Allergists Want to Require EpiPens on Campuses
Public Health Feature — November 2014
Tex Med. 2014;110(11):53-56.
By Kara Nuzback
Thirteen-year-old Cameron Espinosa, a middle school student in Corpus Christi, died after being stung by fire ants while playing football after school in September 2013. No one, including Cameron, knew he was allergic to fire ants before the incident; if they had, Cameron might have had a prescription for epinephrine at school.
Texas does not require schools to stock epinephrine unless it's prescribed for a specific student. Texas allergists are now fighting to pass legislation that would force schools to stock unassigned epinephrine injectors — often called EpiPens after a popular brand of epinephrine injector — so coaches, school nurses, and other trained staff could immediately treat students like Cameron, who suffer a severe and unexpected allergic reaction.
As of this September, Cameron's mother, Josephine Limon, had not yet filed a lawsuit against Corpus Christi Independent School District (CCISD), according to Nueces County court records. She had, however, retained an attorney and filed a petition to take depositions from school officials.
Though it isn't against the law to prescribe or stock unassigned epinephrine, many school districts, including Denton Independent School District (DISD), say they choose not to because Texas law does not legally protect school personnel who administer the medicine to a child without a prescription, nor does it protect physicians who prescribe unassigned epinephrine from liability.
"The good news is, epinephrine pens are really safe," said Corpus Christi allergist and immunologist Wes Stafford, MD, immediate past president of the Texas Allergy, Asthma, and Immunology Society (TAAIS) and a member of the Texas Medical Association Council on Science and Public Health.
Dr. Stafford now writes unassigned epinephrine prescriptions for schools in CCISD, but, he says, it puts him in a vulnerable position. In hopes of protecting himself from liability, Dr. Stafford trains school principals, nurses, coaches, and other select personnel on how to recognize anaphylaxis and how to administer epinephrine.
"To cover my own liability, I'm making people show me they know how to do it," he said.
Bill Would Protect Children, Physicians
Earlier this year, the TMA House of Delegates adopted policy to advocate for legislation requiring all Texas schools, prekindergarten through grade 12, to have EpiPens available on campus and to train school personnel to recognize and treat severe allergic reactions. The proposed legislation also would protect physicians from liability for prescribing unassigned EpiPens for school use.
The TMA Council on Legislation, which makes legislative decisions for the organization, has yet to set its public health priorities for the 2015 session.
Draft legislation, which TAAIS expects Sen. Juan "Chuy" Hinojosa (D-McAllen) to sponsor, mirrors the intent in TMA's policy. The proposed bill would require each school district and open-enrollment charter school to maintain a supply of anaphylaxis medicine in case of an allergic reaction. The amount that must be kept on campus would be determined by the executive commissioner of the Texas Health and Human Services Commission (HHSC). The draft legislation also would require each school district to train employees to recognize signs of an allergic reaction, administer anaphylaxis medicine, and implement "emergency procedures," namely, call an ambulance.
"You give the Epi, you call 9-1-1. There should be no separation between those things," Dr. Stafford said.
Fort Worth allergy and immunology specialist Sue Bailey, MD, who is vice speaker of the American Medical Association House of Delegates, says she believes schools at all levels should stock unassigned epinephrine injectors.
"Children in school with life-threatening food allergies are at a high risk for death if they have a reaction and don't receive epinephrine immediately. These are totally preventable deaths, and this legislation will give Texas schools more tools to keep their students safe," she said.
AMA adopted policy in 2007 encouraging schools to allow children to carry their own epinephrine prescriptions, but the association has no policy on unassigned epinephrine in schools.
San Antonio allergy and immunology specialist Theodore Freeman, MD, president of TAAIS, says if the legislation becomes law, Texas would get more federal dollars for children's asthma treatment.
Dr. Freeman says the death of 7-year-old Ammaria Johnson, of Virginia, in January 2012 sparked the filing of federal legislation on stocking epinephrine in schools. At school, Ammaria came in contact with a peanut, to which she had a known allergy. A dose of epinephrine might have saved her life, but Ammaria's EpiPen was at home, and her elementary school did not have an unassigned stock of epinephrine to treat her.
In November 2013, President Barack Obama signed the School Access to Emergency Epinephrine Act into law. The act encourages schools to keep unassigned epinephrine on campus by offering financial incentives, specifically, federal grants related to children's asthma treatment.
But because the states, not the federal government, control education, the law could not require schools to stock EpiPens.
"It's clearly a national issue that we should have unassigned epinephrine pens available, especially here in Texas, where people are going to get stung by fire ants all the time. We need to be able to protect our children," Dr. Freeman said.
Since the federal law passed, Texas school boards have each set their own policy on epinephrine availability. Both of the two largest school districts in San Antonio stock unassigned epinephrine. Dr. Freeman is chair of the medical advisory board for one — North East Independent School District — and his wife, Karen Freeman, sits on the school board for the other — Northside Independent School District.
But many Texas school districts have resisted, he says.
"The legalities remain difficult," he said. "We need liability protection from the legislature … so they [school personnel] are not afraid to use it when they should."
Denton ISD (DISD), north of Fort Worth, does not currently stock unassigned epinephrine. DISD Superintendent Jamie Wilson says school nurses told him their main concern was liability for the district and for the individual nurse.
"They don't want to risk their licensure," he said.
DISD board member Mia Price, who serves as a special appointee on TMA's Committee on Child and Adolescent Health, notes the double-edged sword facing schools: If they don't stock unassigned epinephrine and a child needs it, they could be sued; if they stock unassigned epinephrine and administer it incorrectly, they could be sued.
"We just felt like we would be a little more comfortable to have legislation to back us up," she said.
Because the current law does not protect physicians from liability, Ms. Price says it could be difficult to find a doctor to write an epinephrine prescription for DISD's 34 campuses.
She says the cost to train staff and stock the medicine is another concern for DISD. She says legislation would make it easier to get EpiPens free of charge.
Mylan, which markets and distributes the EpiPen, offers four free EpiPens to any public or private kindergarten, elementary, middle, or high school in the United States, as long as the school has a doctor's prescription.
"We're fiscally challenged daily, and if we could possibly get these pens free, that's even better," she said.
If the state passes legislation to stock epinephrine, Ms. Price says DISD would find the money to finance the EpiPens, even if the district can't get them free of charge.
Dr. Wilson agreed, adding, "The benefit outweighs the risk."
Physician Support Is Essential
Carla Davis, MD, a specialist in allergy and immunology at Texas Children's Hospital in Houston and a TAAIS member, says 25 percent of children with food allergies have their first reaction at school. Dr. Davis represented TAAIS on an ad hoc committee, established by the Texas Legislature in 2011 with the passage of Senate Bill 27, sponsored by Sens. Judith Zaffirini (D-Laredo) and John Carona (R-Dallas).
The committee created guidelines for school districts to adopt policies to care for students with food allergies. (See "Write to Your Patient's School.")
The guidelines include sections on food allergy management, development of emergency care plans, and training for school staff. Dr. Davis says the guidelines established a best practice of stocking unassigned epinephrine on school grounds. If CCISD had adopted the guidelines, she says, officials at Cameron's school would have been able to treat his anaphylactic reaction to fire ants immediately.
"He would have had epinephrine available for treatment," Dr. Davis said. "We really believe that it's very important for epinephrine to be one of the medications on site at schools to keep children safe."
After Cameron's death, she says, TAAIS collaborated with Senator Hinojosa to pen legislation that would fix the problem for good. Now, she says, they need physicians' help.
"We really need physician support for this bill and advocacy in communities across the state of Texas," she said.
And while some school districts fear they would face more liability concerns by stocking epinephrine, physicians know there's little that can go wrong, she says. An epinephrine injector is no more than a shot of adrenaline, and because children don't suffer heart problems like adults, an EpiPen won't harm them, even if they are not truly experiencing anaphylaxis, she says.
"It really is adrenaline," Dr. Davis said. "In children especially, it's not dangerous."
School districts worry about costs associated with stocking the injectors and training staff, but Dr. Davis says several distributers offer free or discounted stock to schools, including Mylan, maker of the EpiPen, and Sanofi, which markets the Auvi-Q, an epinephrine injector that walks the user through the injection process.
Dr. Davis says Houston Independent School District piloted a program during the 2013-14 school session in which teachers, coaches, and cafeteria staff completed a free online training course, available at allergyready.com, to learn to identify anaphylaxis causes and symptoms and to administer treatment.
"Staff can be trained … just as parents can be trained," she said. "The pilot program was successful."
Staff felt more comfortable with the idea of administering epinephrine in an emergency after taking the course, she says.
"We really believe it's an effective way to train school personnel," she said. "And it's free."
She says Houston ISD made the course mandatory for the current school year.
Kara Nuzback can be reached by telephone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.
Write to Your Patient's School
The U.S. Department of Agriculture requires schools to modify or substitute school meals for children whose allergies restrict their diets. If you have a young patient with a severe food allergy, the Texas Department of State Health Services recommends you give the patient's school a signed statement that includes:
- The child's disability;
- An explanation of why the disability restricts the child's diet;
- The major life activity affected by the disability; and
- The foods the school should omit from the child's diet and foods that the school must substitute.
Source: Texas Department of State Health Services: Food Allergies
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