effects of school staff food allergy education in a large urban school district. Health Behavior and Policy Review, 7(3), 238-247. https://doi.org/10.14485/HBPR.7.3.8
Kraus, C., Wargacki, S., Golden, D., Lieberman, J., Greenhawt, M. & Camargo, C. (2025). Integrated phase I pharmacokinetics and pharmacodynamics of epinephrine administered through sublingual film, autoinjector, or manual injection. Annals of Allergy, Asthma and Immunology, 134(5), 580-586. https://doi.org/10.1016/j.anai.2025.01.006
McGowan, E. C., & Keet, C. A. (2013). Prevalence of self-reported food allergy in the National Health and Nutrition Examination Survey (NHANES) 2007-2010. Journal of Allergy and Clinical Immunology, 132(5), 1216-1219.e5. https://doi.org/10.1016/j.jaci.2013.07.018
McIntyre, L. (2005). Administration of epinephrine for life-threatening allergic reactions in school settings. Pediatrics, 116(5), 1134-1140. https://doi.org/10.1542/peds.2004-1475
Nabors, L. A., Little, S. G., Akin‐Little, A., & Iobst, E. A. (2008). Teacher knowledge of and confidence in meeting the needs of children with chronic medical conditions: Pediatric psychology’s contribution to education. Psychology in the Schools, 45(3), 217–226. https://doi.org/10.1002/pits.20292
Nowak-Wegrzyn, A., Conover-Walker, M. K., & Wood, R. A. (2001). Food-allergic reactions in schools and preschools. Archives of Pediatrics & Adolescent Medicine, 155(7), 790. https://doi.org/10.1001/archpedi.155.7.790
Osborne, N., Koplin, J., Martin, P., Gurrin, L., Lowe, A., Matheson, M., Ponsonby, A., Wake, M., Tang, M., Dharmage, S., & Allen, K. (2011). Prevalence of challenge-proven IgE-mediated food allergy using population-based sampling and predetermined challenge criteria in infants. Journal of Allergy and Clinical Immunology, 127(3), 668-676.e2. https://doi.org/10.1016/j.jaci.2011.01.039
Polloni, L., Baldi, I., Lazzarotto, F., Bonaguro, R., Toniolo, A., Gregori, D., & Muraro, A. (2020). Multidisciplinary education improves school personnel's self-efficacy in managing food allergy and anaphylaxis. Pediatric Allergy and Immunology, 31(4), 380-387. https://doi.org/10.1111/pai.13212
Pouessel, G., Tournoud, C., Gautier, S., Nisse, P. & Tanno, L. (2024). Adverse drug reactions from adrenaline auto-injectors: Data from the French poison control centers. Clinical & Experimental Allergy, 54(6), 435-437. https://doi.org/10.1111/cea.14473
Procurement of epinephrine autoinjectors for public schools. Ohio Rev. Code Ann. § 4729.47 (2025). https://codes.ohio.gov/ohio-revised-code/section-4729.47
Project Adam. (n.d.). Project Adam saves lives. https://projectadam.com/Adam
Pumphrey, R. & Roberts, I. (2000). Postmortem findings after fatal anaphylactic reactions. Journal of Clinical Pathology, 53(4), 273-276. https://doi.org/10.1136/jcp.53.4.273
Ravarotto, L., Mascarello, G., Pinto, A., Schiavo, M. R., Bagni, M., & Decastelli, L. (2014). Food allergies in school: Design and evaluation of a teacher-oriented training action. Italian Journal of Pediatrics, 40(1), 100. https://doi.org/10.1186/s13052-014-0100-8
Rehabilitation Act of 1973, Section 504 Regulations, 29 U.S.C. § 794 et seq. (1973).
https://www2.ed.gov/about/offices/list/ocr/504faq.html
Russell, A., Bingemann, T., Cooke, A., Jobrack, J., Hoyt, A. & Young, M. (2023). The need for required stock epinephrine in all schools: A work group report of the AAAAI adverse reaction to foods committee. The Journal of Allergy and Clinical Immunology: In Practice, 11(4), 1068-1082. https://doi.org/10.1016/j.jaip.2022.12.047
Sampson, H. & Burks, W. (2009). Adverse reactions to foods. In Adkinson, N., Bochner, B., Busse, W., Holgate, S., Lemanske, R., & Simons, F. (Eds.).Middleton’s allergy. Principles & practice (7th ed.). Mosby. 1139-1167. https://doi.org/10.1111/j.1365-2222.2010.03614.x
Sampson, H. A., Mendelson, L, & Rosen, JP. (1992). Fatal and near-fatal anaphylactic Reactions to food in children and adolescents. The New England Journal of Medicine, 327(6), 380–384. https://doi.org/10.1056/NEJM199208063270603
Sasaki, M., Koplin, J. J., Dharmage, S. C., Field, M. J., Sawyer, S. M., McWilliam, V., Peters, R. L., Gurrin, L. C., Vuillermin, P. J., Douglass, J., Pezic, A., Brewerton, M., Tang, M. L. K., Patton, G. C., & Allen, K. J. (2018). Prevalence of clinic-defined food allergy in early adolescence: The SchoolNuts study. Journal of Allergy and Clinical Immunology, 141(1), 391-398.e4. https://doi.org/10.1016/j.jaci.2017.05.041
Sicherer, S. H., Mahr, T., & the Section on Allergy and Immunology. (2010). Management of food allergy in the school setting. Pediatrics, 126(6), 1232–1239. https://doi.org/10.1542/peds.2010-2575
Simons, E. F., Edwards, E. S., Read, E. J., Clark, S., Liebelt, E. L. (2010). Voluntarily reported unintentional injections from epinephrine auto-injectors. The Journal of Allergy & Clinical Immunology 125(2), 419-423. https://doi.org/10.1016/j.jaci.2009.10.056
South Carolina Code of Laws. Title 59, § 17-155 (2025). https://www.scstatehouse.gov/code/t59c017.php
Sudden Cardiac Arrest Foundation. (2025). CPR and AED Laws. https://www.sca-aware.org/about-sudden-cardiac-arrest/cpr-and-aed-laws#:~:text=State%20laws%20addressing%20AED%20placement,require%20AEDs%20in%20nursing%20homes
Turner, P. J., Jerschow, E., Umasunthar, T., Lin, R., Campbell, D. E., & Boyle, R. J. (2017). Fatal anaphylaxis: Mortality rate and risk factors. The Journal of Allergy and Clinical Immunology: In Practice, 5(5), 1169–1178. https://doi.org/10.1016/j.jaip.2017.06.031
Umasunthar, T., Leonardi‐Bee, J., Turner, P. J., Hodes, M., Gore, C., Warner, J. O., & Boyle, R. J. (2013). Incidence of food anaphylaxis in people with food allergy: A systematic review and meta‐analysis. Clinical & Experimental Allergy, 45(11), 1621–1636. https://doi.org/10.1111/cea.12477
Volerman, A., Brindley, C., Amerson, N., Pressley, T. & Woolverton, N. A. (2022). A national review of state laws for stock epinephrine in schools. Journal of School Health. 92 (2), 209-222. https://doi.org/10.1111/josh.13119
Wahl, A., Stephens, H., Ruffo, M., & Jones, A. L. (2015). The evaluation of a food allergy and epinephrine autoinjector training program for personnel who care for children in schools and community settings. The Journal of School Nursing, 31(2), 91–98. https://doi.org/10.1177/1059840514526889
Wang, J., Sicherer, S. H., & Section on Allergy & Immunology. (2017). Guidance on completing a written allergy and anaphylaxis emergency plan. Pediatrics, 139(3), e20164005. https://doi.org/10.1542/peds.2016-4005
Waserman, S., Shah, A., Cruickshank, H., & Avilla, E. (2022) Recognition and management of food allergy and anaphylaxis in the school and community setting. Immunology and Allergy Clinics North America, 42, 91–103. https://doi.org/10.1016/j.iac.2021.09.008
Waserman, S., Cruickshank, H., Hildebrand, K. J., Mack, D., Bantock, L., Bingemann, T., Chu, D. K., Cuello-Garcia, C., Ebisawa, M., Fahmy, D., Fleischer, D. M., Galloway, L., Gartrell, G., Greenhawt, M., Hamilton, N., Hourihane, J., Langlois, M., Loh, R., Muraro, A., … Brozek, J. L. (2021). Prevention and management of allergic reactions to food in childcare centers and schools: Practice guidelines. Journal of Allergy and Clinical Immunology, 147(5), 1561–1578. https://doi.org/10.1016/j.jaci.2021.01.034
White, M. V., Hogue, S. L., Odom, D., Cooney, D., Bartsch, J., Goss, D., Hollis, K., Herrem, C., & Silvia, S. (2016). Anaphylaxis in schools: Results of the EPIPEN4SCHOOLS survey combined analysis. Pediatric Allergy, Immunology, and Pulmonology, 29(3), 149–154. https://doi.org/10.1089/ped.2016.0675
Zirkel, P. A., Granthom, M. F., & Lovato, L. (2012). Section 504 and student health problems:
The pivotal position of the school nurse. The Journal of School Nursing, 28(6), 423–432. https://doi.org/10.1177/1059840512449358