Stock epinephrine improves school allergy safety, nurse survey finds

Schools that do not keep stock epinephrine on hand were more than 4 times as likely as those that do to report having no epinephrine available during an allergic emergency, according to a national survey of school nurses presented at the American College of Allergy, Asthma and Immunology (ACAAI) 2026 Annual Scientific Meeting in Phoenix, Arizona.¹

"Our findings show that having stock epinephrine available at school clearly improves student safety," said lead study author Mahi Singh, MD, a member of ACAAI, "since schools without it were far more likely to end up without a working device in an emergency."¹

School nurse survey on stock epinephrine availability and use

The cross-sectional survey, "Epinephrine Utilization and Management in Schools: A National Survey of School Nurses," was sent to 1847 US school nurses between August and December 2025.¹ A total of 349 nurses completed it, each representing a single school.¹

Overall, 87% of responding schools kept stock epinephrine, yet 74% still required students with known food allergy to supply a personal device.¹ Most nurses (74%) preferred this "dual coverage" approach, whereas 27% said stock epinephrine alone would be sufficient.¹

Epinephrine use was uncommon: 72% of schools reported that no student needed epinephrine in the past year.¹ However, 10% of nurses reported that epinephrine was unavailable during an actual allergic emergency, and schools without a stock supply were more than 4 times as likely to report that gap.¹ Confidence intervals and adjusted estimates were not included in the meeting release.

Cost burden of personal epinephrine autoinjectors for families

According to the investigators, families of children with food allergy often buy a new device for school each year, even though it frequently goes unused and expires.¹ "That can be expensive for families and limit accessibility outside school hours compared to backpack storage," Singh said.¹

Earlier economic modeling points in the same direction. In a 2019 cost-effectiveness analysis, a universal stock model, in which schools supply epinephrine and students do not need dedicated school devices, produced better outcomes at lower cost than either no stock supply or stock used as a supplement to personal devices.⁴ That model estimated savings of $7419 per at-risk student who would otherwise be prescribed an individual school supply.⁴ The supplemental model was cost-effective only when annual school acquisition costs stayed at or below $338 per school.⁴

Pediatric food allergy burden and state stock epinephrine laws

Food allergy affects an estimated 7.6% of US children, and 42.3% of children with food allergy report at least 1 severe reaction.² Because a first reaction can occur at school, a child may have no personal device on hand when anaphylaxis begins.

All 50 states and the District of Columbia permit schools to stock undesignated epinephrine, but state laws vary widely in procurement, training, administration, and liability provisions.³ According to ACAAI, only 10 states require schools to keep it.¹

Interpreting school nurse preferences for dual epinephrine coverage

The survey suggests a tension. Nurses reported that stock epinephrine closes access gaps, yet most still favor having personal devices as well, which suggests they see stock supply as a safety net rather than a replacement. The researchers say their findings support wider adoption of stock epinephrine programs in schools.¹

For pediatricians, the results do not change the standard of prescribing epinephrine autoinjectors and maintaining an anaphylaxis action plan for each child with food allergy. They may, however, inform conversations with families and schools about local stock policies and whether a separate school device is needed.

Limitations of the school epinephrine survey and next steps

Roughly 19% of nurses contacted completed the survey, raising the possibility of response bias. Data were self-reported, and the release did not describe school type, region, or nurse staffing, all of which may affect epinephrine access. The cross-sectional design can show an association between lacking stock epinephrine and device unavailability but cannot establish cause. Findings were presented as a meeting abstract and have not yet appeared in a peer-reviewed journal.

Prospective studies comparing outcomes and costs of stock-only and dual-coverage policies would help clarify whether personal school devices can safely be phased out.

References

1. American College of Allergy, Asthma and Immunology. School nurses find stock epinephrine improves safety of students with severe allergies. News release. November 12, 2026. Accessed November 13, 2026. https://acaai.org/news/school-nurses-find-stock-epinephrine-improves-safety-of-students-with-severe-allergies/
2. Gupta RS, Warren CM, Smith BM, et al. The public health impact of parent-reported childhood food allergies in the United States. Pediatrics. 2018;142(6):e20181235. doi:10.1542/peds.2018-1235
3. Volerman A, Brindley C, Amerson N, Pressley T, Woolverton N. A national review of state laws for stock epinephrine in schools. J Sch Health. 2022;92(2):209-222. doi:10.1111/josh.13119
4. Shaker MS, Greenhawt MJ. Analysis of value-based costs of undesignated school stock epinephrine policies for peanut anaphylaxis. JAMA Pediatr. 2019;173(2):169-175. doi:10.1001/jamapediatrics.2018.4275