When a third-grade student who had been stung by a wasp developed welts on his neck and had trouble breathing, school nurse Amanda Williams had the necessary dose of epinephrine to counter the allergic reaction.
A law Tennessee enacted this year makes it easier for schools to stock the life-saving drug. Williams said the emergency room doctor told the boy's parents that he probably wouldn't have survived without the injection at Tellico Plains Elementary because it's a 30-minute drive to the nearest hospital.
"It would have been tragic," she said.
Fifteen other states enacted similar laws in 2013, joining 11 others that already had them, according to the Asthma and Allergy Foundation of America. While only four of the states require schools to have the medication on hand, all the laws allow schools to stock it without a prescription for an individual person - a legal hurdle in many places - and provide legal protection for staff members who administer it.
The most common form of the medication is packaged inside a device called an auto injector. The tip of the device is placed firmly against the thigh, which releases a short, spring activated needle that injects the epinephrine.
Charlotte Collins is senior vice president of public policy and advocacy for the allergy foundation and has been keeping track of which states are enacting laws to encourage schools to stock the devices. She believes the trend was sparked by last year's death of a Virginia first-grader who had an allergic reaction on a playground after eating a nut. She went into cardiac arrest and died at a local hospital.
Medical experts have said the little girl, who had a peanut allergy, would probably be alive if her elementary school had been able to give her an epinephrine injection.
"Epinephrine is the first line treatment for these severe reactions," said Dr. Michael Pistiner, a pediatric allergist. "Studies show that delays in treatment with epinephrine increase risk of death."
Shortly after the girl's death, Virginia passed a law requiring all its schools to stock the medication.
Fifteen other states followed suit, mostly with legislation that allows schools to have the epinephrine. Bills are also pending in Ohio and Michigan.
So far Virginia, Maryland, Nebraska and Nevada are the only states to require it.
"I think that was just a major trigger in the public consciousness," Collins said of the girl's death, which made national news.
In July, the U.S. House passed legislation that would give states that come up with policies to make epinephrine available in schools special preference when they apply for asthma-related grants. The law could give states further incentive to pass such laws.
The bill was sponsored by Rep. Phil Roe, a Tennessee Republican and doctor, and Rep. Steny Hoyer of Maryland, the House's second-ranked Democrat. One requirement for a state to qualify for a preference is to make sure adequate legal protection is provided to personnel trained to administer the epinephrine.
"My granddaughter has a severe peanut allergy, and the presence of EpiPens in schools can be lifesaving," Hoyer said, referring to a brand of auto-injector.
Collins said she believes more states don't require that epinephrine be stocked in schools to avoid placing a burden on often cash-strapped school districts to purchase the drug.
Still, it's an important step to simply allow schools to stock the medication without a prescription for an individual.
"Typical state laws can otherwise make it impossible for school districts that want to stock to avoid sanctions against dispensing prescription-only medications to an institution rather than a person," said Collins, adding that all the laws contain some form of legal protection for those administering the drug.
While the protections vary, the laws generally shield non-medical staff trained by a nurse to administer the epinephrine.
"A nurse can't be everywhere," said Sally Schoessler, director of nursing education for the National Association of School Nurses. "You need a very quick response when it comes to administering epinephrine for anaphylaxis."
Aside from bee stings, anaphylactic shock can be a reaction to such foods as peanuts, wheat, shellfish, milk or eggs. The epinephrine is particularly effective in stopping swelling in the throat or tongue that can be deadly, as well as preventing respiratory or cardiac failure.
According to the American College of Allergy, Asthma and Immunology, roughly 8 percent of children under age 18, or about 6 million, have at least one food allergy.
Tammy Edwards said those figures are why she and her son lobbied for the legislation in Tennessee. Her 12-year-old son Tyler, who carries an epinephrine auto-injector to school, attended legislative meetings with her and testified.
"It's hard for some people to understand that one little peanut ... could take a life," Edwards said.
About a quarter of anaphylaxis cases in schools occur among students who are not aware that they have an allergy.
Williams, the nurse, said that was the case with the boy who was stung by a wasp at her school in Monroe County, Tenn., which now allows epinephrine injectors to be placed in all 13 of its schools.
Sonia Hardin is the health supervisor for Monroe County schools, where nurses at each school have collectively trained more than 100 people to administer the epinephrine, as the state law allows.
She said having the medication available at schools in isolated rural areas, like where Tellico Plains Elementary is located, is important because she agrees time is valuable.
"It took the ambulance about 15 minutes to get there from the time we placed the 911 call," said Hardin, referring to the incident involving the third-grader. "We are just thankful ... we had that (epinephrine) and was able to use it.
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