A National Review of State Laws for Stock Epinephrine in Schools

Abstract

BACKGROUND:

Anaphylaxis is a life-threatening allergic reaction with significant risk for children with allergies. Access to potentially life-saving medication is critical for these children. This review aims to describe state laws and policies guiding stock epinephrine in schools for allergic or anaphylactic events and detail recommendations for best practices.

METHODS:

This paper is a comprehensive review of the 50 states and District of Columbia’s (DC) laws and policies for stock epinephrine at schools for children in pre-kindergarten through 12^th grade.

RESULTS:

All 50 states and DC allow undesignated epinephrine in schools to use for allergic or anaphylactic reactions. A key difference arises in whether states allow (N=37) or mandate (N=14) that schools stock epinephrine. States exhibit differences in the body responsible for developing stock epinephrine policy (N=48), along with stakeholders responsible for developing procedures (N=30) and implementing them (N=19). Differences also exist in state epinephrine procurement, administration, training, and liability.

CONCLUSIONS:

This review of stock epinephrine laws and policies highlights the significant variation in state legislation despite widespread adoption. Only one-quarter of states mandate that schools have stock epinephrine available for emergency use, underscoring need for a more unified approach with consistent guidelines, comprehensive training, and possible funding for implementation.

Approximately six million American school-aged children, or one in 13, have food allergies.¹ This chronic, life-threatening condition carries risk of anaphylaxis upon exposure to allergen(s), most commonly milk, eggs, wheat, soy, and tree nuts.² Research shows 40 percent of food-allergic children have experienced a serious allergic reaction,¹ and 16–18 percent have had a reaction at school.³ In fact, one-quarter of first-time anaphylactic events occur at school.⁴

During allergic/anaphylactic reactions, immediate care is critical for best outcomes. Epinephrine auto-injectors (EAIs) can be lifesaving in the case of an allergic reaction; however, they must be readily available for use.³ Guidelines have been developed to handle allergies in and out of the healthcare setting.⁵ To support adoption, the federal government passed the School Access to Emergency Epinephrine Act (2013), which incentivizes states to plan for managing anaphylaxis in schools.⁶ As of 2018, all 50 states and the District of Columbia have had laws facilitating allergy management within schools via undesignated epinephrine (termed “stock epinephrine;” Table 1). Studies have described school district-level policies and practices,^7,8 including surveys of school staff/nurses to identify specific practices and preparedness^9–11 and analysis of administrative data to understand use and barriers to stock epinpehrine.^12,13

Table 1.

State laws for schools to stock epinephrine

			Relevant Stakeholders		Obtaining Stock Epinephrine			Maintenance and Administration			Training
State Citation	System(s) regulated	Location(s) covered	Development	Implementation	Prescription	Procurement	Allowable Price	Individual(s) who may administer	Dose	Eligible recipient(s)	Require-ments outlined	Topics
AL Ala. Act 2014–455 (2014), Code § 16–1-48 (2016)	Dept. of Education	Public school campus	Physician, Board of Pharmacy	Local boards of education				School nurse, staff		Student	Yes	Yes
AK Alaska Stat. § 17.22.010, Stat § 17.22.020 (2014)	Dept. of Health and Social Services					18+ individual may obtain prescription or purchase				Person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
AZ* Ariz. Rev. Stat. § 15–157 (2013, amended 2016)	Dept. of Education	School, school-related events	Dept. of Health Services, Dept. of Education, medical professionals, school health professionals, school administrators, org. representing school nurses	School districts, charter schools	Standing order (Chief Medical officer of Dept. of Human Services, Chief Medical Officer of County Health Dept., physician, doctor of osteopathy)		Legislature may appropriate funds to provide for purchase of two juvenile and two adult doses, schools may accept monetary donations or grants	School nurse, staff	Four	Student, adult	Yes	Yes
AR Ark. Code § 6–18-707 (2013, amended 2019)	School district, public charter school				Physician			School nurse, staff		Student	No	No
CA* Cal. Educ. Code § 49414 (2014), Code § 49423 (2017)		School, school-related events		School districts, county offices of education & charter schools	Physician	Local or mail-order pharmacies, manufacturers	May accept gifts, grants, donations from any source	School nurse, staff, volunteer	Two	Person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
CO Colo. Rev. Stat. § 22–1-119.5 (2013, amended 2018)	Board of Education	School, school-related events	Dept. of Health & Environment	Governing authorities of schools	Physician, APN, PA	Manufacturers, TPP	FMP, reduced price, free	School nurse, staff, student		Student	Yes	Yes
CT* Conn. Public Act No. 14–176 (2014)	Board of Education		Commissioner of Public Health	Local & regional boards of education	Physician, APN, PA, optometrist, dentist			School nurse, staff, student		Student	Yes	Yes
DE* Del. Chapter 342 (2014)	Dept. of Education		Dept. of Public Health		Health care provider authorized to prescribe			School nurse, staff			Yes	Yes
DC* D.C. Act 21–259 (2016)	Superintendent of Education, Dept. of Health	School property, school-related events	Dept. of Health	School districts	Physician, PA, NP			School nurse, staff, volunteer, student	Two	Student	Yes	Yes
FL Fla. Stat. § 381.885 (2016)	Board of Education	School property, school-related events	Dept. of Health	School districts	Physician	Wholesale distributors		School nurse, staff, student		Student	Yes	Yes
GA Ga. Code Ann. § 20–2-776.2 (2013)	Board of Education		Dept. of Public Health		Physician, PA, APN	Pharmacies, manufacturers, TPP	F FMP, reduced price	School nurse, staff		Student	Yes	Yes
HI* Haw. Rev. Stat. § 302A-1164 (2019)	Dept. of Health				Health care provider authorized to prescribe	Pharmacies, authorized health care providers		School nurse, staff, student		Student; person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
ID Idaho Code Ann. § 33–520A (2014)		School, school-related events		Governing authorities of schools	Physician, APN, PA	Manufacturers, TPP	FMP, reduced price, free	School nurse, staff, student	One	Student	Yes	Yes
IL 105 Ill. Comp. Stat. 5 / 22–30 (2016)	Board of Education	School, school-related events, under supervision of school personnel, before or after normal school activities			Physician, PA, APN			School nurse, staff, volunteer, student		Person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
IN Ind. Code § 20–34-4.5 (2014)	Dept. of Education				Health care provider authorized to prescribe, pharmacist	Pharmacies		School nurse, staff, volunteer		Student, school personnel, visitor	Yes	Yes
IA Iowa Code § 135.185 (2015)	Dept. of Education, Board of Medicine, Board of Nursing, Board of Pharmacy	School, school-related events, under supervision of school personnel, before or after normal school activities	Org. representing school nurses	Board of directors for each school district	Health care provider, APN, PA			School nurse, staff, student		Person suffering, or believed to be suffering from anaphylaxis	Yes	No
KS Kan. Stat. Ann. § 72–8258 (2014)	Board of Pharmacy	School, school property, school-related event	Consultant pharmacist		Physician	Pharmacies			One	Student, school personnel	No	No
KY Ky. Rev. Stat. § 158.836 (2013)	Dept. of Public Health		Local health depts., local clinical providers, local schools/districts	Local school boards			Donations, purchase	Volunteer	Two	Student	No	No
LA^ La. Rev. Stat. Ann. § 17.436.1 (2012)	Governing authorities of schools				Physician			School nurse, staff		Student	Yes	No
ME Me. Rev. Stat. Sec. 20-A, § 6305 (2014)	Dept. of Education	School property	Dept. of Health and Human Services	Governing bodies of schools	Physician, APN, PA	Manufacturers, TPP	FMP, reduced price, free	School nurse, staff, volunteer, student		Student	Yes	Yes
MD* Md. Code., Educ. § 7–426 (2014)	Dept. of Education, Dept. of Health and Mental Hygiene			Local boards of education	Health care provider			School nurse, staff		Student	Yes	Yes
MA 105 Mass. Code Regs. 210.1159 (2016)	Dept. of Public Health	School, school-related events	Board of Registration in Nursing, Board of Registration in Medicine	School districts			Shall be assessed on surcharge payers	School nurse, staff		Student	Yes	Yes
MI* Mich. Comp. Laws § 380.1178–9 (2013)	Dept. of Education	School property	Dept. of Community Health, Assn. of School Nurses, Nurses Assn., American College of Allergy, Asthma & Immunology, Chapter of Pediatrics, School-Community Alliance of MI, other school orgs./entities				Legislature may appropriate funds to provide for purchase	School nurse, staff, student	Two	Student; person suffering, or believed to be suffering from anaphylaxis	Yes	No
MN Minn. Stat. § 121A.2205, 121A.2207 (2018)	District or school	School property, school-related events	Educational commissioner may develop model policy to transmit to interested schools	Interested community stakeholders		Manufacturers	FMP, reduced price, free	School nurse, staff, student		Student; person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
MS Miss. Code Ann. § 37–11-71 (2014)	School board of each local public school district, governing body of each private or parochial school				Physician, Dept. of Health District Officers	May accept donations from public or private entities	May seek grants to obtain funding	School nurse, staff, student		Student	Yes	Yes
MO Mo. Rev. Stat. § 196.990 (2017)	Dept. of Elementary and Secondary Education		Any appropriate professional assn.		Physician, PA, NP	Pharmacies		School nurse, staff		Student	Yes	Yes
MT Mont. Code Ann. § 20–5-420–21 (2013)	School	School property, school-related events			Physician, APN, PA	Pharmacies		School nurse, staff, student		Students; person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
NE* Neb. Rev. Stat. § 79–224 (2016)	School, educational service unit or program	School property, school-related events, facilities or vehicles for early childhood programs			Physicians, health care provider	Pharmacies		School nurse, staff, student		Person suffering, or believed to be suffering from anaphylaxis	Yes	No
NV* Nev. Rev. Stat. § 633.707 (2013)	Each school district or governing body of each school	School property			Physician, osteopathic physician	Manufacturers, wholesalers	May accept gifts, grants and donations from any source	School nurse, staff, student	Two	Student	Yes	Yes
NH N.H. Rev. Stat. Ann. § 200:44 (2015)	Dept. of Education	School property, school-related events, any time subject to school’s jurisdiction or supervision	Dept. of Health and Human Services	School districts	Health care provider	Pharmacies, manufacturers, TPP	FMP, reduced price, free	School nurse, staff, student		Student; person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
NJ* N.J. Stat. Ann. § 18A: 40–12.6a (2015)	Board of education or chief school administrator	School, school-related events	Guidelines established by Dept. of Education		Physician, APN			School nurse, staff, volunteer, student		Student	Yes	Yes
NM^ N.M. Stat. Ann. § 22–33-3 (2015)	Dept. of Health	School property	School district, governing bodies of schools		Health care provider	Pharmacies, manufacturers, wholesalers	May accept gifts, grants, bequests, and donations from any source	School nurse, staff, volunteer		Student; person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
NY^ N.Y. Educ. Law § 3000-C (2017)	Commissioner of education				Health care provider	Pharmacies	School provide funding	School nurse, staff		Person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
NC* N.C. Gen. Stat. § 115C-375.2A (2014)	Local school board	School, school-related events	Principals in collaboration with appropriate school personnel		Physician, PA, NP of local health dept.			School nurse, staff, student		Person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
ND N.D. Admin. Code Sec. 33–37-01 (1996), Cent. Code § 23–01-05.2 (2011)	State health officer				Physician, pharmacist					Person suffering, or believed to be suffering from anaphylaxis	No	No
OH Ohio Rev. Code Ann. § 3313.7110–7111, 3314.143, 3326.28, 3328.29, 4729.91, 4729.51, 4729.60, 5101.76 (2016)	State Board of Education	School property	Superinten-dent, licensed health professional authorized to prescribe		Health care provider authorized to prescribe	Wholesalers, manufacturers	May accept donations	School nurse, staff, student	Two	Person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
OK Ok. Stat. § 70–1-116.3 (2013)	State Board of Education		Board of Health	School districts	Physician			School nurse, staff, student	Two	Student	Yes	No
OR Or. Rev. Stat. § 339.866 (2013)	State Board of Education	School property, school-related events	Health Authority, Board of Nursing, Board of Pharmacy	School districts	Health care provider authorized to prescribe			School nurse, staff, student		Student; person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
PA 24 Pa. Stat. Ann. § 14–1414.2 (2014)					Physician, NP			School nurse, staff, student		Student	Yes	No
RI R.I. Gen. Law H8328 (2016)	Dept. of Education, Dept. of Health	School property, school-related events, vehicle being used for school purpose			Physician, health care provider authorized to prescribe	Pharmacies		School nurse, staff		Person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
SC S.C. Code Ann. § 59–63-95 (2013)	Governing authorities of school districts		Dept. of Health & Environmental Control, Dept. of Education		Physician, APN, PA	Pharmacies, physicians, manufacturers, TPP	FMP, reduced price, free	School nurse, staff, volunteer, student		Student; person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
SD S.D. Codified Laws § 13–33A-4 (2014)	State Board of Education	During school hours			Health care provider			School nurse, staff		Student	Yes	Yes
TN Tenn. Code Ann. § 49–5-415(f) (2013)	School board of each local public school district, governing body of each private or parochial school				Physician			School nurse, staff	Two	Student	Yes	No
TX Tex. Educ. Code Ann. § 37.605 (2018)	Commissioner of State Health Services	School campus, school-related events, while in transit to or from school event	Commissioner of Education, Advisory Committee (established by Commissioner of State Health Services)	School districts	Physician, health care provider authorized to prescribe	Pharmacies	May accept gifts, grants & donations, federal & local funds	School nurse, staff, volunteer		Person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
UT* Utah Code Ann. § 26–41-102 (2015)	Dept. of Public Health				School district physician, medical director of local health dept., local emergency medical services director	Physicians, pharmacies		School nurse, staff, volunteer, student		Person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
VT Vt. Stat. Ann. Tit. 16, § 1388 (2013)	State Board of Education	School property, school-related events, school-provided transportation, school-related programs	Dept. of Public Health		Physician, APN, PA	Pharmacies, manufacturers, TPP	FMP, reduced price, free	School nurse, staff, volunteer, student		Person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
VA* Va. Code Ann. § 20–671-710 (2015)	Dept. of Education, Dept. of Health	School property, school-related events	Local school boards, Assn. of School Nurses, Chapter of American Academy of Pediatrics, Medical Society of VA, Office of Attorney General		Physician, doctor of osteopathy, PA, NP			School nurse, staff	Two	Student	Yes	Yes
WA Wash. Rev. Code § 28A.210.383 (2013)	Office of Superintendent of Public Instruction	School property, school-related events			Health care provider authorized to prescribe	Pharmacies	May accept donations	School nurse, staff, student		Student	Yes	Yes
WV W. Va. Code § 18–5-22c (2013)	State Board of Education	School property, school-related events	State Health Officer		Allopathic physician, osteopathic physician		Reduced price, free	School nurse, staff, student		Student; person suffering, or believed to be suffering from anaphylaxis	Yes	Yes
WI Wis. Stat. § 118.2925 (2013)	Governing body of schools	School property, school-related events	Physician		Physician, APN, PA			School nurse, staff, student		Student; person suffering, or believed to be suffering from anaphylaxis	Yes	No
WY Wyo. Stat. Ann. § 21–4-316 (2014)	Dept. of Education		Dept. of Health	School districts	Health care provider authorized to prescribe	Manufacturers, TPP	FMP, reduced price, free	School nurse, staff, volunteer			Yes	Yes

^*=State mandates stock epinephrine in schools

^{^}=Policy does not indicate that school and person administering epinephrine will have no fault if there is adverse reaction

[blank] = Not specified

Abbreviations: APN = Advanced Practiced Nurse, Assn. = Association, Dept. = Department, FMP = Fair-Market Price, NP = Nurse Practitioner, Org. = Organization, PA = Physician Assistant, TPP = Third-Party Providers

To date, no comprehensive analysis has assessed laws nationwide for stock epinephrine in schools and how they are carried out and/or enforced. Policies differ in terms of whether stock epinephrine is allowed or mandated, bodies responsible for development, types of regulated school systems, locations covered, relevant stakeholders, procurement processes, maintenance and administration, training requirements, incident documentation, and liability. This review describes these laws and considers how variation among states affects child welfare at school. This analysis holds potential to identify best practices and opportunities for improvement across states to optimally support children with food allergies.

POLICY REVIEW

Allow versus Mandate Stock Epinephrine in Schools

An important distinction in state laws is whether it allows or mandates that schools stock epinephrine. The latter means schools must maintain a supply of EAIs on site. Fourteen states mandate stock epinephrine in schools, while 37 allow it. The number of states with mandates has grown since 2015 (N=7).¹⁴

Body Responsible for Developing School Policy

Most state laws (N=48) outline the body responsible for developing school stock epinephrine policy; three states did not. Most commonly, state education agencies (e.g., board, department) are responsible (N=28). In 12 states, the legislation directs schools, school districts, or other local governing body (e.g., school board) to create policies. Other relevant state agencies cited as responsible include public health (N=15), pharmacy (N=2), and nursing (Kansas). Three states require multiple state agencies to oversee policy development (state education and health agencies in District of Columbia and Maryland; state education, pharmacy, and nursing agencies in Iowa).

Types of School Systems Regulated

Stock epinephrine laws regulate different types of school systems. Thirty-seven states regulate public schools, 29 private, and 16 charter. Eight states reference other school types (eg, parochial, vocational, boarding, tribal). Thirty-four states regulate more than one type of school system, and 13 states do not specify school types. Only 13 states indicate specific school or grade levels covered by the law, all citing elementary and secondary schools. Delaware specifies the law also applies to pre-kindergarten.

Locations Covered

More than half of states (N=31) outline locations where epinephrine policy is active. Most of these identify the law applies on school property (N=28). Twenty-one states also indicate the law covers school-sponsored events.

Relevant Stakeholders

Developing procedures.

Thirty states outline stakeholders responsible for developing procedures for stock epinephrine in schools. The most commonly cited stakeholders are state-level agencies, including health (N=19), education (N=5), and pharmacy (N=2). Three states listed other state-level agencies as stakeholders, including medical and school health professionals (Arizona), boards of registration for nursing and medicine (Massachusetts), and various nursing associations (Michigan). Local stakeholders specified in the laws include schools or school districts (N=5) and providers (N=5). Additional stakeholders are organizations that include school nurses (Arizona, Iowa, Michigan, Virginia) and a consultant pharmacist (Kansas).

Implementing policy/procedures.

Nineteen states identify stakeholders responsible for implementing stock epinephrine in schools. Most often, the local school district, governing authority, or board of education has implementation authority (N=18). Minnesota specifically indicates input should be included from “interested community stakeholders” prior to policy implementation.

Obtaining Stock Epinephrine

Prescription.

Most states (N=45) legislate who must prescribe undesignated epinephrine for school use. The majority of these states indicate a local healthcare provider must prescribe this medication (N=42). Twenty-three states specify a physician must prescribe the epinephrine, while one state indicates standing orders may be used (Arizona). Six states did not identify prescription responsibility.

Procurement.

About half of states (N=27) legislate how schools may obtain stock epinephrine. States specify it may be obtained from local pharmacies (N=17), manufacturers (N=13), third-party suppliers (N=8), wholesalers (N=4), mail-order pharmacies (N=1), and donation (N=1). Alaska indicates any person over 18 years can obtain a prescription and purchase epinephrine if they complete necessary training. Twenty-four states did not indicate where schools obtain epinephrine.

Price/funding.

Less than half of states (N=24) legislate allowable price or funding for procuring epinephrine. Specifically, these states approve fair market/reduced price (N=10) and regular price (N=3); seven states allow donation. Six states indicate schools/districts may seek grants to purchase epinephrine. Michigan stipulates “school boards shall attempt to obtain funds from private sources;” however, if unable, schools can apply for reimbursement from the legislature. Twenty-seven states did not detail allowable spending or funding for epinephrine.

Maintenance and Administration of Stock Epinephrine

Storage (Figure 1).

Figure 1.

Storage conditions of stock epinephrine at school, as indicated in state laws (N=51)

Twenty-six states specify epinephrine should be stored in a secure location, and 22 indicate it should be accessible. Twelve states require storage in an unlocked location, while nine states require a locked location. Three states provide a temperature range for storage (Arkansas, Colorado, Virginia).

Administration (Figure 2).

Figure 2.

Persons who can administer stock epinephrine at school, as indicated in state laws (N=51)

Nearly all states specify the school nurse and staff can administer epinephrine (N=47). Similarly, most state laws require training for the person administering medication (N=46). Fewer states indicate staff may volunteer to administer epinephrine in school (N=12). Twenty-nine states indicate students can administer stock epinephrine themselves.

Dose.

Three-quarters of states (N=39) do not indicate the number of epinephrine doses that should be kept at the school. Among states that did specify, most required two doses (N=9) with a range from one (N=2) to four (N=1, Arizona). Six states detail both child and adult doses of epinephrine should be kept at school. In addition, most states (N=45) require auto-injectable epinephrine to be available at school. One state requires pre-filled syringes (Missouri). Five states do not specify the dispense method for stock epinephrine.

Eligible recipients.

Fifty states indicate who can receive stock epinephrine in school, including students (N=38), school personnel (N=4), or any person (N=26); Delaware does not specify. Nineteen states define eligible recipients as those having or reasonably believed to be experiencing anaphylaxis.

Enforcement.

Two states address epinephrine law enforcement. Alabama enforces the school stock epinephrine law only if the state provides funding. Arizona’s law specifies that each school’s governing body enforces having stock epinephrine.

Training

Requirements.

Most states (N=47) outline required training for schools to stock epinephrine and staff to administer it; four states do not discuss training. Eleven states address training frequency, mostly every one or two years. Twenty-five states’ laws identify who must administer trainings, including individuals (eg, school nurses, registered nurses, certified emergency responders, qualified personnel designated by school district physicians) or organizations (eg, health departments, nationally recognized organizations that train laypersons).

Topics (Figure 3).

Figure 3.

Training topics for individuals administering stock epinephrine in schools, as indicated by 39 states addressing training content

Thirty-nine states’ laws identify training topics. Most commonly, laws specify training should include how to administer epinephrine (N=37), signs/symptoms of anaphylaxis or allergic reaction (N=31), and emergency follow-up procedures (N=27). Less than half of states require training on medication storage (N=20), food allergies (N=6), incident reports (N=5), and liability coverage (N=1).

Incident Documentation

Twenty-five states require schools have anaphylaxis action plans or protocols. Nineteen states require schools to document when stock epinephrine was administered.

School Liability

Nearly all state laws (N=48) indicate the school and person administering epinephrine will have no fault given an adverse reaction. Louisiana, New Mexico, and New York do not comment on liability protection.

IMPLICATIONS FOR SCHOOL HEALTH AND EQUITY

This review shows all states have school stock epinephrine laws in place, yet significant variation exists, creating unnecessary barriers to epinephrine access in schools. The number of children affected by food allergies and the potential of life-threatening allergic reactions warrants a more unified approach is warranted to ensure safe environments in schools.

No requirement for stock epinephrine in every school.

Most states allow stock epinephrine in schools; however, only one-quarter mandate it. Since on average two students in each classroom have food allergies, regardless of race/ethnicity or income,¹⁵ it is critical to ensure epinephrine access in every school, regardless of type. It is also critical to remove variation in epinephrine access based on school administrators or staff, particularly since administrators’ choice not to participate is a common barrier to stock epinephrine.¹⁶

The costs of caring for food allergies is often borne by families, totaling $25 billion annually.¹⁷ By mandating stock epinephrine in schools, consistent environments of care are created in a place where children spend more than half their waking hours, thus minimizing logistical and financial burdens on families to obtain additional epinephrine for school.

Inconsistent policy components.

State laws include varied information about medications, procuring, funding, training, and liability, thus creating uncertainty. A more unified approach is necessary to provide consistent guidance and support to schools while promoting equity.

A key inconsistency across states is specifications about medication types, doses, and storage. Having inadequate number of doses and locking medications for storage limits access in potentially life-saving situations. Minimum requirements should be specified to ensure easy access to adequate medication for an emergency, namely at least two auto-injectors in both child and adult doses that are stored in an unlocked location.

Another inconsistency is obtaining and funding stock epinephrine. Nearly half of states do not detail how schools can obtain stock epinephrine, and just over half provide no funding guidance, including in mandating states. Cost is cited by school nurses as a common barrier to stock epinephrine,¹⁶ and one potential concern is placing additional unfunded mandates on schools. Concrete mechanisms for funding and obtaining stock epinephrine are critical to minimize potential disparities in stock epinephrine access within schools.

A third inconsistency is training. Not all states require instruction in anaphylaxis symptoms or proper epinephrine use, both fundamental for effective treatment. Delayed or improper treatment can contribute to worse outcomes. Also, even where training is required, only one state specifies to address liability. It is important to have liability protections for those who prescribe and administer stock epinephrine and to ensure broad awareness of this protection.

Recommendations

To achieve safe environments for children with allergies at school and ensure support for personnel, it is critical that legislators, policymakers, state agencies, and schools work together to:

• Optimize access of life-saving medication for all children in case of anaphylaxis or allergic reaction by mandating stock epinephrine in every state and school through laws and policies.

• Maintain at least two epinephrine auto-injectors for child and adult doses to ensure appropriate anaphylaxis management in all school buildings.

• Ensure epinephrine available to anyone on school grounds and easily accessible by storing in unlocked locations that are clearly marked.

• Support students’ ability to self-administer epinephrine if they know proper use and have parental/guardian permission.

• Update federal and state laws to delineate funding for stock epinephrine, including appropriating funds, providing flexibility for grants/donations, and regulating market prices of school-designated epinephrine.

• Standardize annual training for school personnel to include key topics for safe stock epinephrine use, including anaphylaxis signs/symptoms, proper use, storage, and follow-up, both as defined in policies and within curricula offered in-person and virtually.

• Ensure liability protection included in all state laws for school personnel administering stock epinephrine and train on these protections to remove barriers.

• Maintain central repository of allergy and epinephrine-related resources to disseminate up-to-date state information, training materials, funding guidance, communication strategies, and best practices for effective implementation at all levels.

• Collect detailed information about epinephrine use at schools for program evaluation and refinement, including analyzing individuals’ demographics and outcomes when epinephrine administrated at each school as well as at the district, local, and state level.

Epinephrine availability in schools is a public health concern. Optimizing stock epinephrine laws creates potential for comprehensive, standardized procedures within schools and reduces disparities in epinephrine access.