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Jane Salter MD, Saral Mehra1, James T. Cairns MD, Gordon Sussman MD, Peter Vadas MD PhD
A few well-publicized Ontario deaths in the early 1990's drew significant attention to anaphylaxis and, in particular, emphasized the potential lethality of peanut and tree nut allergies. This led to awareness programmes for and by schools, restaurants, food manufacturers, physicians and patients.
We wanted to:
- See if these awareness programmes had had a positive impact on the subsequent incidence and patterns of food-related anaphylaxis deaths
- Gather information that would help prevent future deaths
- Study the evidence that surrounded these deaths in order to debunk common anaphylaxis myths
We conducted a retrospective chart review through the Office of the Chief Coroner for Ontario where we were able to examine charts from 1986 onward.
Findings:
Of 63 confirmed anaphylaxis deaths, 32 were food-related, 21 were due to bee sting and 10 were due to medication.
Allergens:
Peanut and tree nut represented 20/32 of the food allergens, followed by seafood (3/32), milk, sesame, sulphite and beer (1/32 each). In 3/32 cases, the allergen was undetermined.
Time Trends:
While there was a slight suggestion that reports of food-related anaphylaxis deaths had declined during the study period and that reports of insect sting related deaths had risen, the entry parameters of the study group were too biased and the sample sizes too small to justify statistical analysis. The incidents were scattered throughout the year with no apparent seasonal grouping.
Demographics:
There were 17 females and 15 males. Significant age differences were noted between the following three subgroups: peanut/tree nut deaths (n=20) (9-39 yrs, mean = 21.7 yrs), other food deaths (n=12) (17-78 yrs, mean = 41.2 yrs) and insect sting (n=21) (26-74 years, mean = 54.6 yrs) (p<0.0001).
Previous History:
Of the food allergic group, 30/32 people had either known that they were food allergic, or had felt unwell after eating certain foods, yet 5/30 had never reported symptoms to their physician. Where previous reactions were described, 6 were listed as 'mild', 1 'moderate', and 7 'severe'. Definitions for these designations were not included in the coroner's report. 2/6 people who died from ingestion of tree nut allergen knew that they were allergic to peanut but had not been tested for tree nuts.
Epinephrine:
Only 11/32 patients had been prescribed epinephrine. 4/11 had it "close by" at the time of reaction and one formulation was 2 years expired. It was difficult to determine the exact timing of epinephrine administration. Two patients died while running to get epinephrine that was within a 100-200 foot radius. Only 8/32 received epinephrine prior to arrival in the emergency room. One had refused to carry epinephrine despite a history of severe reactions and one felt that that they could not afford it.
Where did the deaths occur? What were the food sources?
10/31 reactions occurred at home, including 4/20 peanut reactions. Of the 19/31 that occurred away from home; 12 occurred in restaurants and hotels and 6 in camps or schools. The most encouraging finding was that we did not see a report of death in an Ontario school or camp following 1994.
What were the circumstances surrounding the deaths?
We were able to gather sufficient data to study 24 cases. Of note, the commonest mistakes included failure to read the food label / menu or ask about ingredients (n=11/24). All fatalities involved actual ingestion of food.
Were there any other contributing factors?
Asthma was mentioned in 22/32 cases.
Autopsy Reports and Cause of Death:
An autopsy had been performed on 20/32 patients. A MedicAlert̉ bracelet was mentioned in only two of the autopsy reports. The cause of death was listed as respiratory in 30/32 cases and cardiovascular in 2/32 (ages 22 and 30 yrs).
Conclusions:
Heightened awareness amongst Ontario schools and camps may have led to greater safety for food allergic children. Individuals, however, are still at risk. Most of the deaths in this study were preventable. Key elements that could help to prevent future deaths include the following:
- Patients with even mild reactions to food should be referred to an allergist for accurate diagnosis
- Patients with allergies to peanut or tree nuts should all be considered at risk for anaphylaxis
- Peanut allergic individuals should be informed that they could also be allergic to tree nuts
- Epinephrine should be prescribed for all patients who are considered at risk for anaphylaxis and patients should be encouraged to carry it with them at all times
- Patient education about allergen avoidance is a top priority
- Greater anaphylaxis education is needed amongst primary care physicians
There is also a need to establish a formal Canadian registry of anaphylaxis deaths through each provincial coroner's office.
Last date modified on Friday, July 18, 2003
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