THE JOURNAL OF INFECTIOUS DISEASES. VOL. 139, NO.2. FEBRUARY 1979
From the National Institutes of Health Summary of a Consensus Development Conference on Emergency Treatment of Insect Sting Allergy The National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), convened a consensus development conference on the emergency treatment of insect sting allergy in Bethesda, Md., on September 14, 1978. This conference was one of a series of consensus development programs initiated by the NIH to make useful new findings more quickly available to clinicians. The process brings together authorities in many specialized areas to review recent findings and to reach agreement on the efficacy and safety of diagnostic and treatment approaches. Dr. Philip M. Gottlieb, Clinical Associate Professor of Medicine, Emeritus, of Temple University School of Medicine in Philadelphia, Pa., chaired a panel made up of physicians, nurses, emergency technicians, educators, and lawyers. The panel heard invited speakers describe insect behavior; the epidemiology, diagnosis, and treatment of insect sting allergy; the pharmacology of epinephrine; and the legal aspects of emergency treatment. Brief position papers were presented by representatives from several interested national organizations. Excerpts from letters from a number of national, regional, and local allergy societies, sent in response to a request for opinions, were read. The panel then evaluated the availability and effectiveness of treatment presently administered by health care professionals and others. This report summarizes the presentations heard by the panel.
Epidemiology and Treatment of Insect Sting Allergy
Dr. Robert E. Reisman, Buffalo General Hospital, N.Y., cited retrospective studies that suggest that 0.4% of the population have anaphylactic reactions due to stinging insects. Most reactions occur in males younger than 20 years, although fatalities most often occur in adults older than 40 years. Every year 50-100 persons in this country are reported to have died as a result of reactions to stings, although the actual number may be even higher. For most individuals there are no criteria to predict occurrence of anaphylaxis. A person's previous reaction to an insect sting is not a reliable indicator of the severity of future reactions. Finally, Dr. Reisman observed that comparisons of patients with fatal and nonfatal anaphylaxis suggest that epinephrine is the appropriate medical therapy and that the earlier the drug is administered, the better the outcome. Dr. Martin D. Valentine, Associate Professor of Medicine at the Johns Hopkins University School of Medicine, agreed that prompt treatment of generalized reactions to stings is essential and that epinephrine is the drug, and injection the route, of choice. He explained that serious, generalized reactions to Hymenoptera stings are mediated by antibodies of the IgE class and are secondary to sensitization
Behavior of Insects
Dr. Allen W. Benton, Professor of Entomology at Pennsylvania State University, confirmed that most serious allergic reactions in humans are This article is in the public domain. Please address requests for reprints to Mr. RobertL. Schreiber, Office of Research Reporting and Public Response, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20014.
250
Downloaded from http://jid.oxfordjournals.org/ at University of Sussex on July 29, 2015
caused by certain kinds of stinging Hymenoptera insects, including bees, wasps, hornets, and yellow jackets, and by fire ants. Most stinging Hymenoptera can sting repeatedly. Only the honeybee has a barbed stinger that remains in the victim's skin as the bee flies away and dies. The yellow jacket, one of the most vicious stinging insects, is the most common cause of anaphylactic reactions. Dr. Benton commented that many more insects are found in suburban areas than in rural areas because of the greater availability of overwintering places in the suburbs. Methods for control include several effective bee-wasp-hornet sprays currently on the market. He also suggested pouring ammonia on ground nests at night and then covering the nests.
NIH News
Insect Sting Kits and Pharmacology of Epinephrine
Mr. M. W. Giboney, president of Hollister-Stier Company in Spokane, Wash., described the emergency treatment kits currently available to allergic persons with a physician's prescription. Kits are manufactured by two companies: Hollister-Stier and Nelco Laboratories. Each kit contains enough epinephrine for a normal adult dose. The kit also may contain an antihistamine, disinfecting swabs, a tourniquet, and detailed instructions to the patient. Both companies also recommend that the physician carefully explain to the patient how to use the kit. The kits from both companies are compact and designed to be carried by the patient. Dr. Harry Keiser, Clinical Director of the National Heart, Lung, and Blood Institute, discussed the pharmacology of epinephrine, stating that it was clearly the drug of choice in treating any serious systemic allergic reaction. However, epinephrine must be administered early, since it is less beneficial once a person is in anaphylactic shock. Epinephrine has several safety features, including limitation of its own absorption by induction of vasoconstriction. The only major precaution is that it not be administered intravascularly. Modern preparations remain stable for many years. When decomposition (or inactivation) does occur, the solution turns a distinctive pinkish-brown color and should be replaced. However, there is
no evidence that decomposition makes the solution more toxic. Dr. Claude Frazier, Asheville, N.C., proposed that an insect sting treatment kit containing premeasured doses of epinephrine be available to nonphysicians trained to recognize symptoms of systemic reactions to insect stings. He further proposed that such trained nonphysicians be authorized to inject premeasured epinephrine sc as emergency, on-the-spot treatment of victims of all forms of anaphylaxis, with or without specific authorization of a physician. He reemphasized the importance of prompt treatment to stave off potentially fatal anaphylaxis long enough to transport the victim to a physician or hospital for further necessary medical treatment. Legal Considerations
Dr. Richard A. Nicklas, Bureau of Drugs, Food and Drug Administration, agreed thathypersensitivity to insect stings is a significant medical problem. He recommended that all allergic persons obtain treatment kits from their physicians and that special individuals be trained to administer epinephrine under certain circumstances. Dr. Nicklas did not consider it advisable or necessary to make injectable epinephrine available without a physician's prescription. Mr. Kenneth Wing, School of Law, University of North Carolina, and Dr. George A. Sprecace, an allergist from New London, Conn., both commented on the legal aspects. Dr. Sprecace described his long and eventually successful efforts for specific state laws exempting teachers and other school personnel from liability when they administer emergency treatment to allergic persons. Mr. Wing commented that, at the present time, most state laws probably do not prohibit use of the treatment kit by trained nonmedical personnel. These persons would be protected from liability under so-called Good Samaritan laws. An important factor to consider before introduction of new legislation is that any law which might be introduced to alter the State Medical Practices Act is likely to meet considerable organized opposition more because it would change existing law than because of the specific issue involved.
Downloaded from http://jid.oxfordjournals.org/ at University of Sussex on July 29, 2015
to specific antigens that he believes are found in the venoms of these insects. Immunotherapy can build up protective, or blocking, antibodies of the IgG class. Dr. Valentine believes, on the basis of experimental studies, that relevant antigens are contained in venom and not in insect bodies. Therefore, he recommended that the materials most suitable for diagnosis and therapy are those that contain the greatest amount of venom protein and the least amount of insect body contaminants. At the present time, only honeybee venom is available for testing. The preparations currently in general use for testing and immunotherapy are whole body extracts of Hymenoptera. Dr. Valentine confirmed Dr. Reisman's assertion that data do not exist that allow prediction of the risk of anaphylaxis in patients who have positive skin tests but no history of reactions.
251
Gottlieb
252
Panel Recommendations
PHILIP
M. GOTTLIEB
Clinical Associate Professor of Medicine} Emeritus Temple University School of Medicine Philadelphia} Pennsylvania
Downloaded from http://jid.oxfordjournals.org/ at University of Sussex on July 29, 2015
After considering all the information presented, the panel made the following recommendations. The panel recognized that everyone is a potential victim of life-threatening or fatal allergic reactions from stinging insects. Although valid data regarding the incidence of these occurrences are not available at this time, the data presented to the panel suggested that such allergic reactions occur wi~h ~eate~ fre~uency than is generally thought. Pnor identification of those individuals who will so react is difficult. Better education of the lay and professional populations will improve docu~entat~on of these events and tend to promote immediate and effective medical treatment, which can prevent the majority of fatalities. Efforts to reduce the size of the problem require two approaches. The educational approach entails instructing both laypeople and professionals on the dangers of insect stings and on the means to treat them. The service approach entails increasing the availability of treatment-to the maximal ext~nt permitted by law-by allowing and en~ouragmg all personnel who are properly trained to administer such emergency treatment at the site of the emergency. The belief that certain individuals are restricted from providing treatment may be based less on the applicable law than on misunderstanding of ~he stat.e of law in this area. Given the objective of mcreasmg the availability of emergency treatment, the panel encourages evaluation of the legal risks, placing them in proper perspective. Teaching films and written materials for the lay public should be developed and distributed to help promote recognition of the problem of anaphylactic reactions to insect stings and to make known the available therapeutic regimens. These materials should be disseminated by interested o.rganizations such as school and parent organizanons, youth groups, farmers, and industrial and labor organizations as well as other groups whose members are at high risk. Persons who have had ~ller~ic reactions to insect stings are urged to identify their sensitivity to others; for example, they should have such information with them, in writing, at all times.
Education of physicians should include information on emergency management of systemic reactions, emergency drugs, and the use of immunotherapy (hyposensitization). Physicians and o.ther health care personnel should instruct patI~nts about the importance of avoiding insect stmg~ and about the treatment of life-threatening reactions to such stings. Warnings should be given about the possibility of adverse drug interactions between epinephrine and other drugs. The panel considered and rejected the option of making i~sect sting treatment kits, containing a pr.edetermmed dose of epinephrine for injection, available without a physician's prescription. In the absence of individualized instruction for use of the kit, the panel believes there is considerable P?t~ntial f~r inappropriate use of the kit by individuals with hypertension or certain cardiovascular diseases, or by those who are taking certain medications. The panel believes these concerns would not be addressed adequately by labels or printed instructions that might be required for an over-the-counter item. The potential for drug abuse with such kits was also of great concern. Research is needed to determine whether there may be other drugs and/or modes of administration that would be more effective and safer than those currently in use. Panel members included Dr. Gottlieb, Dr. James Ford, New York, N.Y., Ms. Jessie M. Smallwood, New Orleans, La., Ms. Virginia Rosenb~um, Chevy Chase, Md., Mr. Nathan Hershey, P~tts~urgh, Pa., Ms. Carolyn Whitaker, Tompkinsville, Ky., Dr. Francis C. Lowell, Boston, Mass., Mr. Michael R. Pollard, Washington, D.C., Dr. Robert J. Brennan, Fort Lauderdale, Fla., Dr. Donald E. Cook, Greeley, Colo., Dr. Robert J. Dockhorn, Prairie Village, Kans., Dr. William E. Pierson, Seattle, Wash., Dr. J. Warrick Thomas, Richmond, Va., Capt. Mary Beth Michos, Rockville, Md., Dr. William Waddell, Jr., Galax, Va., and Dr. August Watanabe, Indianapolis, Ind.
From the National Institutes of Health Summary of a Consensus Development Conference on Emergency Treatment of Insect Sting Allergy The National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), convened a consensus development conference on the emergency treatment of insect sting allergy in Bethesda, Md., on September 14, 1978. This conference was one of a series of consensus development programs initiated by the NIH to make useful new findings more quickly available to clinicians. The process brings together authorities in many specialized areas to review recent findings and to reach agreement on the efficacy and safety of diagnostic and treatment approaches. Dr. Philip M. Gottlieb, Clinical Associate Professor of Medicine, Emeritus, of Temple University School of Medicine in Philadelphia, Pa., chaired a panel made up of physicians, nurses, emergency technicians, educators, and lawyers. The panel heard invited speakers describe insect behavior; the epidemiology, diagnosis, and treatment of insect sting allergy; the pharmacology of epinephrine; and the legal aspects of emergency treatment. Brief position papers were presented by representatives from several interested national organizations. Excerpts from letters from a number of national, regional, and local allergy societies, sent in response to a request for opinions, were read. The panel then evaluated the availability and effectiveness of treatment presently administered by health care professionals and others. This report summarizes the presentations heard by the panel.
Epidemiology and Treatment of Insect Sting Allergy
Dr. Robert E. Reisman, Buffalo General Hospital, N.Y., cited retrospective studies that suggest that 0.4% of the population have anaphylactic reactions due to stinging insects. Most reactions occur in males younger than 20 years, although fatalities most often occur in adults older than 40 years. Every year 50-100 persons in this country are reported to have died as a result of reactions to stings, although the actual number may be even higher. For most individuals there are no criteria to predict occurrence of anaphylaxis. A person's previous reaction to an insect sting is not a reliable indicator of the severity of future reactions. Finally, Dr. Reisman observed that comparisons of patients with fatal and nonfatal anaphylaxis suggest that epinephrine is the appropriate medical therapy and that the earlier the drug is administered, the better the outcome. Dr. Martin D. Valentine, Associate Professor of Medicine at the Johns Hopkins University School of Medicine, agreed that prompt treatment of generalized reactions to stings is essential and that epinephrine is the drug, and injection the route, of choice. He explained that serious, generalized reactions to Hymenoptera stings are mediated by antibodies of the IgE class and are secondary to sensitization
Behavior of Insects
Dr. Allen W. Benton, Professor of Entomology at Pennsylvania State University, confirmed that most serious allergic reactions in humans are This article is in the public domain. Please address requests for reprints to Mr. RobertL. Schreiber, Office of Research Reporting and Public Response, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20014.
250
Downloaded from http://jid.oxfordjournals.org/ at University of Sussex on July 29, 2015
caused by certain kinds of stinging Hymenoptera insects, including bees, wasps, hornets, and yellow jackets, and by fire ants. Most stinging Hymenoptera can sting repeatedly. Only the honeybee has a barbed stinger that remains in the victim's skin as the bee flies away and dies. The yellow jacket, one of the most vicious stinging insects, is the most common cause of anaphylactic reactions. Dr. Benton commented that many more insects are found in suburban areas than in rural areas because of the greater availability of overwintering places in the suburbs. Methods for control include several effective bee-wasp-hornet sprays currently on the market. He also suggested pouring ammonia on ground nests at night and then covering the nests.
NIH News
Insect Sting Kits and Pharmacology of Epinephrine
Mr. M. W. Giboney, president of Hollister-Stier Company in Spokane, Wash., described the emergency treatment kits currently available to allergic persons with a physician's prescription. Kits are manufactured by two companies: Hollister-Stier and Nelco Laboratories. Each kit contains enough epinephrine for a normal adult dose. The kit also may contain an antihistamine, disinfecting swabs, a tourniquet, and detailed instructions to the patient. Both companies also recommend that the physician carefully explain to the patient how to use the kit. The kits from both companies are compact and designed to be carried by the patient. Dr. Harry Keiser, Clinical Director of the National Heart, Lung, and Blood Institute, discussed the pharmacology of epinephrine, stating that it was clearly the drug of choice in treating any serious systemic allergic reaction. However, epinephrine must be administered early, since it is less beneficial once a person is in anaphylactic shock. Epinephrine has several safety features, including limitation of its own absorption by induction of vasoconstriction. The only major precaution is that it not be administered intravascularly. Modern preparations remain stable for many years. When decomposition (or inactivation) does occur, the solution turns a distinctive pinkish-brown color and should be replaced. However, there is
no evidence that decomposition makes the solution more toxic. Dr. Claude Frazier, Asheville, N.C., proposed that an insect sting treatment kit containing premeasured doses of epinephrine be available to nonphysicians trained to recognize symptoms of systemic reactions to insect stings. He further proposed that such trained nonphysicians be authorized to inject premeasured epinephrine sc as emergency, on-the-spot treatment of victims of all forms of anaphylaxis, with or without specific authorization of a physician. He reemphasized the importance of prompt treatment to stave off potentially fatal anaphylaxis long enough to transport the victim to a physician or hospital for further necessary medical treatment. Legal Considerations
Dr. Richard A. Nicklas, Bureau of Drugs, Food and Drug Administration, agreed thathypersensitivity to insect stings is a significant medical problem. He recommended that all allergic persons obtain treatment kits from their physicians and that special individuals be trained to administer epinephrine under certain circumstances. Dr. Nicklas did not consider it advisable or necessary to make injectable epinephrine available without a physician's prescription. Mr. Kenneth Wing, School of Law, University of North Carolina, and Dr. George A. Sprecace, an allergist from New London, Conn., both commented on the legal aspects. Dr. Sprecace described his long and eventually successful efforts for specific state laws exempting teachers and other school personnel from liability when they administer emergency treatment to allergic persons. Mr. Wing commented that, at the present time, most state laws probably do not prohibit use of the treatment kit by trained nonmedical personnel. These persons would be protected from liability under so-called Good Samaritan laws. An important factor to consider before introduction of new legislation is that any law which might be introduced to alter the State Medical Practices Act is likely to meet considerable organized opposition more because it would change existing law than because of the specific issue involved.
Downloaded from http://jid.oxfordjournals.org/ at University of Sussex on July 29, 2015
to specific antigens that he believes are found in the venoms of these insects. Immunotherapy can build up protective, or blocking, antibodies of the IgG class. Dr. Valentine believes, on the basis of experimental studies, that relevant antigens are contained in venom and not in insect bodies. Therefore, he recommended that the materials most suitable for diagnosis and therapy are those that contain the greatest amount of venom protein and the least amount of insect body contaminants. At the present time, only honeybee venom is available for testing. The preparations currently in general use for testing and immunotherapy are whole body extracts of Hymenoptera. Dr. Valentine confirmed Dr. Reisman's assertion that data do not exist that allow prediction of the risk of anaphylaxis in patients who have positive skin tests but no history of reactions.
251
Gottlieb
252
Panel Recommendations
PHILIP
M. GOTTLIEB
Clinical Associate Professor of Medicine} Emeritus Temple University School of Medicine Philadelphia} Pennsylvania
Downloaded from http://jid.oxfordjournals.org/ at University of Sussex on July 29, 2015
After considering all the information presented, the panel made the following recommendations. The panel recognized that everyone is a potential victim of life-threatening or fatal allergic reactions from stinging insects. Although valid data regarding the incidence of these occurrences are not available at this time, the data presented to the panel suggested that such allergic reactions occur wi~h ~eate~ fre~uency than is generally thought. Pnor identification of those individuals who will so react is difficult. Better education of the lay and professional populations will improve docu~entat~on of these events and tend to promote immediate and effective medical treatment, which can prevent the majority of fatalities. Efforts to reduce the size of the problem require two approaches. The educational approach entails instructing both laypeople and professionals on the dangers of insect stings and on the means to treat them. The service approach entails increasing the availability of treatment-to the maximal ext~nt permitted by law-by allowing and en~ouragmg all personnel who are properly trained to administer such emergency treatment at the site of the emergency. The belief that certain individuals are restricted from providing treatment may be based less on the applicable law than on misunderstanding of ~he stat.e of law in this area. Given the objective of mcreasmg the availability of emergency treatment, the panel encourages evaluation of the legal risks, placing them in proper perspective. Teaching films and written materials for the lay public should be developed and distributed to help promote recognition of the problem of anaphylactic reactions to insect stings and to make known the available therapeutic regimens. These materials should be disseminated by interested o.rganizations such as school and parent organizanons, youth groups, farmers, and industrial and labor organizations as well as other groups whose members are at high risk. Persons who have had ~ller~ic reactions to insect stings are urged to identify their sensitivity to others; for example, they should have such information with them, in writing, at all times.
Education of physicians should include information on emergency management of systemic reactions, emergency drugs, and the use of immunotherapy (hyposensitization). Physicians and o.ther health care personnel should instruct patI~nts about the importance of avoiding insect stmg~ and about the treatment of life-threatening reactions to such stings. Warnings should be given about the possibility of adverse drug interactions between epinephrine and other drugs. The panel considered and rejected the option of making i~sect sting treatment kits, containing a pr.edetermmed dose of epinephrine for injection, available without a physician's prescription. In the absence of individualized instruction for use of the kit, the panel believes there is considerable P?t~ntial f~r inappropriate use of the kit by individuals with hypertension or certain cardiovascular diseases, or by those who are taking certain medications. The panel believes these concerns would not be addressed adequately by labels or printed instructions that might be required for an over-the-counter item. The potential for drug abuse with such kits was also of great concern. Research is needed to determine whether there may be other drugs and/or modes of administration that would be more effective and safer than those currently in use. Panel members included Dr. Gottlieb, Dr. James Ford, New York, N.Y., Ms. Jessie M. Smallwood, New Orleans, La., Ms. Virginia Rosenb~um, Chevy Chase, Md., Mr. Nathan Hershey, P~tts~urgh, Pa., Ms. Carolyn Whitaker, Tompkinsville, Ky., Dr. Francis C. Lowell, Boston, Mass., Mr. Michael R. Pollard, Washington, D.C., Dr. Robert J. Brennan, Fort Lauderdale, Fla., Dr. Donald E. Cook, Greeley, Colo., Dr. Robert J. Dockhorn, Prairie Village, Kans., Dr. William E. Pierson, Seattle, Wash., Dr. J. Warrick Thomas, Richmond, Va., Capt. Mary Beth Michos, Rockville, Md., Dr. William Waddell, Jr., Galax, Va., and Dr. August Watanabe, Indianapolis, Ind.
