Strategies for reducing anaphylaxis risks in public spaces

According to government figures, between 1998 and 2018, 101,891 people were admitted to hospital for anaphylaxis in the UK, and 30,700 of these were due to a food allergy. The largest increase in hospital admissions was seen in children younger than 15 years of age. Hospital admissions for anaphylaxis for adults increased from 3,751 to 4,756 from 2019 to 2020. The number of adult patients admitted to hospital because of allergies has more than doubled since 2013. 

Some scientists believe that accurate and reliable data on food allergy and anaphylaxis is lacking, and there may be an under-reporting of food allergy-related reactions and deaths.

Understanding anaphylaxis

Anaphylaxis happens when your body has a serious, life-threatening reaction to something you are allergic to. An allergy is your immune system responding to a substance that is usually harmless. The immune system’s job is to defend your body against things such as bacteria and viruses. However, in the case of allergies, your immune system mistakenly identifies a substance, known as an allergen, as being harmful to you and reacts to it. Allergies can vary in severity from mild to severe, and the symptoms can range from being slightly irritating to being life-threatening. 

Anaphylaxis can come on very quickly, so it is important to know what to do in an emergency. It requires immediate medical attention. Anaphylaxis can cause the immune system to release an excess of chemicals which can cause serious symptoms and result in the person going into shock. This is known as anaphylactic shock, which is where there is a sudden drop in blood pressure and there is a narrowing of airways which can block your breathing. If left untreated, anaphylaxis can develop into anaphylactic shock and result in serious complications or even death.

Anaphylaxis is typically triggered by exposure to an allergen, which is a substance that the immune system identifies as harmful even though it is generally harmless to most people.

Young people between 16 and 24 years old are the group recognised as being most at risk of anaphylaxis as they become more independent from their parents and are more likely to experiment with new, unfamiliar foods, they are more likely to travel alone or with friends and may be reluctant to carry two EpiPens with them at all times which is necessary when you have a serious allergy.

Common allergens that can cause anaphylaxis include:

• Certain foods – these can include things like peanuts, tree nuts, shellfish and eggs. These are known as food allergies.
• Insect bites and stings – there are certain insects whose bites or stings are commonly associated with allergies, including bees, wasps, mosquitos, fire ants, bedbugs, ticks and fleas.
• Certain medications – allergic reactions to different medications can vary widely, and people may react differently to the same medication. People may be allergic to standard painkillers or antibiotics.

Symptoms of anaphylaxis happen very quickly and include:

• Swelling of the throat and tongue.
• Difficulty breathing or breathing very fast.
• Wheezing, coughing or noisy breathing.
• Difficulty swallowing or tightness in the throat.
• Feeling faint, dizzy or fainting.
• Becoming unconscious.
• Feeling tired or experiencing confusion.
• Skin that feels cold to the touch.
• Blue, grey or pale lips or face.
• A drop in blood pressure.

If you suspect someone is experiencing anaphylaxis, you should follow these steps:

• Call an ambulance immediately.
• Administer an adrenaline auto-injector, if available. This is sometimes called an EpiPen. You should use it as directed, which usually involves injecting the person into the outer thigh and holding it in place for 10 seconds.
• If their symptoms have not improved after 5 minutes, use a second adrenaline auto-injector.
• Lie the person down and elevate their legs.
• Stay with the person and monitor their breathing.
• Do not offer any food or drinks as this could potentially make their condition worse.
• Do not ask the person to stand or walk at any time, even if they feel better.
• If the person has been stung by an insect, try to remove the sting if it’s still in the skin
• Administer CPR if the person has stopped breathing or their heart has stopped.

There are certain risk factors for someone experiencing anaphylaxis. These include:

• Experiencing anaphylaxis before – if you have already experienced anaphylaxis, this makes it more likely that you will experience it again in the future. Future episodes may also be more severe.
• A family history of anaphylaxis – having a close family member who has experienced anaphylaxis makes it more likely that you will experience it again.
• Having allergies – having allergies makes it more likely that you will experience anaphylaxis.
• Your age – children and young adults may be at a higher risk of anaphylaxis, though it can occur at any age.
• Having asthma – the combination of asthma and anaphylaxis can lead to more serious respiratory symptoms.
• Having multiple allergen sensitivities – people with multiple allergies may be at an increased risk of anaphylaxis.
• A delay in administering an adrenaline auto-injector – there should be no delay in giving this if anaphylaxis is suspected. It is recommended that anyone at risk of anaphylaxis carries two EpiPens with them at all times.

Identifying common allergens

Common allergens that are known to cause anaphylaxis include:

• Food allergens – the most common food allergens include peanuts, almonds, walnuts, cashew nuts, shellfish, fish, milk, eggs, soy and wheat.
• Insect stings or bites – the most common are bee stings, wasp stings, mosquitos, bedbugs, hornets, fire ants, ticks and fleas.
• Medication – common medications are antibiotics, anti-inflammatory drugs, aspirin and certain vaccines.
• Latex – this is a form of rubber found in products like balloons, gloves and some medical equipment.
• Exercise-induced – some people may experience anaphylaxis during or after exercise, especially after the consumption of certain foods which could have triggered the reaction.
• Idiopathic anaphylaxis – this means that the cause is unknown or unidentifiable despite there being a thorough investigation. In idiopathic anaphylaxis, people can experience severe allergic reactions, including symptoms like difficulty breathing, swelling, and a drop in blood pressure, but the trigger remains unknown. This can be particularly difficult to manage in terms of future prevention.

Educating the public

Raising awareness and educating members of the public about anaphylaxis is crucial if there are going to be prompt and appropriate responses to this type of emergency scenario. Some important ways of doing this include:

• Create online resources that are as accessible as possible – creating a dedicated website or webpage with comprehensive information about anaphylaxis and also using social media platforms to raise awareness.
• Create other educational materials – this could include things like brochures, posters and pamphlets that explain what anaphylaxis is, what the symptoms are, what to do in an emergency and the importance of quick intervention.
• Work closely with local healthcare professionals – it is important that the information you are providing is accurate and the most up-to-date health information.
• Community events – this can provide direct information to people; you could hold workshops or information-sharing events.
• Training within workplaces – this will ensure that more workplaces are equipped with the right knowledge and training to be able to act in an emergency situation.
• Training within local schools – this could include training teachers, staff and students about anaphylaxis and the importance of acting quickly. The government also provide specific allergy guidance for schools.

Creating allergy-friendly environments

Creating allergy-friendly environments involves taking steps to minimise allergens and safeguard the people using the space who may have serious allergies. 

It is important to have a thorough understanding of the various food allergies that people may potentially have and which foods contain these allergens. This involves knowledge and education. Some ways that you can create an allergy-friendly environment include:

• Understanding and minimising cross-contamination.
• Cleaning regularly.
• Controlling mould
• Managing pet allergens.
• Having good ventilation.
• Choosing allergy-friendly furniture.
• Using hypoallergenic products.
• Educating other people who are using the space.
• Involving healthcare professionals in the process.

Creating an allergy-friendly environment is not only a legal and ethical responsibility for businesses but it is also a way to attract and retain a diverse group of customers. There are several ways in which businesses can contribute to creating such environments. These include:

• Having allergy training as standard – particularly in the food service industry, staff should be well-trained to handle food allergies and have a good understanding of the risks involved and cross-contamination issues. This includes chefs, servers and other kitchen staff.
• Ensuring menus follow the food labelling requirements and menu transparency – restaurants and other food establishments should provide clear and accurate information about the ingredients used in their food. This helps customers with food allergies make informed choices and feel safe in doing so.
• Hotels and other guest accommodation can provide hypoallergenic rooms with special bedding, air purifiers and other amenities to ensure they cater for guests with allergies.
• Implementing thorough and effective cleaning protocols in order to minimise allergens in the environment.
• Clear labelling of ingredients on food packaging. This is essential for consumers to easily identify potential allergens in the products they purchase.
• Offer allergen-free, alternative products.
• Event organisers at public events can take steps to ensure that events are allergy-friendly by offering allergen-free food options, providing information about allergens, and creating designated areas for the people attending who have allergies.
• Transport services can implement measures in order to minimise allergen exposure for passengers. This can include cleaning protocols and restrictions on certain allergenic products.
• Businesses can actively engage with the community to understand and address specific allergy concerns and needs.

Allergy UK work tirelessly to campaign for and support people living with allergies.  

Legal and policy considerations

The first-line emergency treatment for anaphylaxis is adrenaline auto-injectors. These are classified as an essential medicine by the World Health Organization (WHO) and as a life-saving treatment for anaphylaxis by the European Medicines Agency (EMA). However, this does not mean that it is mandatory to have the medication available in public spaces. 

For adults and children suffering from life-threatening allergic reactions to have available to them life-saving shots of adrenaline in public places, for example in restaurants and entertainment venues, would be such a positive step. This has come a step closer as a result of a report published by the government’s independent advisory body, the Commission on Human Medicines (CHM). In order for this to actually happen, it would require a change in legislation. The recommendations to have this in place have come from learning from inquests following fatalities from anaphylaxis. 

Success stories and best practices

Anaphylaxis is a condition that is under-recognised and under-treated. Early recognition of the condition and early treatment is vital in preventing anaphylactic shock and the life-threatening respiratory and/or cardiovascular symptoms. 

Some things to consider when thinking about being prepared for a case of anaphylaxis are to:

• Have a good understanding of anaphylaxis – this will involve education and training including the common triggers such as food allergies, insect stings and medication.
• Provide regular training – whether this is in a workplace or school, regular training will help people to feel prepared and confident in dealing with such cases.
• Ensure that people who are known to be at risk are supported – this will include being aware of any changes and gathering information about guests before an event takes place.
• Encourage workplaces and other public spaces to develop and implement an Anaphylaxis Policy – this should be done with the help of healthcare professionals who can advise accordingly. This should involve developing clear, step-by-step emergency response procedures including contacting the emergency services and parents or carers. Policies should be reviewed and updated regularly.

Creating public spaces that take steps to reduce the risk of anaphylaxis can have positive impacts on people with severe allergies and for the community as a whole. These can include:

• Creating a safe environment for people with allergies – by implementing safety measures to reduce the risk of anaphylaxis, such as providing allergen-free zones or clearly labelling allergens in food establishments, the chances of accidental exposure decrease.
• Being prepared for an emergency situation – by taking steps to prevent anaphylaxis in public spaces, it contributes to better emergency preparedness. In the event of a severe allergic reaction, the availability of trained staff, emergency response equipment, such as adrenaline auto-injectors, and clear emergency protocols can improve the chances of an effective response.
• Benefits for the business – by demonstrating that you are prioritising customers with allergies, it will be positive for your reputation and is likely to attract a diverse group of customers.

Many organisations particularly in the food catering industry and healthcare industry take positive steps to cater for people with allergies, therefore reducing the risk of anaphylaxis. This includes things such as:

• Allergen training.
• Allergen information on menus.
• Staff being expected to communicate with customers about their allergies.

In schools and educational establishments there are some important ways that they are reducing anaphylaxis risks. These include:

• Having a good understanding of anaphylaxis – this involves education and training including knowledge about the common triggers. If there are students within school who have severe allergies, it is important that staff are aware of who these children are and have a good understanding of their condition. School staff should be educated about anaphylaxis, its causes, symptoms and the importance of prompt intervention.
• Providing regular training for school staff on recognising anaphylaxis symptoms and administering epinephrine.
• Educating other students – ensuring that students are aware of their classmates who are at risk and the importance of not sharing food in these circumstances. It is important that students know how to seek help in an emergency situation.
• Maintaining up-to-date records – keeping staff up to date with any changes.
• Supporting students who are at risk – this should involve working closely with parents, healthcare providers and students of those at risk of anaphylaxis. This should also involve creating individualised care plans, which should include triggers, symptoms and emergency contact information as well as clearly outlining the steps for prevention and an emergency response.
• Developing and implementing an anaphylaxis policy – this should be done with the help of healthcare professionals who can advise you accordingly. Develop clear, step-by-step emergency response procedures including contacting the emergency services and parents or carers. You should review and update policies regularly and periodically review and update the school’s anaphylaxis policies and procedures to incorporate any new information or changes in students’ health conditions.
• Ensuring that emergency medication is available – there should be a designated member of staff available at all times who has been trained to administer the medication.

Anaphylaxis UK also provide information and training for workplaces.