Written By: Natalie Minton, Recipient of the University of Mississippi’s Terence Downer Scholarship

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_{^{ABOUT THE TERENCE DOWNER SCHOLARSHIP
For more than a decade, the Terence E. Downer Scholarship has supported pharmacy students at the University of Mississippi. The endowment honors Terence E. Downer, who died April 25 after a short battle with cancer, and will benefit the school in perpetuity. Scholarships from the endowment are awarded annually to students pursuing careers in pharmaceutical marketing. A committee of faculty members from the School of Pharmacy’s Center for Pharmaceutical Marketing and Management and Department of Pharmacy Administration selects the recipients.}}

Executive Summary

Under existing state law, auto-injectable epinephrine is the only form of epinephrine approved for use in Mississippi public schools, and the law fails to designate a decision-maker responsible for making a school’s decision to stock epinephrine. We propose amending Mississippi Code Title 37. Education § 37-11-71, also known as the Mississippi Asthma and Anaphylaxis Child Safety Act, to redefine “anaphylaxis mediation” to include additional FDA-approved forms of epinephrine. Further, we support naming school nurses and school principals as anaphylaxis decision-makers. Expanding epinephrine delivery options for Mississippi schools may encourage increased adoption of state-required anaphylaxis policy to protect the lives of Mississippi children.

Background

Anaphylaxis is a severe, life-threatening allergic reaction most often caused by food, medicine, or insect venom, and can cause death in less than 15 minutes via airway swelling, loss of consciousness, cardiac arrest, or respiratory failure.^1–3 Nationally, there is an anaphylaxis-related pediatric fatality rate estimated between 0.65% and 2%.⁴ And in Mississippi, where children make up about 20% of the population, 53% of anaphylaxis-related insurance claims are in patients ages 0-18 years old.^5,6

On average, at least one child in every U.S. classroom has a food allergy, and 40% of that group have multiple food allergies.^7,8 Given this prevalence, school reactions are not uncommon. A 2005 study of 109 Massachusetts school districts reported 115 anaphylactic reactions in two years.⁹ Notably, 25% of anaphylactic reactions occurred in students with no prior diagnosed allergy.¹⁰ A similar story was found in a 2014 study of Chicago public schools that reported 21 anaphylactic reactions in undiagnosed children in one year.¹¹

Epinephrine is the first line treatment for anaphylaxis and must be administered promptly to be effective.¹² However, epinephrine is only carried by students with a pre-existing diagnosis. Without an anaphylactic allergy diagnosis, the 1-in-4 children experiencing an anaphylactic reaction at school face no life-saving treatment options, risking fatal outcomes, unless one of the following occurs:

1. the school nurse or trained school employee uses another child’s prescribed epinephrine leaving the school district responsible for replacing the ~$700 used epinephrine, or
2. the school nurse or trained school employee uses epinephrine provided to the school free-of-charge through pharmaceutical school programs that also provide free replacements.^13–15

Option 2 is cost avoidant, and Mississippi law allows for it. The Mississippi Asthma and Anaphylaxis Child Safety Act, passed in 2014, mandates that public school districts and their school boards allow each school to maintain a supply of undesignated epinephrine.¹⁶ Undesignated epinephrine is prescribed by a licensed physician or Mississippi Department of Health officer and issued to the school district or individual school. However, a review of epinephrine policies in Mississippi public schools shows that school districts often do not consider option 2.

Findings

In September 2026, we reviewed the 141 Mississippi school district policy manuals and handbooks for epinephrine policies (Addendum A). The review revealed that only 5 schools had policies that explicitly stated they stock undesignated epinephrine, and only 33% of school boards have adopted the entire state-mandated policy. Comparative content analysis of the state law versus school policies shows that a lack of specificity on epinephrine delivery and ambiguity around decision-making may have left schools without a clear direction on whether to stock and administer undesignated epinephrine.

DRUG ADMINISTRATION LANGUAGE

Mississippi law specifies “auto-injectable epinephrine” and defines “anaphylaxis medication” as auto-injectable epinephrine.¹⁶ School policies make the same distinction; some even specifically refer to the brand name, EpiPen.

Yet, the method of epinephrine delivery is not incidental, but of vital importance in a primary and secondary school setting. A 2022 study showed significant delays in administering auto-injectable epinephrine due to fear of needles, even when administered by physicians.¹⁷ Delays in epinephrine administration are more likely to lead to poor neurological and fatal outcomes than when epinephrine is administered within five minutes.^18,19 Neffy – an epinephrine nasal spray – has proven to be more accessible and effective¹⁵ and provides four free nasal sprays to any school with a prescription.¹⁴ However, the nasal spray delivery-method is currently not permitted in Mississippi schools under the current “auto-injector”-specific language.

ANAPHYLAXIS DECISION-MAKING

Mississippi law mandates that the “school board” allow each “school” to maintain a supply of auto-injectable epinephrine but does not specify who within the school should make that decision.¹⁶ Decision-making ambiguity leads to the bystander effect, which is the lack of responsibility felt by any individual person in a group, causing everyone to wait for another person to act.²⁰

Mississippi law extends the right to administer undesignated epinephrine to the “school nurse or trained school employee.”¹⁶ Studies recognize school nurses as the most knowledgeable about school anaphylaxis policies and what is needed in their schools to reduce allergen exposure and manage anaphylaxis.²¹ However, school nurses are often not in control over those decisions.²¹

Recommendation

Amend Mississippi Code Title 37. Education § 37-11-71, to:

• Redefine “anaphylaxis medication” as “any Food and Drug Administration approved form of premeasured epinephrine used to administer epinephrine into the human body to prevent or treat a life-threatening allergic reaction,” (language derived from Alabama HB533, passed April 2026²²), and remove the words, “auto-injector” and “auto-injectable.”
• Include a section stating, “The school nurse is authorized to determine whether the school stocks undesignated epinephrine for use in the event of an anaphylactic emergency. In schools without a school nurse, this decision rests with the school principal.”
• Epinephrine decision-makers will also need to be included in the civil liability protection clause.

Conclusion

Amending the legal definitions of the Mississippi Asthma and Anaphylaxis Child Safety Act may seem like a minor policy change, but when dealing with anaphylaxis-related pediatric fatality every minor detail counts. This small change could allow Mississippi schools access to more effective treatment options, empower knowledgeable medical professions with defined decision-making ability, and improve the odds for Mississippi school children who have undiagnosed anaphylactic allergies.

References

1. Anaphylaxis. nhs.uk. October 20, 2017. Accessed April 14, 2026. https://www.nhs.uk/conditions/anaphylaxis/
2. Epinephrine (Adrenaline): What It Is, Function, Deficiency & Side Effects. Cleveland Clinic. Accessed April 14, 2026. https://my.clevelandclinic.org/health/articles/22611-epinephrine-adrenaline
3. Pflipsen MC, Colon KMV. Anaphylaxis: Recognition and Management. Am Fam Physician. 2020;102(6):355-362. Accessed April 14, 2026. https://www.aafp.org/pubs/afp/issues/2020/0915/p355.html
4. Tanno LK, Demoly P. Anaphylaxis in children. Pediatr Allergy Immunol Off Publ Eur Soc Pediatr Allergy Immunol. 2020;31 Suppl 26:8-10. doi:10.1111/pai.13336
5. FAIR Health. State-By-State Data for Food Allergy – FoodAllergy.Org. Food Allergy Research & Education; 2018. Accessed September 5, 2026. https://www.foodallergy.org/resources/state-state-data-food-allergy
6. U.S. Census Bureau QuickFacts: Mississippi. Accessed August 6, 2026. https://www.census.gov/quickfacts/fact/table/MS/IPE120224
7. 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
8. Waserman S, Cruickshank H, Hildebrand KJ, et al. Prevention and management of allergic reactions to food in child care centers and schools: Practice guidelines. J Allergy Clin Immunol. 2021;147(5):1561-1578. doi:10.1016/j.jaci.2021.01.034
9. McIntyre CL, Sheetz AH, Carroll CR, Young MC. Administration of epinephrine for life-threatening allergic reactions in school settings. Pediatrics. 2005;116(5):1134-1140. doi:10.1542/peds.2004-1475
10. White MV, Hogue SL, Odom D, et al. Anaphylaxis in Schools: Results of the EPIPEN4SCHOOLS Survey Combined Analysis. Pediatr Allergy Immunol Pulmonol. 2016;29(3):149-154. doi:10.1089/ped.2016.0675
11. DeSantiago-Cardenas L, Rivkina V, Whyte SA, Harvey-Gintoft BC, Bunning BJ, Gupta RS. Emergency epinephrine use for food allergy reactions in Chicago Public Schools. Am J Prev Med. 2015;48(2):170-173. doi:10.1016/j.amepre.2014.09.005
12. Morriello F, Chapman M. Epinephrine in anaphylaxis. CMAJ Can Med Assoc J. 2023;195(19):E683. doi:10.1503/cmaj.221319
13. White MV, Hogue SL, Odom D, et al. Anaphylaxis in Schools: Results of the EPIPEN4SCHOOLS Survey Combined Analysis. Pediatr Allergy Immunol Pulmonol. 2016;29(3):149-154. doi:10.1089/ped.2016.0675
14. Free neffy® (epinephrine nasal spray) in Schools Program. neffy®. Accessed September 18, 2026. https://www.neffy.com/community-programs/
15. Nasser S, Bottazzi L, Lang A, Skou R, Danø A, Carlqvist P. EE438 Evaluating the Cost-Effectiveness of Nasal Adrenaline Spray vs. Adrenaline Autoinjector for Treatment of Anaphylaxis: A Cost-Utility Modeling Approach. Value Health. 2025;28(12):S192. doi:10.1016/j.jval.2025.09.821
16. Mississippi Code Title 37. Education § 37-11-71. FindLaw. Accessed April 14, 2026. https://codes.findlaw.com/ms/title-37-education/ms-code-sect-37-11-71/
17. Rooney E, Tanimoto S, Kaplan H, Lowenthal R. TIME BEFORE USE OF EPINEPHRINE INJECTABLE DEVICES AND TRIGGERS DRIVING USE: A PATIENT/CAREGIVER SURVEY. Ann Allergy Asthma Immunol. 2022;129(5):S16-S17. doi:10.1016/j.anai.2022.08.547
18. Staff RT. Fatal Pediatric Anaphylaxis Linked to Delays in Epinephrine Treatment. Respiratory Therapy. April 29, 2026. Accessed September 26, 2026. https://respiratory-therapy.com/disorders-diseases/chronic-pulmonary-disorders/allergies/fatal-pediatric-anaphylaxis-linked-delays-epinephrine/
19. April: Fatal delays in EpiPen treatment for food anaphylaxis in children | News and features | University of Bristol. April 28, 2026. Accessed September 26, 2026. https://www.bristol.ac.uk/news/2026/april/fatal-delays-in-epipen-treatment-for-food-anaphylaxis-in-children.html
20. Blagg R. Bystander effect – Diffusion of Responsibility. Britannica. August 6, 2026. Accessed September 26, 2026. https://www.britannica.com/topic/bystander-effect/Diffusion-of-responsibility
21. Kao LM, Wang J, Kagan O, et al. School nurse perspectives on school policies for food allergy and anaphylaxis. Ann Allergy Asthma Immunol. 2018;120(3):304-309. doi:10.1016/j.anai.2017.12.019
22. Barrett A. Alabama Senate passes bill allowing nasal epinephrine use in schools. Alabama Reflector. April 8, 2026. Accessed September 26, 2026. https://alabamareflector.com/2026/04/08/alabama-senate-passes-bill-allowing-nasal-epinephrine-use-in-schools/

About the Author

Natalie Minton is a graduate student and research assistant at the University of Mississippi’s Department of Pharmacy Administration. Her research focuses on family and maternal health with special attention to social determinants of health and health policy. A proud Mississippian, she grew up in Terry, Mississippi and resides in Taylor, Mississippi with her husband and three children.

_{^{Formatted and presented by the Center for Mississippi Health Policy. The Center for Mississippi Health Policy is an independent, non-partisan, non-profit organization that provides objective information to inform health policy decisions.}}

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