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Management of anaphylaxis in schools: Evaluation of an epinephrine auto-injector (EpiPen®) use by school personnel and comparison of two approaches of soliciting participation

Nha Uyen Nguyen Luu12*, Lisa Cicutto3, Lianne Soller1, Lawrence Joseph14, Susan Waserman5, Yvan St-Pierre4 and Ann Clarke46

Author Affiliations

1 Department of Epidemiology and Biostatistics, McGill University, 687 Pine Avenue West, V Building, Room V1.09, Montreal, Quebec, H3A 1A1, Canada

2 Department of Medicine, Division of Clinical Immunology and Allergy, University of Montreal, Montreal, Quebec, Canada

3 Department of Medicine, National Jewish Health, Denver, CO, USA

4 Department of Medicine, Division of Clinical Epidemiology, McGill University Health Center, Montreal, Quebec, Canada

5 Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, ON, Canada

6 Department of Medicine, Division of Clinical Immunology and Allergy, McGill University Health Center, Montreal, Quebec, Canada

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Allergy, Asthma & Clinical Immunology 2012, 8:4  doi:10.1186/1710-1492-8-4

Published: 26 April 2012



There has been no large study characterizing selection bias in allergy and evaluating school personnel’s ability to use an epinephrine auto-injector (EpiPen®). Our objective was to determine if the consent process introduces selection bias by comparing 2 methods of soliciting participation of school personnel in a study evaluating their ability to demonstrate the EpiPen®.


School personnel from randomly selected schools in Quebec were approached using a 1) partial or 2) full disclosure approach and were assessed on their ability to use the EpiPen® and identify anaphylaxis.


343 school personnel participated. In the full disclosure group, the participation rate was lower: 21.9% (95%CI, 19.0%-25.2%) versus 40.7% (95%CI, 36.1%-45.3%), but more participants achieved a perfect score: 26.3% (95%CI, 19.6%-33.9%) versus 15.8% (95%CI, 10.8%-21.8%), and identified 3 signs of anaphylaxis: 71.8% (95%CI, 64.0%-78.7%) versus 55.6% (95%CI, 48.2%-62.9%).


Selection bias is suspected as school personnel who were fully informed of the purpose of the assessment were less likely to participate; those who participated among the fully informed were more likely to earn perfect scores and identify anaphylaxis. As the process of consent can influence participation and bias outcomes, researchers and Ethics Boards need to consider conditions under which studies can proceed without full consent. Despite training, school personnel perform poorly when asked to demonstrate the EpiPen®.

Anaphylaxis; Epinephrine; Food allergy; School; Treatment; Selection bias; Consent bias; Volunteer bias