Pediatric anaphylaxis management in schools: Current issues and challenges in Asia and Hong Kong. A scoping review

Shaun Chad Lee

doi:10.4103/prcm.prcm_22_22

REVIEW ARTICLE

Year : 2022 | Volume : 6 | Issue : 3 | Page : 54-62

Pediatric anaphylaxis management in schools: Current issues and challenges in Asia and Hong Kong. A scoping review

Shaun Chad Lee
Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China

Date of Submission	12-Dec-2022
Date of Decision	15-Jan-2023
Date of Acceptance	16-Jan-2023
Date of Web Publication	09-Mar-2023

Correspondence Address:
Mr. Shaun Chad Lee
Faculty of Medicine, The Chinese University of Hong Kong, Central Avenue, Hong Kong SAR
China

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/prcm.prcm_22_22

Abstract

Hong Kong has the highest prevalence of food allergies compared with Mainland China, Russia, and India. There has been a twofold increase in anaphylaxis incidence between 2009 and 2019, of which 20% occur in day-care and school settings. A scoping systemic search was performed with the aim of reviewing existing literature in the Asia-Pacific region regarding food allergy management in the school setting. Current loopholes and inadequacies on governmental policy regarding school anaphylaxis management were explored. 28 articles from MEDLINE-OVID were compared with a PRISMA scoping review published in 2022 having similar search terms but focusing on Western countries. Furthermore, current loopholes and inadequacies on governmental policy regarding school anaphylaxis management in Hong Kong were explored. An Internet search was later conducted to supplement the information on governmental policies for school anaphylaxis management. Most publications identified focused on assessing food allergy prevalence and causative agents. However, there is an evident lack of literature on emergency action plans and school training programs. Existing governmental policies regarding school anaphylaxis were reviewed and compared. Hong Kong currently lacks legal protection for bystanders and policies, encouraging school staff training for anaphylaxis management. Governmental regulations and subsidization are also absent in encouraging schools to purchase backup stocks of unassigned epinephrine autoinjectors. Raising awareness and improving guidelines and policies in schools are integral in the management of food-induced adverse events and anaphylaxis. Governmental support through policymaking and legislation can significantly enhance and hasten the process, thus minimizing the impact adverse food reactions bring to the pediatric population.

Keywords: Action plans, anaphylaxis, Asia, epinephrine autoinjector, food allergy, Hong Kong, hypersensitivity, management, pediatric, schools, training

How to cite this article:
Lee SC. Pediatric anaphylaxis management in schools: Current issues and challenges in Asia and Hong Kong. A scoping review. Pediatr Respirol Crit Care Med 2022;6:54-62

How to cite this URL:
Lee SC. Pediatric anaphylaxis management in schools: Current issues and challenges in Asia and Hong Kong. A scoping review. Pediatr Respirol Crit Care Med [serial online] 2022 [cited 2023 Jun 1];6:54-62. Available from: https://www.prccm.org/text.asp?2022/6/3/54/371405

Introduction

Food allergy is a common problem globally, affecting 7%–8% children worldwide.^[1] In other words, two children in each classroom of 25 students have food allergies. Hong Kong’s local incidence of food allergy is not low, with parent-reported, and parent-reported, doctor-diagnosed adverse food reactions (AFRs) being 9.7% and 4.6%, respectively, according to two local studies.^[2],[3] The EuroPrevall-INCO survey conducted in 2019 also concluded that Hong Kong had the highest prevalence of food allergies compared with Mainland China, Russia, and India.^[4]

The most severe form of AFR is anaphylaxis, which is defined as a “serious allergic reaction that is rapid in onset and can cause death.^[5] It is a medical emergency that can be unpredictable and life-threatening. In Hong Kong, there has been more than a twofold increase in anaphylaxis incidence between 2009 and 2019.^[6] The most common food allergens include milk, eggs, nuts, seafood, soy, and wheat, all of which are commonly found in school meals and snacks.^[7] A total of 20% of pediatric anaphylactic reactions occur in day-care and school settings, environments that are integral to a child’s life, and poses a significant problem in Hong Kong, where policies on food allergy management and its implementation lack sufficient support from the government.^[1]

Materials and Methods

A scoping systemic search was performed on MEDLINE-OVID with the aim of reviewing existing literature and studies conducted in the Asia-Pacific region regarding food allergy management in the school setting. Current loopholes and inadequacies on governmental policy regarding school anaphylaxis management were explored.

Keywords and search terms are provided below, and the screening and selection process is summarized in [Figure 1]. The search revealed 90 registers, of which 28 were included in the review after screening and assessment for relevance to the school setting and food allergy. There were no restrictions to the study design, and Chinese, Japanese, and Korean-language articles were included in addition to English. Results were later compared with a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) scoping review published in 2022 having similar search terms but focusing on Canada, America, Australia, and European countries. An Internet search was also conducted to supplement the discussion on governmental policies for school anaphylaxis management.

Figure 1: PRISMA flow diagram depicting the selection process articles and reports in the current scoping review

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Search terms

Ovid MEDLINE(R) <1946 to August 23, 2022>

Food Hypersensitivity/

(food hypersensitivit* or food intoleran* or food allerg* or food hyper sensitivit*).tw,kw.

1 or 2

Schools/ or schools, nursery/

exp Child Day Care Centers/

(school* or daycare* or day care* or preschool*).tw,kw.

4 or 5 or 6

3 and 7

(Asia or Asia Pacific or China or Hong Kong or Japan or Korea or Singapore or Taiwan or Thailand or Philippines).mp.

8 and 9

Results

Out of the 28 publications, which have been summarized in [Table 1] below, the majority focused on assessing prevalence of food allergies and identification of common causative agents in schools.^{[2],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34]} Only four articles (from Japan and Korea) investigated school’s preparedness and measures taken to prevent food-related adverse reactions.^{[8],[16],[18],[22]} A survey conducted regarding food-dependent exercise-induced anaphylaxis found insufficiencies with level of understanding of the allergies, collection of precise information from students, and lack of implementation of measures to prevent incidence and recurrence.^[18] Approximately 35% of schools did not know how to implement safeguards.

Table 1: Summary of articles’ country of origin, research design, aims, and findings, presented in chronological order^{[2],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34]}

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Notably, no Asian studies identified mentioned about emergency action plans nor educational training programs in schools for staff, regarding anaphylaxis management. In contrast, a PRISMA scoping review published this year in 2022 by Santos et al.,^[1] with identical search terms but focusing on Canada, USA, Australia, and European countries, found at least 12 publications in the recent 5 years reporting on school staff management of food allergies. These studies investigated teacher’s past experience, presence and effectiveness of training programmes, as well as in-school emergency preparedness such as guidelines and policies on food allergy emergency action plans. The distribution of articles is summarized in [Figure 2].

Figure 2: Two charts summarizing the distribution of articles identified from the scoping search. Left: Articles restricted to Asian countries; Right: Articles restricted to Western countries

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Discussion

The lack of relevant studies and publication may point toward an inadequate awareness and training on food allergy management in Asian countries, including Hong Kong. It is important that the government steps in to take up a leading role regarding food allergy adverse event prevention in the community and schools. Some suggestions are made in the following section on how governmental intervention could greatly improve food allergy management in schools and have been summarized in [Figure 3] and [Table 2].

Figure 3: A schematic diagram of potential interventions to improve schools’ anaphylaxis management

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Table 2: Recommendations for governmental intervention improvements – A comparison of Hong Kong and other developed countries

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Food allergy action plans

Although food-induced allergic reactions are not uncommon, preparation for management is often inadequate in the school setting. It is essential that carers and school staff are on alert for anaphylaxis and can recognize signs of food allergic reactions. They should also understand the indication for epinephrine, have rapid and convenient access to the autoinjectors, and be capable in its administration.

Patients in Hong Kong are now given anaphylaxis action plans by physicians, detailing confirmed food allergens, as well as providing information on signs to be aware of and the appropriate actions to be taken in event of anaphylaxis; these greatly help in the prevention of allergic reactions.^[35] Standardized, easily understandable action plan templates are now being promoted and distributed freely by organizations such as the CUHK Allergy Team at Prince of Wales Hospital.

In Hong Kong, where the main carers at home may not be the parents who accompanied the children to the doctor’s office, but instead domestic helpers and grandparents, the emergency action plans and leaflets help convey and provide clear guidance, thus minimizing the risk of miscommunication and inadequate relay of information. However, more could still be done in the school setting. The Hong Kong government could refer to practices in Australia and European countries, where it is required by the law that schools develop individualized action plans for students with known food allergies, after receiving the physician-issued anaphylaxis action plan from the child and carer.^[36] These include risk assessment of the school environment, actions to be taken to minimize such risks, and such action plans are reviewed annually between the school and the parents. School staff could thus pay more attention to students with known allergies and be better prepared on how to react to anaphylaxis.

Legal protection of volunteers and bystanders

Apart from improving prevention of food allergy, governmental support is crucial in enhancing the response to anaphylaxis. In the event of anaphylaxis, administration of injectable adrenaline, such as Epipen, Anapen, or JEXT, is lifesaving. However, the patient may not be capable of self-administration during the life-threatening event, particularly in the pediatric age group.

Legal protection of “good Samaritans” is necessary as the fear of being sued for negligence following administration of Epipen to a student may deter teachers or volunteers at school from offering assistance. Hong Kong currently does not have any measure of statutory protection offered to volunteer rescuers that can protect bystanders from civil liability after providing emergency assistance to a victim.^[37] Although teachers may be considered to be in a special relationship with students, thus having a duty of care, the lack of legal protection and reassurance is still a barrier that may deter bystanders. Instead of proceeding with assisting in administration of Epipen, volunteers may cease to help after calling the emergency hotline.

Training of school staff

Even if bystanders and school staff are willing to intervene, adequate training is necessary to ensure prompt identification of anaphylaxis and proper administration of intramuscular adrenaline. There are currently no standardized training programs in Hong Kong, nor is it a legal requirement for schools to host education programs for staff on anaphylaxis management. Skin signs, such as generalized urticaria and flushing, may be absent in 10%–20% of anaphylactic reactions, and the lack of knowledge and other signs and symptoms may lead to delay in the administration of epinephrine.^[38] Administration of Epipen also requires some baseline knowledge—apart from differentiating between the safety cap and needle cap of the autoinjector, it needs to be injected at a 90° angle against the outer thigh, pressed down for 10 s, and afterward, the patient should be laid flat with legs elevated to prevent empty vena cava syndrome, in a position similar to that in [Figure 3].^[35] Much could be learnt from countries like Australia, where school staff are required by law to undertake regular training in anaphylaxis management as part of the school anaphylaxis management policy.^[39] Free online training courses are available and are developed by the government specifically for school staff and carers. Studies have shown participants to have better knowledge and increased confidence in managing food allergy and anaphylaxis after training.^[1] As most schools in Hong Kong do not employ full-time nurses, the government could work hand in hand with healthcare professional outreach teams to educate school staff on anaphylaxis management. Apart from training programs for teachers, many other countries, such as the Centers for Disease Control and Prevention, in consultation with the US Department of Education, have developed national voluntary guidelines for food allergy management in schools.^[40] These could help support the implementation of food allergy management and prevention plans and practices in schools by providing practical information and strategies for reducing allergic reactions for school administrators and staff.

Epinephrine autoinjector availability

The availability of injectable epinephrine could also be further improved in Hong Kong. Although children with known food allergies are often given an Epipen to carry around, there is always a risk of not having the prescription medication by their side in the event of anaphylaxis, or other possibilities such as malfunction and expired devices. Combined with the schools’ lack of individualized action plans for students with allergies, access to the child’s prescribed epinephrine may thus be hampered. Although Epipens prescribed to patients by the Hospital Authority cost around $100 apiece, commercial epinephrine autoinjectors could cost up to $1000.^[41] Together with the short shelf-life of 1–2 years, schools may lack incentive to purchase back-up stocks of unassigned epinephrine autoinjectors.

Governmental regulations and subsidization could assist in ensuring community availability of these life-saving medication. In the United Kingdom, the Human Medicines Regulations was amended in 2017, allowing schools to purchase epinephrine autoinjector devices without prescription. In US, the School Access to Emergency Epinephrine Act gives financial incentives to states that require elementary and secondary schools to maintain a supply of epinephrine in an easily accessible and secure location.^[42]

Limitations

This article is liable to evidence selection bias. While efforts have been made to follow the PRISMA extension for Scoping Reviews (PRISMA-ScR) 2020 Checklist as closely as possible, the screening and selection of registers in this scoping search was completed by only one individual researcher.

Furthermore, while the search terms have been kept intentionally identical to the PRISMA scoping review by Santos et al.^[1] for comparison, the number and size of the databases utilized differ significantly, and the search for registers limited to the Asian geographic location could be expanded to include more registers.

Conclusion

In conclusion, raising awareness of anaphylaxis, as well as improving guidelines and policies in schools are integral in the management of food-induced allergic reactions and anaphylaxis. Governmental support through policymaking and legislation in Hong Kong can significantly enhance and hasten the process. With cooperation by stakeholders including the patient, carers, physicians, schools, and the government, the impact that AFRs bring to the pediatric population can be minimized.

Acknowledgements

The Hong Kong Society of Paediatric Respirology and Allergy for motivating me to research on this topic; Prof. Agnes Leung for her inspiration on anaphylaxis management (Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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