In December 2015, Ministerial Order No. 706 (the Order) was released. The Order came into effect on January 1, 2016 and states that any Victorian school with enrolled student/s at risk of anaphylaxis is required by law to have a School Anaphylaxis Management Policy (Policy). Two weeks ago, the Victorian Department of Education and Training provided greater detail, releasing Anaphylaxis Guidelines: A resource for managing severe allergies in Victorian schools which are to be read alongside the Order.

Ministerial Order 706: An overview

Overall the Order discusses the following concepts:

• Policy - a school's Policy must state that it complies with the Order and a number of requirements listed below;
• Individual Management Plans - the principal is responsible for developing Individual Management Plans for at-risk students. These plans must be in place as soon as practicable after an at-risk student enrols and where possible before the student's first day of attendance at the school. The plan must include details about the student's condition and strategies to reduce the risk of exposure to known allergens;
• Prevention strategies - a school's Policy must include prevention strategies designed to lower the risk of incidents occurring;
• School management and emergency response - a school's Policy must outline how the school's first aid policy and emergency response protocols integrate with its anaphylaxis procedures. A school must be able to identify at-risk students, locate Individual Management Plans and ASCIA Plans, determine the location of adrenaline auto-injectors, and provide a summary of the Communication Plan. The Policy must state that a sufficient number of suitably qualified teachers must be present when at-risk students are outside of normal class activities;
• Adrenaline auto-injectors for general use - a school's Policy must include a plan for the purchase of, and upkeep of adrenaline auto-injectors;
• Communication Plan - a school's Policy must include strategies to advise parents, staff, and students of the risk of anaphylaxis, and the ways in which schools and the community should react to incidents of anaphylaxis;
• Staff training - a school's Policy must include the requisite training for teachers and state the requirements for briefings; and
• Annual Risk Management Checklist - the Principal must complete an Annual Risk Management Checklist.

Updates to Ministerial Order No. 706

The updated Order has introduced, most importantly, requirements regarding staff training. Staff must undertake 'face to face anaphylaxis training' or 'online anaphylaxis management training'.

Acceptable 'face to face training' under the Order includes training that is:

• accredited as a VET course;
• accredited under Section 4 of the Education and Training Reform Act 2006 (Vic) by the VRQA;
• endorsed and delivered by a tertiary level specialist allergy service within a tertiary level academic teaching hospital; or
• any other course approved and advertised by the Department of Education and Training.

An 'online anaphylaxis training course' means the ASCIA Anaphylaxis e-training for Victorian schools course developed by ASCIA and approved by the Department.

Courses must include an adrenaline auto-injector competency test. 

Ultimately, it is every school's responsibility to keep its staff up to date with anaphylaxis training.

The Guidelines 

The Guidelines build upon the framework set out by the Order. Going beyond the Order, the Guidelines outline the responsibilities of principals, staff, anaphylaxis supervisors and parents/carers. In the Guidelines, there are specific sections that deal with the requirements for principals, staff, anaphylaxis supervisors and parents/carers.

It is the duty of principals to:

• ensure there is an updated Policy;
• identify at-risk students;
• ensure parents provide an ASCIA Action Plan;
• oversee food handling in school canteens;
• monitor the upkeep of personal and general use auto-injectors;
• oversee training of staff;
• review the Policy at staff meetings;
• oversee the creation of an annual review of Individual Anaphylaxis Management Plans; and
• ensure the Communication Plan and Risk Management Checklist are monitored.

The role and responsibilities of staff generally are to follow the recommendations of the principal, be aware of and follow all of the Policy's procedures and flag any compliance issues with the principal or the anaphylaxis supervisor.

The role and responsibilities of anaphylaxis supervisors are to ensure training is provided, twice yearly briefings are conducted and that the Principal and staff are driving the requirements of the Policy and Individual Anaphylaxis Management Plans.

The role and responsibilities of parents/carers of at-risk children are to inform the school of any diagnosis, provide an up to date photo as well as maintain a supply of personal adrenaline auto-injectors and participate in reviews of their child's Individual Anaphylaxis Management Plan.

The Guidelines now specify that a school's Policy should be available on the school's website.

Anaphylaxis: A risk management approach

From a risk management perspective, the outcome of an anaphylactic shock incident is catastrophic; in that, it can result in the death of a child. In March 2007 one school encountered the catastrophic result of mismanagement. While on school camp, a 13-year-old student went into anaphylactic shock after ingesting peanuts as part of a beef satay meal. By the time an EpiPen was administered, his condition had worsened and he died soon after. The Coroner's inquest found that the school failed in its duty of care towards the student in not mitigating the risk of anaphylactic shock. The Coroner said that the school had failed to properly avail itself of readily available information regarding anaphylaxis and in particular anaphylaxis related to peanut allergy.

In order to manage the risk of anaphylaxis, schools should implement a clear and comprehensive policy and accompanying procedures that adhere to the school's Individual Anaphylaxis Management Plans, and comply with a Risk Management Checklist. By taking these actions, schools will significantly reduce the likelihood of a catastrophic incident from eventuating.

Generic Adrenaline Auto-injector to be released

At present, there are few competitors to adrenaline auto-injector product EpiPen by Mylan. Yesterday, it was reported that New York's Attorney General, Eric Schneiderman, has launched an anti-trust probe into Mylan's EpiPen contracts. The cost of auto-injectors is a major issue for parents of at-risk students and schools as the injectors must be replaced annually or when they lose efficacy. This is particularly important for students in the United States where there are no government subsidies on the product. However, in recent news, Mylan is set to introduce a generic branded EpiPen. The product will be available for half of the current cost price. These reports come following criticism of the global pharmaceutical company's price hike on its branded product in the United States. Bernie Sanders, former candidate for the White House in this year's US election, has attacked Mylan for its prices, tweeting that the product has increased by 500 per cent of its starting price of $57 USD in 2007.

It is hoped that further pressure on the pharma-giant will push down the price and ease the burden on parents and schools.

Summary

Anaphylaxis is a life-threatening condition. An allergen does not need to be consumed in a high quantity for the dose to cause a lethal anaphylactic reaction. The critical issue schools face is how to react in an emergency. The new Guidelines have updated staff training requirements which the Victorian Department of Education and Training sees as integral to the management of anaphylaxis in schools. If the Principal and supervisors have briefed staff twice annually and staff adhere to the Policy, the risk of an incident is radically reduced - and in the rare event of an incident occurring, the school will be able to draw the attention of regulators or the court to its compliance.