Anaphylaxis Fatalities Research Articles

At-home Management of Food-induced Anaphylaxis

Anaphylaxis is an acute, potentially life-threatening, systemic reaction characterized by the involvement of two or more body systems. The National Institute of Allergy and Infectious Diseases and Food Allergy and Anaphylaxis Network (NIAID/FAAN) have well-established criteria for the clinical definition of anaphylaxis. Anaphylaxis is a severe allergic reaction that occurs suddenly after contact with an allergy-causing substance (e.g., peanuts), insect venom or medications (e.g., antibiotics). Anaphylaxis criteria include an acute onset of symptoms (within minutes to several hours) involving the skin, mucosal tissue, or both, which may present with generalized hives, pruritus or flushing, or swollen lips, tongue, and uvula. In addition, one or more of the following must be present: respiratory compromise, reduced blood pressure, or associated symptoms of end-organ dysfunction. Anaphylaxis results in a sudden release of mediators, including, but not limited to, histamine from activated mast cells and basophils following the cross-linking of specific immunoglobulin E. Together with downstream mediators, such as prostaglandin D2, platelet activating factor, and leukotrienes, this reaction manifests clinically through peripheral vasodilation, bronchoconstriction, and increased vascular permeability, presenting as a multi-organ emergency requiring immediate intervention. It is estimated that up to 5% of the population has experienced anaphylaxis, although fatality rates are very low at approximately 0.3% and occur most commonly with drug-induced anaphylaxis. Older age, often consistent with pre-existing comorbidities, and delayed epinephrine administration, pose the most significant risk factors for anaphylaxis fatality. While the global rates of anaphylaxis appear to be on the rise, case fatalities fortunately do not seem to follow this trend.

A Health Economic Analysis of Non-injectable Epinephrine Compared with Intramuscular Epinephrine

Noninjectable epinephrine to treat allergic reactions addresses an unmet need. Intranasal epinephrine is approved and a sublingual form is under development. Inhaled epinephrine is poorly studied for anaphylaxis. These forms have unknown cost-effectiveness. To evaluate cost-effectiveness of commercially available noninjectable epinephrine compared with intramuscular epinephrine for treatment of anaphylaxis. Markov cohort analyses evaluated the cost-effectiveness of noninjectable epinephrine forms. The base-case assumed exaggerated anaphylaxis fatality rates (50-fold increase) for using inhaled epinephrine given low certainty evidence in anaphylaxis and deliberately reduced fatality risk for nasal or sublingual forms (10-fold reduction) theorizing higher adherence and early use during an allergic reaction. In the base-case scenario, assuming a 10-fold decreased risk in peanut allergy fatality associated with intranasal or sublingual epinephrine treatment for a severe allergic reaction (net monetary benefit [NMB], $2,189,134) vs intramuscular epinephrine use (NMB, $2,189,114), intranasal or sublingual epinephrine was the most cost-effective option (incremental cost-effectiveness ratio [ICER], $83,748/quality-adjusted life-year [QALY]), but only at a marginal annual cost of $4. Intramuscular epinephrine was cost-effective (ICER, $17,900/QALY) vs inhaled epinephrine (NMB, $2,183,531), although inhaled epinephrine reached cost-effectiveness (willingness to pay [$100,000/QALY]) if associated fatality risk fell below 2.5-fold. Substituting a single noninjectable form of epinephrine for a second injectable device (in patients prescribed 2 autoinjectors already) would be cost-effective; however, adding a supplemental noninjectable device was not cost-effective, even assuming a 10-fold risk reduction with multiple device carriage (ICER, $858,462). Noninjectable routes of epinephrine can be cost-effective options provided fatality risk is not significantly elevated. Carriage of redundant epinephrine autoinjectors with noninjectable forms is not cost-effective if associated with excess cost of redundant device packs.

Fatal and Near-Fatal Anaphylaxis: Data From the European Anaphylaxis Registry and National Health Statistics

Anaphylaxis is a serious systemic reaction-data on fatal and near-fatal reactions are limited. To better understand clinical patterns and risks factors of severe anaphylaxis by a deep analysis of data from fatal and near-fatal anaphylaxis. Data from the European Anaphylaxis Registry on fatal/near-fatal anaphylactic reactions and national data on anaphylaxis fatalities were investigated. A total of 305 fatal/near-fatal reactions among children and adults including 35 fatalities from the European Anaphylaxis Registry were identified. The most frequent elicitors were drugs, insects, and food. Male patients (66%/60%) were more frequently affected. Male sex, higher age, concomitant mastocytosis, and cardiovascular disease were associated with a more severe outcome. With increasing reaction severity, skin symptoms were less frequently observed (45% of fatal reactions). In parallel, anaphylaxis mortality rates were studied. The data show that anaphylaxis mortality rates increased in Germany from 0.48 (2009) to 0.59 per 1,000,000 population per year (2020). This increase was apparent only in the female population. In this data set, drugs were the most frequent elicitor of anaphylaxis fatalities, and the rate for this increased over time. We identified not only elicitors but also individual factors to be associated with an increased risk of fatal anaphylaxis. Such patients should be recognized and managed with great caution. The increase in drug-induced fatalities points to the need for a better allergological care of patients suffering from drug hypersensitivity.

Is epinephrine truly lifesaving, and can we prove this?

Injectable intramuscular epinephrine is first-line treatment for anaphylaxis. Epinephrine is touted as "life-saving", in particular because observational studies have identified lack of prompt epinephrine treatment as a critical risk factor associated with anaphylaxis fatality. While association is not causal, few would argue that epinephrine is not the optimal treatment for anaphylaxis, do we have sufficient proof to suggest that epinephrine is actually "life-saving"? Epinephrine indeed works swiftly to reverse such symptoms of an immediate allergic reaction. However, there is abundant observational data that many cases of anaphylaxis are inherently self-limited, and may resolve within 1-2 hours in the vast majority of cases with or without treatment. In this perspective, the intent is to address and re-frame the reality of the evidence we do have for what epinephrine does and does not accomplish, and provide a perspective regarding the common "dogma" regarding the drug. There is a danger in using terms such as "life-threatening" and "life-saving" for anaphylaxis and epinephrine treatment, especially under the caution of frequently cited rhetoric that subsequent reactions are likely to be progressively more severe or potentially fatal. Use of such descriptions risks negatively polarizing our patients and adversely affecting their quality of life, given these terms can potentiate unnecessary fear. Epinephrine is in fact a wonderful drug, but it is important to not lose sight of the evidence for what it actually does in anaphylaxis treatment, and why it is important to use this drug in anaphylaxis, as opposed to an emphasis on what it does not do.

A Synopsis of the Synopses, 2020–2021

A Synopsis of the Synopses, 2020–2021

Separating Fact from Fiction in the Diagnosis and Management of Food Allergy

Separating Fact from Fiction in the Diagnosis and Management of Food Allergy

Exploiting nut cross-reactivity to facilitate real-world treatment of tree nut allergy

Oral immunotherapy (OIT) for food allergy has become increasingly common among practicing allergists. 1 Wasserman RL Jones DH Windom HH Meeting FacultyReaching for best practices in food oral immunotherapy: report on the second annual Food Allergy Support Team meeting. Ann Allergy Asthma Immunol. 2019; 123: 129-130 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Tree nut allergy accounts for approximately 33% of food-induced anaphylaxis fatalities and only 9% outgrow their allergy. 2 Bock SA Munoz-Furlong A Sampson HA Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol. 2007; 119: 1016-1018 Abstract Full Text Full Text PDF PubMed Scopus (749) Google Scholar ,3 Fleischer DM Conover-Walker MK Matsui EC Wood RA The natural history of tree nut allergy. J Allergy Clin Immunol. 2005; 116: 1087-1093 Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar Tree nut OIT has been successful 4 Bégin P Winterroth LC Dominguez T et al. Safety and feasibility of oral immunotherapy to multiple allergens for food allergy. Allergy Asthma Clin Immunol. 2014; 10: 1 Crossref PubMed Scopus (102) Google Scholar ,5 Elizur A Appel MY Nachshon L et al. Walnut oral immunotherapy for desensitisation of walnut and additional tree nut allergies (nut cracker): a single-centre, prospective cohort study. Lancet Child Adolesc Health. 2019; 3: 312-321 Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar but is burdened by frequent sensitization, as assessed by positive specific immunoglobulin or skin prick tests to multiple nuts, often without a previous exposure history. Although allergy to each nut could be confirmed or refuted by an oral food challenge (OFC) and OIT performed to each reactive nut, such an approach is not only onerous for patients, but each challenge carries the risk of a serious reaction. Although simultaneous treatment with multiple nuts has been successful, 4 Bégin P Winterroth LC Dominguez T et al. Safety and feasibility of oral immunotherapy to multiple allergens for food allergy. Allergy Asthma Clin Immunol. 2014; 10: 1 Crossref PubMed Scopus (102) Google Scholar each nut added to the treatment increases the complexity for patients and for treating allergists. In addition, increasing the number of nuts treated increases the maintenance dose, further increasing the burden for patients. Cashew and pistachio nuts are known to be cross-reactive, as are walnuts and pecans, and walnut OIT has been found to partially or fully desensitize some patients to other nuts. 5 Elizur A Appel MY Nachshon L et al. Walnut oral immunotherapy for desensitisation of walnut and additional tree nut allergies (nut cracker): a single-centre, prospective cohort study. Lancet Child Adolesc Health. 2019; 3: 312-321 Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar , 6 Smeekens JM Bagley K Kulis M Tree nut allergies: allergen homology, cross-reactivity, and implications for therapy. Clin Exp Allergy. 2018; 48: 762-772 Crossref PubMed Scopus (39) Google Scholar , 7 Elizur A Appel MY Nachshon L et al. NUT Co Reactivity – Acquiring Knowledge for Elimination Recommendations (NUT CRACKER) study. Allergy. 2018; 73: 593-601 Crossref PubMed Scopus (65) Google Scholar

A Cost-Effectiveness Evaluation of Hospitalizations, Fatalities, and Economic Outcomes Associated with Universal Versus Anaphylaxis Risk-Stratified COVID-19 Vaccination Strategies

BackgroundVaccine-associated anaphylaxis is a rare event (1.34 events/million doses; 0.00017% occurrence over 26 years). Several reports of allergic reactions concerning for anaphylaxis have been reported early into the Pfizer-BioNTech and Moderna coronavirus disease 2019 (COVID-19) vaccine campaign in the United States, Canada, and the United Kingdom.ObjectiveTo perform a cost-effectiveness analysis characterizing the risks of COVID-19 versus vaccine anaphylaxis, comparing universal COVID-19 vaccination versus risk-stratified vaccination approaches.MethodsCohort analysis models were created to evaluate the cost-effectiveness of universal vaccination versus risk-stratified vaccination (eg, contraindicated in persons with a history of any previous episode of anaphylaxis) with a threshold for cost-effective care at $10,000,000 per death prevented. In the base case, risk of anaphylaxis was estimated at 0.1%, with case-fatality estimated at 0.3%.ResultsOn a population level (n = 300,000,000 simulated persons), universal vaccination was associated with a cost-savings of $503,596,316 and saved 7,607 lives, but the cost-savings was sensitive to increasing rates of vaccine-associated anaphylaxis. The universal strategy dominated at higher rates of COVID-19 infection and low rates of vaccine-associated anaphylaxis in both the health care and societal perspectives. When the risk of vaccine-associated anaphylaxis exceeded 0.8%, the risk-stratified approach to vaccination was the most cost-effective strategy. There was also an interaction between anaphylaxis risk and anaphylaxis fatality, with a risk-stratified approach becoming cost-effective as each risk increased concurrently. Stratified observation time by anaphylaxis history (15 minutes vs 30 minutes) was not cost-effective until a 1% anaphylaxis case-fatality was assumed and risk of vaccine anaphylaxis exceeded 6%.ConclusionsThis study demonstrates that unless vaccine anaphylaxis rates exceed 0.8%, a universal vaccination approach dominates a risk-stratified approach where persons with any history of anaphylaxis would be contraindicated from vaccination, with lower cost and superior health outcomes.

Anaphylaxis in children

AbstractAnaphylaxis in children is a potential acute life‐threatening systemic hypersensitivity reaction. Anaphylaxis fatality rate is estimated to be 0.65% to 2%. Food is the main anaphylaxis trigger in children, notably cow's milk, peanuts, and tree nuts. Mucocutaneous manifestations are observed in more than 90% of cases, but it is not essential for diagnosis. Deaths are rather secondary to the laryngeal edema, observed in 40%‐50% of cases. Personal history of asthma, allergy to particular foods such as peanuts and tree nuts, and adolescence are known risk factors for anaphylaxis and more severe reactions. Epinephrine (adrenaline) is the medication of choice for the first‐aid treatment of anaphylaxis. However, adrenaline auto‐injectors (AAIs) are commercially available in only 32% of world countries. There are still considerable unmet needs in the field of anaphylaxis in children. Therefore, the Montpellier WHO Collaborating Centre aims to start the global action plan applied to anaphylaxis.

The Health and Economic Outcomes of Early Egg Introduction Strategies

Researchers in this study modeled rates of egg allergy development and costs associated with early egg introduction (EEI) without screening compared with skin prick test (SPT) or serum-specific immunoglobulin E (sIgE) screening and delayed egg introduction.The computer simulation modeled high-risk infants with early-onset eczema in the United States, Canada, and Europe.The Markov modeling was based on published data including risks and benefits of EEI with cooked egg, eczema prevalence, 24% positive egg SPT results in infants with eczema, 6.6% annual egg tolerance development, and 5% annual inadvertent reactions to egg over a 20-year time frame. Infant cohorts were as follows: (1) EEI without screening, (2) SPT for egg sensitization in consultation with a board-certified allergist, (3) egg sIgE testing by a primary care provider, and (4) delayed egg introduction (>12 months of age) without screening. Costs considered included SPT, sIgE, allergy consultation, epinephrine autoinjectors, additional visits, and job-related opportunity costs.Egg allergy occurred in 2.5% of infants with EEI without screening versus 9.5%, 12%, and 21.4% with SPT screening, delayed introduction, and sIgE screening, respectively. Base model per patient incremental costs were $6865 US dollars for SPT by an allergist and $16 722 for sIgE by a primary care provider. Quality of life was similar across groups. Cooked EEI without screening remained the preferred strategy across multiple sensitivity analyses, including higher rates of allergy on first egg-exposure, lower rates of subsequent accidental egg reactions in children with egg allergy, lower rates of natural egg tolerance, higher rates of anaphylaxis fatality, exclusion of discount rates, and across both shorter and longer time horizons. A supplemental analysis of raw pasteurized EEI demonstrated that although this strategy was inferior to cooked EEI, raw pasteurized EEI was still preferred to screening testing (and also to delayed cooked egg introduction provided no more than 15.6% of infants reacted to initial raw pasteurized egg exposure).EEI without screening for high-risk infants resulted in the lowest percentage of infants developing egg allergy and the lowest cost. EEI after SPT screening and challenge for all positive SPT results resulted in fewer children with egg allergy and lower cost than delayed introduction.These simulations suggest that EEI without screening for egg sensitization is the preferred strategy for infants with no previous reactions to egg. SPT followed by a challenge if the SPT result is positive is associated with less egg allergy than delayed introduction, suggesting a role for limited SPT screening to facilitate early introduction in infants with eczema whose families are reluctant to introduce egg without screening. Although the modeling required making assumptions, extensive sensitivity analyses were performed and demonstrated robustness of EEI as the preferred strategy.

Estimation of Health and Economic Benefits of Clinic Versus Home Administration of Omalizumab and Mepolizumab

Biologic therapy is a paradigm-shifting management strategy for many patients with asthma and chronic urticaria, but concerns for therapy-associated anaphylaxis may limit access to these therapies for patients unable to travel to medical clinics. To characterize the cost-effectiveness of in-clinic versus at-home biologic therapy with omalizumab and mepolizumab. Economic evaluation using microsimulations was performed from societal and health care sector perspectives for patients with asthma or chronic spontaneous urticaria receiving omalizumab or mepolizumab in an allergy clinic, primary care provider (PCP) office, or at home over a 1-year time horizon (12 injections per year in each base case with sensitivity analysis to 24 injections per year). Travel times and distances were applied to a population attending a tertiary care allergy clinic in Northern New England receiving omalizumab or mepolizumab, using a willingness-to-pay value of $10 million per death prevented and in-clinic administration reducing anaphylaxis fatality and hospitalization 10- to100-fold. Deterministic and probabilistic sensitivity analyses were performed. One-way allergy clinic travel distances significantly exceeded local PCP offices (49 miles, 95% CI, 42-56, vs 12 miles, 95% CI, 10-15). In the omalizumab societal analysis, annual PCP and allergy clinic administration cost $1369.14 (mean) ± $51.33 (SD) and $1916.68 ± $40.86, respectively. Small reductions in medication-related fatalities with in-clinic administration were offset by the potential increase in automobile fatalities resulting from traveling to the allergy clinic (14.6 ± 15.0 per million person-years for this strategy). Compared with at-home administration, in-clinic omalizumab administration was not cost-effective, with an incremental cost-effectiveness ratio of $500,648,430 (PCP), and with allergy clinic administration dominated by higher costs and automobile-related fatalities. Routine mepolizumab clinic administration was dominated by at-home administration unless anaphylaxis rates or self-administration teaching costs were high. For many patients, at-home administration of omalizumab or mepolizumab may be a cost-effective strategy.

Drug-induced anaphylaxis: is it an epidemic?

The present review addresses the epidemiology, analyzes the current data and promotes global awareness of drug-induced anaphylaxis. Anaphylaxis is a medical emergency that may cause death! In the last decade, studies have shown an increasing incidence and prevalence of anaphylaxis. Drug-induced anaphylaxis fatalities have increased, and this syndrome remains underdiagnosed and undertreated.

Increases in anaphylaxis fatalities in Australia from 1997 to 2013.

Recent epidemiological studies indicate increases in Australian, UK and US hospital anaphylaxis admission rates. The aim of this study was to determine whether Australian anaphylaxis fatalities are increasing in parallel and to examine the characteristics of fatalities recorded in the National Coronial Information System (NCIS). Time trends in Australian anaphylaxis fatalities were examined using data derived from the Australian Bureau of Statistics (ABS) 1997-2013 and the NCIS 2000-2013, the latter providing additional information to verify cause and identify risk factors. The ABS recorded 324 anaphylaxis fatalities by cause: unspecified (n = 205); medication (n = 52); insect stings/tick bites (n = 41); food (n = 23); and blood products (n = 3). From 1997 to 2013, all-cause fatal anaphylaxis rates increased by 6.2%/year (95% CI: 3.8-8.6%, P < 0.0001) or from 0.054% to 0.099/10(5) population. Fatal food anaphylaxis increased by 9.7%/year (95% CI: 0.25-20%, P = 0.04) and unspecified anaphylaxis deaths by 7.8% (95% CI: 4.6-11.0, P < 0.0001). There was an insignificant change in medication-related fatalities (5.6% increase/year; 95% CI: 0.3% decrease to 11.8% increase, P = 0.06), and sting/bite fatalities remained unchanged. Hospital anaphylaxis admission rates for all-cause, food, unspecified and medication anaphylaxis increased at rates of 8%, 10%, 4.4% and 6.8%/year, respectively. A total of 147 verified NCIS deaths were examined in detail: medication- and sting/bite-related fatalities occurred predominantly in older individuals with multiple comorbidities. Upright posture after anaphylaxis was associated with risk of sudden death (all causes). Seafood (not nuts) was the most common trigger for food-related anaphylaxis deaths. Australian anaphylaxis fatality rates (most causes) have increased over the last 16 years, contrasting with UK- and US-based studies that describe overall lower and static overall anaphylaxis fatality rates (0.047-0.069/10(5) population).

Anaphylaxis Fatalities in Australia 1997 to 2013

Anaphylaxis Fatalities in Australia 1997 to 2013

Anaphylaxis

Anaphylaxis occurs commonly in community settings. The rate of occurrence is increasing, especially in young people. Understanding potential triggers, mechanisms, and patient-specific risk factors for severity and fatality is the key to performing appropriate risk assessment in those who have previously experienced an acute anaphylactic episode. The diagnosis of anaphylaxis is based primarily on clinical criteria and is valid even if the results of laboratory tests, such as serum total tryptase levels, are within normal limits. Positive skin test results or increased serum specific IgE levels to potential triggering allergens confirm sensitization but do not confirm the diagnosis of anaphylaxis because asymptomatic sensitization is common in the general population. Important patient-related risk factors for severity and fatality include age, concomitant diseases, and concurrent medications, as well as other less well-defined factors, such as defects in mediator degradation pathways, fever, acute infection, menses, emotional stress, and disruption of routine. Prevention of anaphylaxis depends primarily on optimal management of patient-related risk factors, strict avoidance of confirmed relevant allergen or other triggers, and, where indicated, immunomodulation (eg, subcutaneous venom immunotherapy to prevent Hymenoptera sting-triggered anaphylaxis, an underused, potentially curative treatment). The benefits and risks of immunomodulation to prevent food-triggered anaphylaxis are still being defined. Epinephrine (adrenaline) is the medication of first choice in the treatment of anaphylaxis. All patients at risk for recurrence in the community should be equipped with 1 or more epinephrine autoinjectors; a written, personalized anaphylaxis emergency action plan; and up-to-date medical identification. Improvements in the design of epinephrine autoinjectors will help to optimize ease of use and safety. Randomized controlled trials of pharmacologic agents, such as antihistamines and glucocorticoids, are needed to strengthen the evidence base for treatment of acute anaphylactic episodes.

Anaphylaxis fatalities and admissions in Australia

Detailed data on fatal anaphylaxis are limited, with national anaphylaxis fatality data for the United Kingdom and food-induced anaphylaxis fatality data for the United States. Time trends for anaphylaxis fatalities are not available. We examined causes, demographics, and time trends for anaphylaxis fatalities in Australia between January 1997 and December 2005 and compared these with findings for anaphylaxis admissions. Data on anaphylaxis deaths and hospital admissions were extracted from a national database. Death certificate codes were analyzed to determine the likely cause and associated comorbidities. There were 112 anaphylaxis fatalities in Australia over 9 years. Causes were as follows: food, 7 (6%); drugs, 22 (20%); probable drugs, 42 (38%); insect stings, 20 (18%); undetermined, 15 (13%); and other, 6 (5%). All food-induced anaphylaxis fatalities occurred between 8 and 35 years of age with female preponderance, despite the majority of food-induced anaphylaxis admissions occurring in children less than 5 years of age. Most insect sting-induced anaphylaxis deaths occurred between 35 and 84 years almost exclusively in male subjects, although bee sting-induced admissions peak between 5 and 9 years of age with a male/female ratio of 2.7. However, most drug-induced anaphylaxis deaths occurred between 55 and 85 years with equal sex distribution similar to drug-induced anaphylaxis admissions. There was no evidence of an increase in death rates for food-induced anaphylaxis, despite food-induced anaphylaxis admissions increasing approximately 350%. In contrast, drug-induced anaphylaxis deaths increased approximately 300% compared with an approximately 150% increase in drug-induced anaphylaxis admissions. The demographics for anaphylaxis deaths are different to those for anaphylaxis presentations. Anaphylaxis mortality rates remain low and stable, despite increasing anaphylaxis prevalence, with the exception of drug-induced anaphylaxis deaths, which have increased.

Food-Induced Anaphylaxis

Food-induced anaphylaxis is most frequently caused by proteins in peanut, fish, tree nuts, crustaceans, milk, egg, or soy; in many instances, the individual allergens have been isolated and characterized. Although persons sensitized to one food are often advised not to eat other foods from the same food family, recent studies using DBPCFC feedings suggest that clinically significant cross-allergenicity among legumes and among fish may be less common than formerly suspected. Cow’s milk allergy in infants may disappear spontaneously with time, but sensitivity to peanut, fish, or nuts is usually long-lasting. Newer hypoallergenic formulas prepared from casein or whey hydrolysates are not completely allergen-free and may pose risks to infants highly sensitive to cow’s milk. The diagnosis of food-induced anaphylaxis is made from the clinical history and can be confirmed by puncture skin testing or by in vitro demonstration of food-specific IgE antibodies. Immunoassays have been developed for "hidden" or contaminating allergens that are not listed on food product labels. The drug of choice for treatment of food-induced anaphylaxis is subcutaneous epinephrine, and sensitive persons should carry epinephrine and be familiar with its use. Most cases of fatal food-induced anaphylaxis occur away from home, and food-sensitive persons need to develop an anticipatory action plan to deal with reactions that occur at work, at school, or in distant communities. The number of anaphylaxis fatalities could be reduced by better patient education, better food labeling, and a greater awareness of food allergy by restaurant service personnel and paramedical rescue teams.