Schools Require Emergency Allergy Medicine, But Doctors Balk

When a Murietta Valley Unified School District elementary student bit into a cupcake made with peanut butter in April, she quickly struggled to breathe. A school health aide grabbed a pre-loaded syringe of adrenaline from the supply cabinet, injected the girl and contained the girls' allergic reaction to peanuts until she got to the emergency room. This is exactly as a new California law intended –- but not, in fact, how the law is playing out in many districts.

Six months after the Jan. 1 law required schools to stock these pre-loaded syringes – known as epinephrine automatic injectors and considered the first line treatment for potentially life-threatening allergic reactions – many districts have been unable to obtain what Riverside County's Murietta Unified has: a doctor’s prescription for the devices.

Up and down the state, doctors have declined to write prescriptions for epinephrine auto-injectors for districts, citing liability concerns and derailing the promise of the law. A February survey of 408 school nurses by the California School Nurses Organization found that 57 percent had been unable to obtain epinephrine auto-injectors for their district, calling the inability to find a doctor to write a prescription a major obstacle.

Many districts have turned to city and county public health doctors as the logical prescription writers, only to be rebuffed. “They are being asked to sign these orders, but are being told by their county counsel and their risk managers that the liability risks are real,” said Kat DeBurgh, executive director of the Health Officers Association of California, a Sacramento-based membership group for city and county public health doctors.

The impasse has prompted the author of the law, state Sen. Robert Huff, R-Diamond Bar, to introduce follow-up legislation designed to protect physicians from prosecution if they write these prescriptions. The bill, Senate Bill 738, passed the Senate this month and is in the Assembly.

Brett Curtis, a consulting physician for the Oakland Unified School District, is all for it. “The standard is to prescribe on the basis of a good faith exam,” he said. But the law asks doctors to write a prescription naming the school district as the patient, with the injectors to be used to treat a student or adult as needed – which means “a patient I’ve never seen,” Curtis said.

“The law indemnified everybody except the doctor,” he said.

His medical liability insurance company agreed. In order to write a prescription to bring Oakland Unified into compliance with the new law, Curtis took out additional liability insurance. Now he writes prescriptions for stock epinephrine auto-injectors for all 86 schools in Oakland.

About 8 percent of children nationwide have food allergies, and of those, nearly 40 percent have had a severe reaction known as anaphylaxis, where blood pressure drops and airways constrict. Other symptoms include hives, a swollen tongue and vomiting.

Severe food allergies have become an issue in schools across the state and the nation as the percentage of children who are allergic to nuts, milk, wheat and other substances has increased, according to the Centers for Disease Control, for reasons researchers can’t definitively explain.

Some schools have introduced nut-free zones in school cafeterias and ingredient inspections for classroom birthday treats. But enforcement can be difficult.

For instance, just days before the Murietta Valley student took a bite of the peanut butter-filled cupcake, Cathy Owens, a school nurse, sent a memo to teachers stating that parents must give advance permission for their child to eat food brought in for school events. But at the classroom cupcake party, that notification never happened, Owens said.

The result is a lot of anxiety for parents and for school nurses like Martha Wallis, who said she has given at least four emergency epinephrine injections in the past five years in the unified districts of Moreno Valley and Lake Elsinore. A local physician was willing to write a prescription for stock epinephrine even before the law required schools to have it, she said.

While many students with severe allergies carry their own epinephrine auto-injectors or keep one at the school office, others don’t. And 20 percent of severe allergic reactions at school happen to children who have never been diagnosed with a severe allergy, said Dr. Marc Lerner, medical officer for the Orange County Department of Education.

As a school district employee, Lerner says he is covered by the district’s risk insurance. So he’s written prescriptions for epinephrine auto-injectors for 600 schools in 28 districts in Orange County, using the website EpiPen4Schools.com, which offers free and reduced price epinephrine auto-injectors to schools across the country.

Lerner is one of a group of doctors who have stepped up to write prescriptions for districts.

At a hearing of the state Senate Judiciary Committee earlier this month, school nurse Melissa Locketz urged passage of the new legislation to dispatch physicians’ liability worries. She read five statements from fellow school nurses, including this one: “It does not seem fair that some schools are lucky to have relationships with physicians, while others can’t comply because no one will sign.”