Preparedness for allergic reactions in Japanese schools: a prefecture-wide survey of school nursing teachers

Abstract

Background

Allergic diseases are common among schoolchildren, and appropriate management within school settings is essential. This study aimed to assess the adequacy of schools' preparedness for managing allergic reactions by investigating both actual cases and measures in place via a cross-sectional survey.

Methods

A questionnaire survey was conducted in all public schools in Gifu Prefecture, Japan. Data were collected on students' allergic diseases, allergy management training, and allergic reactions that occurred at school. Further analysis was conducted to identify factors associated with the implementation of role-playing in training programs for allergy management.

Results

Overall, 561 schools with 160,505 students participated in the survey. Among the students, 6.8% and 0.7% had declared food allergies and anaphylaxis, respectively. In total, 775 students (0.5%) were prescribed adrenaline auto-injectors, and 326 schools (58.1%) had students who were prescribed these devices. Allergy response training was conducted at 543 schools (96.8%). While 92.1% of the schools provided practical training on adrenaline auto-injector use, only 45.5% conducted role-playing simulations. The implementation of role-playing was significantly associated with the presence of students who had submitted certificates for school life management related to anaphylaxis (adjusted odds ratio = 1.835). Among the allergic reactions reported at school, 12.1% occurred in students without previous food allergy declarations.

Conclusions

Most schools showed a high level of preparedness through allergy management training. However, to address unexpected reactions, including those in undiagnosed students, simulation or role-playing-based training should be promoted universally.

Introduction

Schoolchildren often experience allergic reactions caused by food while at school [1–8]. Given that children spend a considerable portion of their time at school, it is crucial for schools to implement appropriate measures for managing allergic reactions. The Japanese Guidelines for the Management of Allergic Diseases in Schools, first published in 2008 and revised in March 2020 [9, 10], outline comprehensive measures for addressing allergic diseases in schools and have been widely implemented nationwide.

A tragic accident occurred in December 2012 in Japan, where a schoolchild with a food allergy passed away due to anaphylactic shock caused by school lunch [11]. This incident highlighted the critical need for managing food allergies specific to school meals and preparing for anaphylaxis management in schools. Consequently, "Policies for Food Allergies in School Lunches," were developed and implemented in March 2015 [12], offering detailed guidance on the safe provision of meals to children with food allergies. This incident also led to the revision of the Japanese Guidelines for the Management of Allergic Diseases in Schools in March 2020 [10]. These policies and guidelines provide an integrated framework for the management of food allergies in the context of school lunches.

The Guidelines for the Management of Allergic Diseases in Schools [9, 10] include provisions concerning the "Certificate for School Life Management (for allergic diseases)." This certificate contains a physician's description of the child’s allergic disease and the associated management needs. In Japanese schools, where school lunches are provided, students with food allergies may require modified meals with the causative ingredients removed. In addition, students with a history of anaphylaxis who have been prescribed an adrenaline autoinjector (AAI) and carry it at school are also considered to require management. Management may also be necessary for bronchial asthma during exercise or episodes of acute symptoms, for atopic dermatitis when precautions related to contact with animals or sweating are needed, and for allergic rhinitis or conjunctivitis during outdoor activities. In these situations, submission of a certificate for allergic diseases is commonly required. According to the "Policies for Food Allergies in School Lunches," all students who need to manage their food allergies are required to submit the aforementioned certificate with a physician's diagnosis [12].

Japanese national surveys conducted in 2004, 2013, and 2022 have shown a steady increase in the prevalence of food allergies (2.6%, 4.5%, and 6.3%, respectively) and anaphylaxis (0.14%, 0.48%, and 0.62%, respectively) among schoolchildren [9, 13–15]. As the number of children requiring allergy management increases, schools are expected to take more comprehensive action. However, few studies have thoroughly investigated how such measures are actually implemented or what challenges schools face. To promote effective allergy management, it is essential to understand both how often allergic reactions occur at school and how well schools are prepared for managing allergic reactions, including anaphylaxis.

Gifu Prefecture has 370 public and private elementary schools (including one branch school), 186 junior high schools (including one branch school), and two compulsory education schools. National and public schools constitute the vast majority of these institutions, and the corresponding number of these institutions is 368 (99.5%), 177 (95.2%), and 2 (100%). We believe that investigating allergy management practices in public schools within Gifu Prefecture will provide valuable insights into the broader context of allergy management. The Gifu Prefectural Board of Education, in collaboration with the Gifu Medical Association, has developed its own comprehensive guidelines for managing food allergies in schools. These guidelines include photographs of actual staff rooms, serving areas, and school lunch menus to illustrate concrete procedures related to daily meal management, emergency response, and accommodations during off-campus activities. They also address educational initiatives on food allergies for all students. In addition, the guidelines note the recommendation of conducting simulation-based emergency drills and state that school staff are expected to acquire basic knowledge of food allergies even when no students with diagnosed food allergies are currently enrolled.

While guidelines on allergy management in schools emphasize the importance of preparedness, it remains unclear whether schools that do not have students diagnosed with severe allergies are as proactive as those that do have such students. Determining this is essential for promoting consistent and effective allergy management across all schools. Therefore, this study aimed to clarify the current state of allergy management in public schools in Gifu Prefecture and associated issues through a questionnaire-based survey conducted among school nursing teachers.

Methods

Study design and participants

This study was conducted in July 2019 with the cooperation of the Gifu Prefectural Board of Education, concurrently with a separate study targeting parents of children with allergic diseases, part of which has already been published [16]. The survey was based on the 2008 version of the Japanese Guidelines for the Management of Allergic Diseases in Schools, which preceded the 2020 revision. All public schools in Gifu Prefecture, including elementary schools, junior high schools, compulsory education schools, and special-needs schools, were included in this study. Questionnaire forms were distributed to each school and collected through the Gifu Prefectural Board of Education. School nursing teachers at each institution were responsible for the questionnaires.

This study was approved by the Ethics Committee of Gifu University Graduate School of Medicine (No. 2019–056). Written informed consent to participate in the survey was obtained from the school nursing teachers, who were the respondents from the public elementary and junior high schools.

Questionnaire

The survey aimed to examine both the occurrence of allergic reactions, including anaphylaxis, and the extent of school preparedness, such as the presence of manuals and training programs. In addition, its purpose was to explore factors associated with the implementation of practical measures such as role-playing in response training. Therefore, the questionnaire included questions on the following aspects: the number of students in the school; the number of students who declared having each allergic disease and submitted a "Certificate for School Life Management (for allergic diseases),"" which contains information filled by the diagnosing physician for the purposes of documentation and management of allergy-related needs of students at schools; and the number of students who had an AAI. The survey also inquired about preparedness for managing allergic reactions, including whether training or a manual was available and the specific content of the training or manual. For training, respondents were provided with specific options regarding the content, including practical training for AAIs, role-play training, and lectures by experts. Regarding manuals, we investigated whether schools were using the manual developed by the Gifu Prefectural Board of Education. This manual was created with reference to the manual issued by the Tokyo Metropolitan Government, which developed a detailed emergency response manual for food allergies—including AAI administration—in 2013, after a 2011 accident. The Tokyo manual was later included as a reference in the Japanese Food Allergy Guidelines 2021. Furthermore, the survey investigated the number of students who required care or monitoring for allergic symptoms and the number of students who required care or monitoring for newly developed allergic symptoms that had not been previously declared, and emergency transport to a medical facility or instances of AAI use in the school during the year preceding the survey.

Data analysis and statistics

The survey was conducted using a bubble answer sheet format. The questionnaire data were digitized using a specialized scanning program for bubble answer sheets, and each input value was individually verified by the research team. For all questions, only valid responses were included in the analysis, and subjects with missing answers were excluded from the analysis of the corresponding questions. Data analysis, including calculations and graph generation, was conducted using Microsoft Excel 2019 (Microsoft Corporation, Redmond, WA, USA).

The chi-square test was used for univariate analysis. Additionally, multivariate analysis was performed using logistic regression. Explanatory variables for training programs related to allergic reactions included the submission of a medical certificate for each allergic disease, enrollment of children carrying an AAI, automated external defibrillator (AED) training, elementary schools, and urban areas (Gifu City; the prefectural capital of Gifu). These variables were selected because they are considered to influence whether schools implement role training for allergy management. Specifically, elementary schools were included because age-related differences in allergy prevalence and the level of involvement of students and parents in health management may affect training implementation. Urban areas were included because schools in urban settings generally have better access to medical facilities, which may facilitate the implementation of such training. Statistical analyses were performed using IBM SPSS Statistics, version 28 (IBM Corp., Armonk, NY, USA).

Results

The study participants

This study included 562 public schools in Gifu Prefecture. Responses were obtained from 561 schools—including 364 elementary schools, 172 junior high schools, 20 special-needs schools, 3 annexed schools, and 2 compulsory education schools – resulting in a response rate of 99.8%. The participating schools encompassed a total of 160,505 students, comprising 106,544 elementary school students and 53,961 junior high school students. The valid response rate for each question ranged from 92.2% to 100%. Figure 1 shows the allergic diseases identified by schools, including specific allergic diseases declared by guardians. The survey revealed that 33.1% of elementary and junior high school students declared having at least one allergic disease. Allergic rhinitis was the most frequently declared disease (18.3%), followed by food allergy (6.8%). Additionally, schools identified 0.7% of students with a documented history of anaphylaxis.

Fig. 1.

The prevalence of allergic diseases as declared by guardians. Prevalence of each allergic disease among all students, as declared by their guardians. White, gray, and black bars represent the prevalence among elementary school students, junior high school students, and all students, respectively

Students who needed allergy management at school

Table 1 shows data on students requiring allergy management at school and those who submitted certificates. Among students who declared anaphylaxis, 91.7% required management at school, the highest proportion among all allergic diseases. Of the students who declared food allergies, atopic dermatitis, or bronchial asthma, 62.7%, 28.6%, and 34.6%, respectively, needed management at school.

Table 1.

Students with allergic diseases requiring management

Allergic diseases (%) †	Students with allergic diseases	Students with allergic disease requiring management
		Total	Students who submitted certificates	Certificate utilization rate §
	N	N (%)‡	N	%
Total allergic diseases (86.8)	44,728	13,321 (29.8)	5504	41.3
Food allergy (95.1)	10,514	6588 (62.7)	4760	72.3
Anaphylaxis (93.2)	1054	967 (91.7)	913	94.4
Atopic dermatitis (89.2)	7102	2033 (28.6)	625	30.7
Bronchial asthma (89.1)	4492	1552 (34.6)	565	36.4
Allergic rhinitis (87.2)	25,184	5579 (22.2)	1200	21.5
Allergic conjunctivitis (86.2)	7815	2271 (29.1)	779	34.4

^†Percentage of school nurses who responded to each question

^‡Rates were calculated for all students who required allergic disease management

^§Percentages were calculated for students who declared allergic diseases and required allergic disease management

Anaphylaxis was associated with the highest utilization rate of certificates (94.4%), followed by food allergy (72.3%). In contrast, although allergic rhinitis was the most commonly declared allergic disease in schools, management measures at school were required in only 22.2% of cases of the disease (5579 of 25,184 students), and the associated certificate utilization rate was the lowest (21.5%).

AAIs in schools

A total of 775 students (0.5%) across all schools had AAIs, including 589 (0.6%) and 186 (0.3%) students in elementary and junior high schools, respectively (Table 2). Schools with students who had AAIs included 219 elementary schools (60.2%), 97 junior high schools (56.4%), and 10 other schools (40.0%), i.e., a total of 326 schools (58.1%). Of the 913 students who submitted an anaphylaxis certificate, 639 (70.0%) had been prescribed AAIs.

Table 2.

Prevalence of adrenaline auto-injector prescription in students and schools

	N	%
Students who had AAIs†
Elementary school students	589	0.60
Junior high school students	186	0.30
Total	775	0.50
Schools with students who had been prescribed AAIs
Elementary schools	219	60.2
Junior high schools	97	56.4
Others	10	40.0
Total	326	58.1

^†AAI adrenaline auto-injector

Preparedness for allergic disease management at schools

Manuals addressing individual cases of allergic diseases were prepared at 438 out of 561 schools (78.1%) (Fig. 2A). Among these 438 schools, 399 (91.9%)—representing 71.1% of all schools (561 in total)—used the food allergy emergency action manual published by Gifu Prefecture Board of Education (Fig. 2B). Training sessions on allergic reactions were conducted at 543 out of 561 schools (96.8%); AED training sessions were conducted in almost the same number of schools (530 out of 561 schools, 94.5%) (Fig. 3A and 3B). Figure 3C shows the training content at the 538 schools with valid responses. The most common activity was practical training on the use of AAIs (n = 505, 93.9%), followed by simulation or role-playing (n = 245, 45.5%), tabletop training (n = 39, 7.2%), expert lectures (n = 64, 11.9%), and viewing DVDs (n = 11, 2.0%).

Fig. 2.

Action plans for allergic diseases. A Preparedness of individualized support plans for students with allergic diseases in schools. B Utilization of the action plan for food allergy emergencies provided by the Gifu Prefectural Board of Education

Fig. 3.

Emergency response training at schools. A Proportion of schools that conducted training sessions for managing allergic reactions. B Proportion of schools that conducted training sessions on automated external defibrillator (AED) use. C Content of allergy training sessions conducted in schools that provided valid responses

Further analysis was conducted to examine the factors influencing the implementation of role-playing in training programs for allergic reactions (Table 3). Univariate analysis revealed that the submission of medical certificates for anaphylaxis (p < 0.001), atopic dermatitis (p = 0.006), bronchial asthma (p = 0.044), allergic rhinitis (p = 0.038), and allergic conjunctivitis (p = 0.011), as well as the enrollment of students carrying an AAI (p < 0.001), were all significantly associated with the implementation of role-playing. Multivariate logistic regression analysis identified the submission of medical certificates for anaphylaxis as the sole significant background factor (p = 0.025, adjusted odds ratio [aOR] = 1.835).

Table 3.

Analysis of factors associated with the implementation of simulation or role-playing among schools that conducted allergy response training

Variables	Conducted a simulation or role-playing		No simulation or role-playing		Univariate analysis			Multivariate analysis
					OR	95% CI	P-values	aOR†	95% CI	P-values
Enrollment of students who submitted a certificate for each allergic disease
Food allergy, n = 490	225/240	93.8%	260/290	89.7%	1.731	0.908–3.299	0.096	1.076	0.528–2.191	0.841
Anaphylaxis, n = 312	163/236	69.1%	145/284	51.1%	2.140	1.492–3.071	< 0.001	1.835	1.081–3.116	0.025
Atopic dermatitis, n = 240	123/232	53.0%	114/280	40.7%	1.643	1.157–2.334	0.006	1.351	0.771–2.370	0.294
Bronchial asthma, n = 221	110/232	47.4%	108/280	38.6%	1.436	1.009–2.043	0.044	0.862	0.507–1.465	0.583
Allergic rhinitis, n = 267	132/232	56.9%	133/279	47.7%	1.449	1.021–2.057	0.038	0.788	0.364–1.576	0.500
Allergic conjunctivitis, n = 231	118/231	51.1%	111/279	39.8%	1.580	1.111–2.248	0.011	1.202	0.582–2.481	0.619
Enrollment of students who were prescribed AAIs‡, n = 324	166/245	67.8%	155/293	52.9%	1.871	1.315–2.662	< 0.001	1.281	0.783–2.095	0.324
AED§ training, n = 514	236/244	96.7%	273/293	93.2%	2.161	0.935–4.997	0.072	2.363	0.975–5.727	0.057
Elementary schools, n = 355	163/245	66.5%	190/293	64.8%	1.078	0.754–1.541	0.682	1.014	0.688–1.495	0.943
Located in Gifu City, n = 158	66/245	26.9%	90/293	30.7%	0.832	0.571–1.211	0.336	0.731	0.475–1.125	0.154

^†Odds ratios are adjusted for variables including the submission of a medical certificate for each allergic disease, presence of children with AAIs, implementation of AED training, school being an elementary school, and school location in Gifu City (the prefectural capital of Gifu)

^‡AAI adrenaline auto-injector

^§AED automated external defibrillator

Treatments for allergic reactions in schools

In total, 517 schools (92.2%) provided valid responses to the relevant questions (Table 4). The survey revealed that 41.7% of schools had experienced allergy-related incidents within the past year, with 13.6% of schools reporting undeclared allergic reactions. Among students who required care at school, 12.1% had newly developed food allergy symptoms that had not been previously declared. Similarly, among students who required emergency transport, 36.4% had not previously declared a food allergy. Emergency cases involving newly developed and previously undeclared allergy symptoms tended to be more common among elementary school students (44.4%) than among junior high school students (26.7%). AAIs were used for seven students at school during the study period, including four elementary school students and three junior high school students.

Table 4.

Characteristics of allergy management and incidents in elementary and junior high schools

	Elementary school		Junior high school		Total
	N	%	N	%	N	%
Schools (unit of analysis: schools)
Valid responses	341		176		517
Allergy care/monitoring required	152	44.7	63	35.8	215	41.7
Unexpected allergy reactions managed	51	15.8	19	10.8	70	13.6
Emergency transport due to allergy	16	4.7	13	7.4	29	5.6
Unexpected emergency transport	7	2.1	4	2.3	11	2.1
AAI† use	3	0.9	3	1.7	6	1.2
Students (unit of analysis: students)
Any allergy care provided at school	473		188		661
No previous declaration	59	12.5	21	11.2	80	12.1
Emergency transport	18		15		33
No previous declaration	8	44.4	4	26.7	12	36.4
AAI†use	4		3		7

^†AAI: adrenaline auto-injector

Discussion

Our research involved a large-scale, cross-sectional study of schoolchildren with allergic diseases, the preparedness of schools in terms of managing allergic reactions, and the circumstances surrounding allergy episodes that occurred in school settings. In this study, schools recognized that 33.1% of students had various allergic diseases. Among the students who declared food allergies and anaphylaxis, 62.7% and 91.7%, respectively, required specific management measures at school. Furthermore, approximately half of the schools had students who had been prescribed AAIs, indicating that emergency allergy care was required at schools. Of the cases in which schools needed to respond to allergic reactions, 12.1% involved students who experienced newly developed allergic symptoms caused by allergens that had not been declared in advance. This finding highlights the necessity for schools to be prepared not only for known cases but also for unexpected allergic reactions.

The number of children with food allergies is increasing in Japan, and schools are required to manage allergic reactions. Our survey found that 41.7% of schools had experienced at least one allergic reaction in the previous year. Studies have reported that 1.8–20% of children have experienced allergic reactions in nursery or school settings [1–5]. These findings suggest that allergic reactions are relatively common and should be anticipated by school staff. Additionally, surveys on anaphylaxis have indicated that 9–14% of cases occur in schools or daycare centers [17–20]. In 2013 and 2014, 11% of schools in the United States reported suspected cases of anaphylaxis [21]. Surveillance of AAI use in Japanese children has shown that 25% of administrations occurred in nurseries and schools [22]. Another study also reported that AAI use for food-induced anaphylaxis in children is more frequent in nurseries and schools than at home [20]. Collectively, these reports indicate that potentially life-threatening anaphylaxis does occur in school settings. In our study, approximately half of the schools had students who were prescribed AAIs, suggesting that many schools may be required to manage anaphylaxis. Therefore, it is essential that all schools acknowledge the possibility of allergic reactions, including severe cases, and be adequately prepared to respond to anaphylaxis.

Allergic symptoms often develop unexpectedly. In our study, food allergies required clear school-based procedures such as management during school lunch, resulting in high declaration rates; in contrast, conditions such as allergic rhinitis, which rarely require specific measures at school, naturally showed low certificate utilization. Nevertheless, our findings indicate that new-onset allergic symptoms still occur even among students without prior declarations. Previous studies have reported that 25–33% of allergic reactions at school were new-onset cases [4, 10] and that 21–25% of cases of anaphylaxis or AAI use involved children with no prior allergy diagnosis [21, 23–25]. Similarly, our study found that 12% of allergic reactions and 36% of emergencies involved students who had not previously declared an allergy. Both mild and severe reactions included unexpected onset, consistent with previous findings [4, 10, 21, 23–25].

International practical guidelines developed for childcare centers and school personnel recommend implementing site-wide protocols to manage suspected allergic reactions, including those in children without a submitted allergy action plan [26]. The Guidelines for the Management of Allergic Diseases in Schools [10] acknowledge that anaphylaxis can develop for the first time during school life, and recommend that schools be familiar with the basic knowledge and response to anaphylaxis, even in the absence of previously declared cases. However, the latter part of the guideline assumes that the relevant certificate has been submitted, and the section for emergency response mainly presumes the students have been prescribed AAIs. Therefore, the guidelines may provide limited direction for managing allergic reactions in students without a prior declaration. Gifu Prefecture has provided a protocol for emergency management of food allergies; however, only 399 schools (71.1%) have adopted it. A survey of elementary schools in European countries found that schools without allergic students were significantly less likely to have a standard management protocol for severe allergic reactions compared with those that had allergic students [27]. These findings indicate that protocols for allergic emergency preparedness in schools often remain inadequate. Schools must, therefore, consider the possibility of first-time allergic reactions and implement a protocol that can be applied universally, even for students without a medical certificate. A meta-analysis identified difficulties in accessing adrenaline (epinephrine) as a barrier to managing anaphylaxis in schools [28], and international guidelines have recommended that unassigned AAIs be made available in educational settings [26]. In Japan, unlike in some other countries, AAIs can legally be prescribed and used only by individuals who have been diagnosed by a physician. In our study, some students without a previously declared allergy experienced severe allergic symptoms requiring emergency transport. Since AAI use is restricted to those with prescriptions, it is essential for schools to have protocols in place to recognize anaphylaxis promptly and to ensure rapid transfer to medical facilities.

Previous studies have reported that school staff often lack confidence in managing food allergies and recognizing and treating anaphylaxis [29, 30]. Training in food allergies and anaphylaxis management has been shown to improve the self-efficacy of teachers and school administrators [11, 31]. In our study, we found that most schools had already conducted training programs on responding to allergic symptoms, such as the use of AAIs, as well as training in AED use, which reflects a commendable level of preparedness. However, simulation-based training or role-playing was conducted in only 45.5% of these schools. Although this exceeds the national average of 26.8% reported in the 2022 survey by the Japan School Health Association [15], the implementation rate is still not sufficient. Moreover, simulation or role-play training was more commonly implemented in schools where the certificates for anaphylaxis had been submitted. This association may indicate a reactive tendency among schools, in which preparedness measures are strengthened only after a clear risk becomes apparent. In particular, in schools without identified high-risk students, insufficient awareness that severe allergic reactions—including new-onset anaphylaxis—can occur unexpectedly is likely a major reason for not implementing role-play training. Additionally, limited recognition of the educational value of role-playing may also hinder its adoption. Given the possibility of newly emerging allergic reactions, practical training for AAI use may be insufficient, and simulation or role-playing may be necessary for all schools to quickly recognize and respond to these situations.

The importance of simulation or role-play in preparing for emergency responses has been emphasized in both school and healthcare settings. In school environments, simulation or role-playing has been shown to improve staff confidence and preparedness for managing anaphylaxis and other allergic emergencies [32, 33]. Multiple studies in the field of healthcare education have shown that simulation-based and role-play training enhances clinical skills, communication, and emergency response performance [34–38]. A meta-analysis further supports the effectiveness of these methods in fostering active learning and improving procedural competence [39]. In these studies, scenario-based role-play with feedback has been evaluated as an effective educational method. Similarly, school guidelines in Japan for managing allergic diseases introduce action cards to support practical simulation training [10]. Together with our findings, these results highlight the critical importance of implementing scenario-based role-play training, including the use of action cards, in all schools. Such training can better prepare staff to respond effectively to severe allergic reactions, even in students without prior allergy declarations. Our findings show that severe allergic reactions often occurred in students without prior allergy declarations, highlighting the critical need for practical emergency training to be included in all schools, not just those already managing anaphylaxis risks.

This study has several limitations. First, the total number of students with each type of allergy reflects only those recognized by the school. This survey included the number of students whose parents submitted declarations to the school but who did not require allergy management. However, it should be noted that it does not include students whose parents have not declared to the school. Second, the number of valid responses was limited for questions regarding cases that actually required allergy care. Only schools that answered all relevant questions were included in this analysis, resulting in different numbers of valid responses across questions. Third, this study was limited to Gifu Prefecture. Because the implementation of emergency training may be influenced by prefectural committee policies, the generalizability of these findings to other regions remains uncertain. Finally, it should be noted that the number of cases of allergic reactions reported in this study was limited to those recognized and recorded by School Nursing Teachers. Mild cases may have been overlooked, and incidents managed solely by homeroom teachers without notification to the School Nursing Teachers may have been excluded. This potential self-reporting bias should be considered when interpreting the results.

Conclusions

While many schools have already established important systems for managing allergic reactions, newly emerging cases can still occur unexpectedly. Therefore, universal protocols for managing food allergy-related symptoms in all students remain essential. To further strengthen preparedness, comprehensive training that includes role-playing practice should be considered. Collaboration with allergists is also important in developing and managing effective response systems.

Abbreviations

AAI

Adrenaline auto-injector

AED

Automated external defibrillator

Authors’ contributions

NK and CK designed this study. CK, NK, TK, and MK were involved in data handling. NK and CK performed the data analyses. SK and HO provided critical feedback for the study. All the authors provided critical feedback and helped shape the research, analysis, and writing of the manuscript. All authors have read and approved the final version of the manuscript.

Funding

This study was commissioned by Gifu Prefecture. The funding body had no role in the study design, data collection, analysis, interpretation of data, or manuscript preparation.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Gifu University Graduate School of Medicine (No. 2019–056). Written informed consent for participation in the survey was obtained from the school nursing teachers.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.