Implementation and barriers to stock adrenaline auto-injectors in French secondary schools.

Data from many countries suggest an increase in hospital admissions for anaphylaxis, particularly in children and related to foods.1 In children, around 10% of anaphylaxis cases occur at school with 20% to 40% of these cases occurring in children without any prior food allergy.2, 3 Prevention policies, legislation, and school staff training are crucial to reduce the risk of anaphylaxis and improve the quality of life of allergic children at school. In 2021, an international panel of key stakeholders provided practice guidelines on the prevention and management of allergic reactions to food in schools and suggested that stock undesignated adrenaline auto-injectors (AAI) should be available on-site.4 In 2022, a review of the United States (US) stock AAI policies reported a significant variation in state legislation in whether states allow or mandate school stock AAI, and differences in state AAI procurement, administration, training, and liability.5 Few data on stock AAI implementation and barriers are available, coming mostly from the US. In France, prevention measures in allergic children at school were introduced into law in 2003 and have been updated in 2021 to propose an individual health care plan (IHCP) for each child.6 In September 2019, national policies also mandated secondary schools to stock undesignated AAI. French school policies also promote the training of school staff in anaphylaxis recognition and appropriate use of AAI. Our objective was to assess the implementation of stock AAI and school staff training in anaphylaxis recognition and management and to assess the barriers to implementation. An electronic questionnaire survey was sent to principals of all secondary schools in the Nord-Pas-de-Calais region (in 2022, 4,060,000 people including 360,000 children in secondary schools) during a 2-month study period in November–December 2019 and March–April 2023. The provision of prescribed AAI in children with a known allergy and an IHCP was not assessed in this survey. Statistical analysis was descriptive, and exact Fisher's and chi-squared tests were used to perform comparisons of categorical data. Comparisons of proportions between the two study periods were assessed with Mc Nemar tests. A p value <.05 was considered significant. In 2019, 469/676 (69%) secondary schools (396/494 [80%] public and 73/182 [40%] private) participated in this survey whereas in 2023, 463/818 (57%) secondary schools (400/463 [86%] public and 63/355 [14%] private) participated. The distribution of stock AAI in secondary schools and comparisons between the two study periods are presented in Figure 1. In total, 221/469 secondary schools (47% of respondents, 54% and 11% in public and private schools, respectively) had implemented stock AAI in 2019 compared to 334/463 (72%) (81% and 14% in public and private schools, respectively) in 2023 (p < 10−3) with an increase of 25% (95% CI: 19–31). In 2019 and 2023, implementation of stock AAI was more frequent in public secondary schools compared with private secondary schools (p < 10−3 for both study periods). The main barriers to stock AAI implementation were AAI cost and issues to replace AAI devices due to their short expiry date (Figure 2). Between 2019 and 2023, there was also an increase in the percentage of schools that have not implemented stock AAI due to the lack of training (from 8% to 16%) and even the ignorance of the law (from 5% to 16%) (Figure 2). These are key points that need to be addressed (Table 1). Use reduced-cost AAI from manufacturers delivered by local pharmacists. Advocate for regional/national education agencies funding to schools. Consider legal ability to stock AAI offered by the manufacturer. Increase awareness of pharmacists regarding legislation regarding stock AAI and the role of school nurses. Advocate for private schools to designate a physician prescribing stock AAI. Expand generic AAI options. Work to address AAI shortage. Advocate for a stock AAI stored in a full-time accessible unlocked room. Increase number of full-time school nurses, including in private secondary schools. Advocate the presence of school nurses in primary schools and nursery schools. Clarify the role and scope of practice of school nurses regarding this topic. Provide toolkits and structured allergy training programs in connection with expert allergists to train school nurses. Encourage school nurses to train school staff in return using toolkits through structured allergy training programs. Provide advocacy and education to schools on the utility of stock AAI, mostly for children with no prior IHCP and AAI available. Provide accurate information regarding liability concerns. Advocate legal ability to every school staff to use AAI. In 2023, in secondary schools with stock AAI, devices were stored in the sick room (70%), in an administrative office (43%), and in the school restaurant (25%). They were available for every school staff member in 48% and for only authorized members in the other cases. When not available for every school staff member, the devices were stored under lock and key in 89% of cases. In 2019, school staff training regarding anaphylaxis recognition and AAI use was performed in 53/221 (24%) secondary schools with stock AAI compared to 256/334 (77%) in 2023 (p < 10−3) with an increase of 53% (95% CI: 46–60). Among the 463 secondary schools that responded to the questionnaire, 92 (20%) secondary schools declared to have encountered barriers to perform school staff training: “anaphylaxis recognition and AAI use are not of my responsibility” (n = 40; 43%), organizational issues (n = 34; 37%), and fear to act in a wrong way (n = 22; 24%). To our knowledge, this is the first study in Europe that aims to assess the implementation of stock AAI and school staff training and also barriers to implementation. We found an increase in the rate of secondary schools that have implemented stock AAI by 25% between 2019 and 2023 where this rate remains suboptimal reaching 72%. There was an increase of 53% in the rate of school staff training provided by secondary schools with stock AAI, reaching 77%. Our results also illustrate the variety of barriers to implementation related to three main topics (Table 1): 1. AAI issues, 2. information and allergy training of school nurses and staff, and 3. lack of knowledge or even ignorance of national school policies and liability issues. In our study, the main barriers were the cost of stock AAI and issues to replace AAI devices due to short expiry date. These barriers were also pointed out in the US.7 In a school nurses' survey in Ohio (US), 43% of respondents did not have stock AAI in their schools and the two main barriers to implementation were AAI cost (55%) and refusal to participate from administration (50%).8 Another barrier pointed out by our study is the lack of school staff training despite an increasing number of training sessions between 2019 and 2023. In the US, the Maricopa County (Arizona) Program demonstrated the feasibility of school-centered stock AAI program by providing school training through an e-learning course.9 Training school staff on correct AAI use requires to clarify key tasks: proper assessment of anaphylaxis symptoms, severity and need for adrenaline without delay, correct first-aid management (AAI use and call for emergency medical services), and legal protection of individuals who offer aid in emergency situations. We also found that the main barrier to participate in the allergy training relies on the liability protection of school staff faced with a suspected anaphylaxis and the use of AAI. This is another key point that conditions the feasibility of this implementation and should be targeted as a key message toward school staff. In addition, our data showed that AAI devices were available for every school staff member in only around half secondary schools and when not available for all school members, they were stored under lock and key in nine out of ten cases. These findings highlight the need for a secure, quickly accessible, and unlocked location to ensure that AAI will be available to every school staff member at any time. Our study has some limitations. The rate of respondents was of 69% and 57% with a number of secondary schools nearly similar between 2019 and 2023. It may be that secondary schools that have not participated in this survey had not implemented stock AAI and that the rate of secondary schools with stock AAI is overestimated. Our study was conducted in a single French region, which may not reflect the national situation. In conclusion, our findings highlight the key role of school nurses regarding stock AAI implementation and school staff training. There are still barriers to implementation that require targeted improvement strategies and further adjustments in the school policies, mainly regarding AAI devices (cost and availability/accessibility), continuous school staff training and law protection knowledge. Guillaume Pouessel: Conceptualization; investigation; writing – original draft; methodology; validation; visualization; writing – review and editing; software; formal analysis; supervision. Muriel Dehay: Conceptualization; investigation; methodology; validation; supervision; project administration; formal analysis; writing – review and editing; visualization. Blandine Delomez: Conceptualization; investigation; methodology; validation; project administration; supervision; writing – review and editing; visualization. Blondel Nathalie: Conceptualization; investigation; methodology; validation; visualization; writing – review and editing; project administration; supervision. Rebecca Ponthieu: Conceptualization; investigation; methodology; validation; visualization; writing – review and editing; writing – original draft; formal analysis; software; supervision. Yasemin Karaca-Altintas: Writing – original draft; methodology; validation; visualization; writing – review and editing; software. Clarisse Santos: Validation; visualization; writing – review and editing; formal analysis. Antoine Deschildre: Writing – review and editing; visualization; validation; formal analysis. We would like to thank all the principals and school nurses who participated in this survey. GP has provided consultation and speaker services for Aimmune Therapeutics/Nestlé, Bausch and Lomb, Stallergenes, Novartis, ALK-Abello, and Bioprojet and serves as a medical consultant/advisor for Bioprojet and Theravia. AD reports personal fees from Novartis, ALK, GSK, Sanofi, Regeneron, Aimmune Therapeutics, DBV Technologies, Nestlé, Stallergenes Greer, DBV Technologies, and Nutricia. Grant from Fondation du Souffle, Conseil Régional Hauts-de-France Research Program 2014–2018, outside of the submitted work. The other co-authors declare no conflict of interest in relation to this work. The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer-review/10.1111/pai.14000. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.