The tragic death of a Pembroke teen sparks a campaign to make high schools safer for pupils with deadly food allergies. Ian Macleod reports.
Ian Macleod
The Ottawa Citizen
September 18, 2004
The day before she died, Sabrina Shannon rose early for a breakfast of bacon, toast and orange juice. Her mother was in the kitchen preparing a school lunch with a plain, milk-free English muffin and a slice of Maple Leaf ham. It was a Monday, the end of Sabrina's first month in Grade 8 at Pembroke's Bishop Smith Catholic High.
"Mom, I'm not eating that sandwich," Sabrina protested. "I can eat french fries" from the school cafeteria. "I ate them on Friday. It's OK, I checked. I can eat those french fries."
Sara Shannon resisted. Her only child had food anaphylaxis, a life-threatening allergic condition triggered by certain foods. In Sabrina's case, trace amounts of peanuts, soy protein and dairy products could kill her. She also suffered from asthma, which typically makes anaphylactic children far more susceptible to severe allergic reactions.
Sabrina had eaten french fries before, but because allergies severely restricted her diet, her mother wanted what she could eat to be nutritious. Fries had always been limited to a Friday-night treat at McDonald's.
But Sara Shannon also trusted Sabrina's judgment. Her daughter was a poster child for food allergy safety. Three years earlier, Sabrina produced a documentary about her anaphylaxis for CBC Radio. Since age two, she'd experienced a handful of anaphylactic reactions and emergency trips to hospitals. She was extremely vigilant and, if unsure of a food, would not go near it.
"With allergies, it's no --or you die," Sabrina told the radio audience. She giggled and said she'd love to be allergic to spinach, broccoli and cauliflower.
Her mother eventually gave into her daughter's demand for school french fries and the freckle-faced, red-headed Sabrina headed off that morning, Sept. 29, 2003, wearing a new pair of jean shorts and one of her mother's Gap T-shirts, with "Rescue Patrol" across the front.
Her knapsack contained her Epipen injector syringe with a dose of life-saving epinephrine (adrenaline) in case she suffered another potentially fatal anaphylactic reaction. She also carried a Ventolin puffer for her asthma.
Sabrina soon arrived at Bishop Smith, a pile of grey brick and blue glass overlooking an athletic field where the Crusaders girls' rugby team routinely rides off with the annual county championship. These would be the final hours of her life.
Almost one year later, the chief coroner for Eastern Ontario, Dr. Andrew McCallum, is about to launch a public awareness campaign about the dangers anaphylactic students face in high schools. His endeavour is part of Sabrina's story.
Sabrina was passionate about life: Harry Potter books, summer drama camp, writing short-story fiction, swimming, skiing, collecting Yu Gi Oh cards and anything else to do with Japanese anime art, which she had a remarkable talent at drawing. At her Grade 7 graduation dance the previous spring, she danced every song.
She didn't hold back at Bishop Smith either, seeming not to care what other people thought of her bubbly, talkative and sometimes off-the-wall personality. She took pride in her ability to be assertive. She even refused to hang around with the popular crowd because they wouldn't accept one of her friends, who was a bit overweight.
In some ways, Sabrina had found her voice at a very young age.
But the fall of 2003 was to be very different. The allergen-safe zone of her former elementary school was gone. Bishop Smith is a big, busy place, with a cafeteria and students as old as 20.
Sara Shannon spoke with school officials, including Sabrina's homeroom teacher, about her daughter's anaphylaxis. Sabrina also knew she now had to be much more responsible about her condition and had no intention of coming into contact with an allergen that would set off her defective immune system.
She may, in fact, have been more worried about being teased because of her allergies. Once in elementary school, a bullying student smeared butter on her face. In Grade 7, kids began teasing her about the red fanny pack she wore with her Epipen inside. She eventually stopped wearing it and kept her medicine in her desk. At Bishop Smith, she kept it in her knapsack, desk or locker.
Around 11:40 a.m., Sabrina and her best friend, Kelsey Gulliver, headed to the cafeteria for lunch. Sabrina checked with the cafeteria staff, as she'd done the previous Friday, to make sure the french fries were cooked in vegetable oil. Assured, she bought some, along with a Coke.
After eating, Sabrina and Kelsey headed to Ms. Sernoskie's 12:30 geography class in the Grade 8 wing on the second floor. Before class, Sabrina stood at Kelsey's desk talking. Then it hit: Sabrina started to wheeze. "I think I'm having an asthma attack."
Sabrina told the teacher, who sent her, accompanied by another student, to the ground-floor school office at the other end of the building. Because she thought she was having an asthma attack, her Epipen remained behind in her unlocked locker.
panic sets in
Vice-principal Clint Young popped his head out of his office when he heard Sabrina arrive. She was now struggling to breathe and panicking. "It's my asthma, it's my asthma."
An ambulance was soon called.
The other student said Sabrina was anaphylactic and Mr. Young, whose young son has anaphylaxis, asked Sabrina what she'd eaten.
"It's not my allergies, it's not my allergies," she insisted.
But inside her body, her over-reactive immune system was launching an all-out "systemic reaction" to repel what it believed to be a foreign invader. Mast and basophil cells in her blood stream and tissues were releasing a variety of defensive chemicals, including a massive amount of histamine, which dilated her blood vessels and sent her blood pressure plummeting. Her heart raced to keep blood flowing to her brain and other organs. The histamine also caused her respiratory muscles to contract, strangling her ability to breathe and further reducing the amount of oxygen flowing to her brain.
Within two minutes of arriving in the office, she lost consciousness and crumpled to the floor. She was going into cardiac arrest.
About 30 seconds later, her homeroom teacher arrived with Sabrina's Epipen. Mr. Young administered it in her thigh, followed by CPR.
She was taken to Pembroke General Hospital, then CHEO. She never regained consciousness and died the following night from food-induced anaphylaxis. She was just 13.
Laboratory tests on her blood were unable to determine what specific allergen was responsible. But Dr. McCallum suspects the cafeteria tongs used to handle her french fries may have been contaminated with milk products picked up from earlier orders of poutine.
"I don't see any single person who didn't do what they should have done," he says of the staff at Bishop Smith. "But I do think that there's a cascade of things that led to this."
As a result of Sabrina's death, this Wednesday, Dr. McCallum, flanked by Sabrina's parents and a panel of allergy and anaphylaxis experts, will hold a press conference at CHEO.
"We want to make sure people are aware of this and that we can, as widely as possible, distribute this information so we can prevent another child from suffering the same fate," he says. "We ought to, as a society, stop allergic children from dying."
The switch to high school is one of the most potentially dangerous points in the lives of allergic children emerging from the protective and highly controlled elementary system.
Dr. McCallum likens the move to high school to "handovers" in hospitals, when patients are transferred from one department to another or medical staff change shifts. It's a well-documented risky time for patient safety.
Because of their size and diversity, high schools can be allergen danger zones. Young teens mix with older teens. They're at an age when they take more risks. Students are not only far more autonomous, but want to fit in with their peers. Anaphylactic pupils may not want to carry their Epipens or even talk about their allergies with new friends for fear of being different or being teased. And most don't want their photographs posted in classrooms, cafeterias and the school office.
Yet the kids most likely to die from food-induced anaphylaxis are teenagers. The peak age for food-related anaphylaxis deaths in Ontario, and presumably the rest of Canada, is between 15 and 25 years of age.
But advice on how to protect themselves often falls on deaf ears, says Dr. Peter Vadas, director of the division of allergy and clinical immunology at Toronto's St. Michael's Hospital.
Teenagers "don't want to hear what you've got to say. They're going to take chances as they often do with anything and that includes food allergies and anaphylactic sensitivity. They're also not going to carry rescue medication with them. With all of those problems that confront teenagers, that's why these things tend to happen."
Anaphylactic deaths in Canada, from all sources including food, stings, latex allergies and even vigorous exercise, are difficult to confirm, but estimates range from 12 to 50 annually. Between 1986 and 1991, up to three children a year died in Ontario from food-induced anaphylaxis. It's believed that the last school-related death in Canada before Sabrina's was in Ontario in 1994.
Though deaths are rare, Dr. McCallum and others believe food-induced anaphylaxis deaths in schools should never happen.
But in many high schools, even some where school boards have policies for dealing with anaphylactic students, there are few or no firmly enforced rules and protocols for preventing or handling an emergency such as Sabrina's.
In 2001, Anaphylaxis Canada, which promotes awareness and research, sent a survey to the more than 600 schools under the Toronto District School Board to assess how the schools were dealing with the threat. Only 200 schools replied and all but about 20 were elementary schools.
lack of response
The absence of responses, especially from high schools, "I think says something," says Laurie Harada, the organization's executive director. And even among school boards that have policies, "it's not translating into really good anaphylactic management plans at the school level," she says.
For example, the Renfrew County Catholic District School Board, to which Bishop Smith belongs, had an anaphylactic policy. Sabrina's death has resulted in a sweeping new policy, drafted with the help of Anaphylaxis Canada.
Dr. Vadas, who worked with the Canadian School Boards Association to draft a comprehensive guidebook for creating effective anaphylaxis management policies, says that while many boards are addressing the issues, there's no uniform approach.
"That's fundamentally where the problem is," he says. "Some are great in terms of handling food allergies, others are not so great.
"A lot of people equate what happens during food allergies to what happens during the ragweed season. Maybe a runny, stuffy nose, a little bit of itching, no big deal. They don't appreciate the fact that people can, and do, die from these things. So you run into resistance, you run into a lack of appreciation, you run into a lack of motivation to implement what are sometimes difficult types of policies."
Dr. Zave Chad, an Ottawa allergist and chair of the Canadian Allergy, Asthma and Immunology Foundation, believes the prime responsibility for safety should lie with the students.
"They have to realize that they've got follow the rules for themselves and if the schools can help them out by having less exposure to this stuff, fine. But in the end, it's the kids who have to" take charge of their safety.
Bishop Smith now has perhaps the most stringent high school anaphylaxis safety plan in Canada. Measures include:
- Parents must supply the school with at least one Epipen, which is kept in the school office. All staff have been trained on how to use them;
- The school has prioritized its list of students with medical conditions. The list singles out about 25 students with life-threatening conditions, including nine seriously anaphylactic pupils. The school's electronic student files automatically flash a red flag each time one of the at-risk student's files is opened. Another click of the mouse opens a detailed page on the student's condition and how to respond;
- Anaphylactic students are routinely stopped in hallways by administrators and asked to show that they're carrying an Epipen. They must also tell new teachers the location of their Epipens;
- Photos of anaphylactics are discreetly posted in the school office, the teachers' preparatory room and lunch room, and in a section of the cafeteria used by cafeteria staff. As well, the school is working with a company contracted to run the cafeteria to reduce employee turnover and increase the likelihood that food staff will better know which students moving through the lunch line are anaphylactic;
- Anaphylactic students have been paired with a student "buddy," usually a friend who is often around and who knows of their condition. The buddies have been taught about how to spot the early signs of an anaphylactic reaction and whom to alert;
- Part of the Grade 9 health curriculum this year will included lessons about anaphylaxis.
Ottawa's two main school boards also have anaphylaxis policies and protocols covering elementary and secondary levels.
The Ottawa-Carleton District School Board protocols, developed with the help of the City of Ottawa health department, include:
- Detailed records are kept about anaphylactic students, including where they store their Epipens if they don't follow the board's recommendation to carry them on their person, their bus route numbers and the typical reactions a student experiences during an anaphylactic episode. The record also includes a basic course of action for school officials to follow in the case of an emergency;
- Parents and physicians of anaphylactic students are asked to sign a form permitting school officials to inject a student with their Epipen in the event of an emergency and agree the board will not be held responsible for harm that might occur as a result;
- Parents and students are strongly urged to supply the school with a back-up Epipen, with a photograph of the student attached, to be kept in the office;
- At least one school staff member has a detailed knowledge of each anaphylactic student's medical needs;
- Mandatory, annual training for most school staff on how to administer an Epipen. All schools also have designed teams of staff members trained in emergency first aid;
- Signs posted in school cafeterias encourage allergic and anaphylactic students to check with cafeteria staff about ingredients used to make meals.
training considered
The Ottawa-Carleton Catholic School Board does not have Epipen training for its staff, but "that might be something worth us looking at," says Julian Hanlon, deputy director of education.
The separate board relies more on students and their parents to let school officials know what sort of precautions they feel are necessary. For example, schools will store a backup Epipen in the school office if asked.
"When the parent comes forward, and they are encouraged to do that, then we'll put into place, short of an allergy-free zone, whatever they recommend in conjunction with what the school has done in the past," says Mr. Hanlon.
"I'm comfortable with the approach we've taken, it has worked for us. Certainly, we're not saying to our (high school) principals 'Don't worry about it, they're old enough now, they can look after themselves.'"
Information Online
- On May 21, 2001, CBC Radio's Outfront broadcast A Nutty Tale, a documentary about food anaphylaxis produced by and featuring then 10-year-old Sabrina Shannon. It can be heard on the Web at cbc.ca/outfront/ webfeatures/sabrina/sab_shell.html.
- Other informative websites about anaphylaxis and schools include Anaphylaxis Canada (www.anaphylaxis.org) and the Canadian School Boards Association's Anaphylaxis: A Handbook for School Boards (cdnsba.org. Search for keyword "allergies".) Also the Calgary Allergy Network at www.calgaryallergy.ca
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