During a community health rotation as a pediatric resident at the University of Utah in Salt Lake City, Benjamin Wright, MD, noticed a troubling reality inside the state’s schools: The person most prepared to handle a life-threatening allergic reaction often was not available.

Wright worked with a school nurse responsible for multiple campuses. In the absence of the nurse, school staff were instructed to call 911 and to not administer epinephrine themselves.

“Training nonmedical staff on how to recognize and treat [anaphylaxis] is really important because it’s often going to be a non-nurse who’s actually right there at the forefront when it’s happening,” he said.

Wright and his colleagues set out to do just that in 2011 by developing a training program to help school personnel quickly identify a severe allergic reaction and administer lifesaving treatment.

The statewide program coincided with more than 5700 completed trainings across 421 schools and a 245% increase in schools stocking unassigned epinephrine during an 11-year time span, according to a study published in Pediatrics co-authored by Wright, who is now an allergist and clinical immunologist at Mayo Clinic in Phoenix. Wright and his colleague attributed the increase to their training, existing state law, and efforts to expand access through pharmaceutical assistance programs.

Food allergies affect about 8% of US children, according to the US Centers for Disease Control and Prevention. About 16%-18% of children who have had anaphylaxis experience at least one reaction at school, and roughly 25% of those treated at school have no known history of allergies.

The Utah initiative includes a 10-minute, web-based training. Of the staff trained, 52.2% were teachers, and 25.7% worked in administrative roles. Since 2015, more than 68% of participants have returned for the training in consecutive years. Despite these positive indicators, Wright did not evaluate whether the intervention led to measurable improvements in health outcomes.

Still, Wright said that the intervention targets well-established risks.

“There is strong existing evidence that delayed epinephrine administration is associated with worse outcomes, including increased mortality, so improving access and training are likely critical steps toward improving outcomes,” he said. “Our program addresses those upstream barriers, and evaluating downstream clinical outcomes is an important next step” that they plan on eventually analyzing.

Collaborating With School Nurses

School nurse coverage in Utah remains limited, with a ratio of about 1 nurse per 2445 students, far below the recommended 1 per 750 ratio. That shortage is not unique to Utah. In some districts, a single nurse may cover multiple schools or large geographic areas. Challenges also remain in states with stronger school nursing systems, Wright said.

“It is critically important to empower nonmedical school staff to recognize and treat anaphylaxis given that early administration of epinephrine is a critical determinant of outcomes,” said Julie Flom, MD, pediatric allergist and immunologist at Yale Medicine in New Haven, Connecticut.

Survey data from Utah highlight that reality. From 2008 to 2013, epinephrine was used in 68% of nearly four dozen cases of anaphylaxis. However, school nurses administered the medication in just 4% of those incidents, suggesting that other staff often respond first in emergencies.

Although all states allow stock epinephrine in schools, uncertainty around legal protections slowed adoption in some parts of the state, said Wright.

“Nurses were worried about administering an unassigned medication or having nonmedical staff give an injection,” and opening themselves to lawsuits, Wright said.

Recent developments in the delivery mechanism of epinephrine could help reduce that hesitation, said John Lee, MD, clinical director of the Food Allergy Program at Boston Children’s Hospital, Boston, who was not involved in the study. Lee pointed to emerging alternatives to traditional auto-injectors, including needle-free options.

“Needle-free delivery methods will not only make it much easier to deliver epinephrine when needed, but its ease of use will also help nonmedical staff and even parents feel much more comfortable responding,” Lee said.

Supplying Schools

The program helped schools obtain epinephrine through pharmaceutical assistance programs, but long-term sustainability remains a concern as the model expands.

“Cost is a factor,” Wright said. “Many laws allow or require schools to stock epinephrine but do not appropriate funding to purchase the devices.”

The study showed that in 25% of cases in which epinephrine was used, the drug was from an unassigned supply available for any student, suggesting that some youth had no prescription or did not have their medication on hand. A little under one quarter of reactions occurred in individuals with no known allergy.

He said maintaining training over time presents another challenge.

“Staff turnover means education has to be ongoing, and as new delivery systems become available, curricula need to be updated so staff remain confident using them,” he said.

Participation has been lower in some rural and underresourced areas where staffing shortages may make preparedness even more urgent. Wright said his research team is planning targeted outreach and surveys to better understand and address those gaps.

Wright reported receiving in-kind research support from Regeneron for an unrelated clinical trial and royalties from Nestlé related to a technology access fee. Lee reported being a study investigator for a clinical trial for neffy, a nasal delivery product for epinephrine. Flom reported having no conflicts of interest.

Lara Salahi is a health journalist based in Boston.