8

Managing Food Allergies in Retail, Food Service, Schools, Higher Education, and Travel Settings

In Chapter 5, this report described current knowledge about how biological and environmental systems influence the development of food allergies. The key roles of the individual, the family, and the health care system in managing food allergies were addressed in Chapter 6. The food processing industry also has an essential role in preventing food allergies, with their ability to inform individuals at risk about the presence of allergens in packaged foods, and this was discussed in Chapter 7. However, in order for an individual with food allergy to manage his or her food allergy successfully, it is vital to acknowledge the individual’s interactions with many social systems beyond those directly providing health care. These interactions were outlined in the developmental and ecological model described in Chapter 1. For example, after birth, a child has direct experiences with other people and physical environments in addition to the health care system (e.g., early care education settings). As they develop, children continue to interact with numerous new systems, including peer groups, schools, and community services for children and families. Eventually, children begin to interact directly with media, workplaces, and social and recreational contexts, such as sport teams, and religious or other cultural contexts. Although an individual with food allergy must always try to avoid allergenic foods, direct interactions with foods can occur in many of those settings and avoidance is not easy. Moreover, settings that could be of concern for an individual with food allergy change as an individual becomes more independent. For adolescents and adults, who make many independent decisions about food every day, the safety of their food environment is essential. Thus, in addition to schools, the food environment includes many settings that

offer food information (media, food labels) and food itself (restaurants and friends’ houses). It would not be feasible to include here a description of how all these settings can influence the safety of individuals in regard to food allergies. Rather, this chapter describes those that the committee views as essential to consider in depth. Those selected settings—food service and retail, schools and day care centers, higher education, and the travel industry—are organized in the chapter from the more general (food retail that everybody experiences) to the narrower (travel). For each setting, the chapter emphasizes the current approaches (i.e., policies, guidelines, and practices) to manage food allergies. The recommendations and research needs related to these settings are at the end of the chapter.

FOOD RETAIL AND FOOD SERVICE

Consumers with food allergies must depend on personnel in restaurants, retail outlets, and retail food service establishments (e.g., ice cream parlors, bakeries, grocery stores, food carts) to obtain allergen-safe foods. Errors could be deadly. In two publications of case series of fatal food-allergic reactions in the United States, at least 17 of 63 deaths involved restaurant meals or items from food services (Bock et al., 2001, 2007). A systematic review of unexpected allergic reactions suggested that 21 to 31 percent occur in restaurants (Versluis et al., 2015). Errors resulting in allergic reactions could occur from problems with communication from the consumer or from a variety of circumstances in the establishment such as hidden ingredients and cross-contact. Although most severe reactions from food allergens originate from consumption of the relevant food and the risk of an allergic reaction from environmental contact is rather low (see Box 8-1), less severe food allergic reactions also have been reported in food establishments (see Chapter 6; Furlong et al., 2001) and some of those might be due to environmental exposures. In a survey directed to understand allergic reactions in restaurant foods or other establishments, 7 (out of 156 episodes) were reported to be due to skin contact or inhalation (i.e., due to residual food on tables, peanut shells covering floors, or being within 2 feet of the cooking of the food).

Several studies have characterized potential problems in understanding and managing food allergy on the part of restaurant and food service staff. In 2006, Ahuja and Sicherer conducted a survey of 100 personnel (42 managers, 32 servers, 24 chefs, 2 other) in 100 establishments in the New York City area (48 restaurants [17 continental, 19 Asian, 12 Italian], 18 fast food, 34 take-out [8 bakery, 13 ice cream, 9 Asian, 4 pizza]) (Ahuja and Sicherer, 2007). The personnel turnover rate was high (on average, between 5 and 30 new staff per year), suggesting a serious challenge to training. Even so, respondents reported high levels of comfort in providing “safe” meals.

A rating of “very” or “somewhat” comfortable was selected by 72 percent for providing a safe meal and 70 percent for “guaranteeing” a safe meal. Regarding food allergy training, 42 percent indicated prior training and 6 percent were unsure. Training was primarily (76 percent) through “one-on-

one” (apprentice) sessions rather than a set program. Importantly, respondents did not show high understanding of food allergy when faced with knowledge-based questions. For example, 24 percent thought that small ingestions of the food were acceptable, 35 percent thought heat destroys most allergens, 34 percent thought giving water is an appropriate response to a consumer having an allergic reaction, 54 percent thought a buffet “kept clean” was safe for an allergic patron, and 25 percent thought removing a nut from a finished meal was safe. Only 22 percent of participants selected the correct response for all five of the true-false questions. Rates of correct responses did not vary significantly among managers, servers, and chefs. Also, the number of correct responses was not associated with comfort level for providing or guaranteeing a safe meal (P>0.9), suggesting that staff may profess knowledge to a patron but lack understanding. In regard to training, 61 percent indicated an interest in future training programs, 22 percent were not interested and 17 percent were unsure. Respondents were asked whether they thought certification and regulation should be required for food allergy education. To this question 55 percent agreed, 24 percent disagreed, and 21 percent were unsure. Studies conducted in a similar manner using the Ahuja and Sicherer (2007) survey in Brighton, United Kingdom (Bailey et al., 2011), and in Turkey (Sogut et al., 2015) and other surveys (Lee and Xu, 2015; Leitch et al., 2005; Mandalbach et al., 2005) have come to similar conclusions. No studies of issues have been conducted for retail food outlets, such as supermarkets that sell prepared foods, but these outlets have particular food allergy–related issues that would be useful to investigate in studies. These issues include take-away samples that are not allergen labeled, nut butter grinding, self-serve areas, bulk bins, shellfish steaming, open food preparation areas, and shared equipment.

The Food Code¹ (FDA, 2013) provides advice from the Food and Drug Administration (FDA) for uniform systems and practices that address the safety of food that is sold in food service and certain retail establishments. As of October 2015, all 50 states and the District of Columbia

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¹ The Food Code began with the activities of the U.S. Public Health Service (PHS) in the area of food protection, particularly studies on the role of milk in the spread of disease at the turn of the 20th century. The first model code, Grade A Pasteurized Milk Ordinance—Recommendations of the PHS/Food and Drug Administration (FDA), was initially published in 1924. Today, the FDA maintains an updated model food code, the FDA Food Code, to assist food control jurisdictions at all levels of government. The model Food Code is neither federal law nor federal regulation and is not preemptive. Instead, it is a model code and reference document for state, city, county, and tribal agencies that regulate operations such as restaurants, retail food stores, food vendors, and foodservice operations in institutions, such as schools, hospitals, assisted living, nursing homes, and child care centers. It is developed by the Conference of Food Protection, a nonprofit organization created to provide a formal process to develop food safety guidance. Members of industry, regulatory, academia, and consumer and professional organizations contribute to the development of the Food Code.

have adopted codes patterned after previous versions of the FDA Food Code, but only 7 states have adopted the 2013 Food Code, which includes food allergen provisions (see the Annex of this chapter for selected 2013 Food Code provisions) based on the 2004 Food Allergen Labeling and Consumer Protection Act.² The 2013 Food Code defines “major food allergens” and suggests that a “person in charge” who can respond correctly to an inspector’s questions about the specific food operation should be present during all hours of operations. The areas of knowledge include the identification of major food allergens and food allergy symptoms in a sensitive individual who has an allergic reaction. The Food Code also references the need for restaurant and food service managers “to be aware of the serious nature of food allergies” and “to avoid cross-contact during food preparation and service.” In addition, the Food Code indicates that the person in charge shall ensure that employees are properly trained in food allergy awareness. That statement “allows industry to develop and implement operational-specific training programs for food employees.” However, “it is not intended to require that all food employees pass a test that is part of an accredited program.” The Food Code also mandates the information that should appear on a label. The Food Code does not provide specific advice on methods to ensure safety for those with food allergy, but does provide specific procedures about activities such as general cleaning, managing raw foods, and other details aimed primarily at reducing infection risks.

Individual states in the United States decide upon adoption of the Food Code. As mentioned above, only seven states have adopted the 2013 Food Code, which includes the provisions relevant to food allergies. In addition, several states (i.e., Massachusetts, Michigan, Rhode Island, Virginia) have adopted food allergy laws that include requirements for informative posters with notices such as “Before placing your order, please inform your server if a person in your party has a food allergy,” and requirements that food safety managers complete required training courses, among other provisions (FARE, 2016a).

Food allergy training is available for personnel in food establishments from several resources. For example, the National Restaurant Association’s ServSafe is a 1.5- to 2-hour online course that addresses issues, including defining food allergens, recognizing symptoms, identifying allergens, dangers of cross-contact, proper cleaning methods, proper communication, workstations and self-serve areas, special dietary requests, dealing with emergencies, importance of food labels, handling food deliveries, proper

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² Public Law 282, 108th Cong., 2nd sess. (August 2, 2004). The Food Allergen Labeling and Consumer Protection Act mandates that the labels of foods containing major food allergens (milk, egg, peanut, tree nuts, wheat, soy, fish, and crustacean shellfish) declare the allergen in plain language.

food preparation, and cleaning and personal hygiene. Many additional programs are available through vendors, and individual companies also have created their own programs. A study of such educational programs suggest they are effective at improving knowledge and changes in practice (Bailey et al., 2014).

EARLY CARE AND EDUCATION SETTINGS AND SCHOOLS

Early care and education settings and schools play an important role in the lives of our children. Although a parent can rather effectively alter the food environment at home to accommodate the needs of a child with food allergy, these types of accommodation become more complex and difficult to implement outside the home.

It has been reported that 16 to 18 percent of school-aged children with food allergy have experienced a reaction in school (Nowak-Wegrzyn et al., 2001; Sicherer et al., 2001). However, although the potential of a reaction from skin exposure to dust with allergen particles exists, the studies to date do not indicate that the risk of reactions, especially severe reactions, is high from environmental exposures (see Box 8-1).

Schools can be a risky setting in which to suffer a severe reaction, such as anaphylaxis. Alarmingly, one study noted that 24 percent of the severe and potentially life-threatening reactions (anaphylaxis) that were reported at schools occurred in children who had no previous diagnosis of food allergy (McIntyre et al., 2005). In a case series of food allergy–related fatalities in children, 9 of 32 happened in school and were associated primarily with significant delays in administering epinephrine (Bock et al., 2001). However, the majority of food allergic reactions that occur in preschool- and school-aged children are not anaphylaxis (Boros et al., 2000; Gold and Sainsbury, 2000) and deaths are rare overall (Macdougall et al., 2002; Umasunthar et al., 2013).

State Laws for School Settings

Fortunately, much progress has been made in the area of ensuring appropriate access to medical treatment for anaphylaxis. In 2013, the School Access to Emergency Epinephrine Act³ authorized the U.S. Department of Health and Human Services to give funding preferences to schools if they maintain an emergency supply of epinephrine and if they develop a plan so that epinephrine can be administered at the school. Since then, almost all states have authorized schools to keep medications on hand to treat severe allergic reactions, with 10 states requiring schools to keep epi-

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³ Public Law 48, 113th Cong., 1st sess. (November 13, 2013).

nephrine auto-injectors on hand (AAFA, 2015). Furthermore, every state grants students the right to carry and use their anaphylaxis medications while at school and most states have approved laws that allow for stocking of epinephrine auto-injectors at school (FARE, 2016b). The Chicago Public Schools, for example, implemented an initiative to stock undesignated epinephrine auto-injectors in all of its schools. The importance of this initiative based on the use of undesignated epinephrine auto-injectors for food allergy has been reported (DeSantiago-Cardenas et al., 2015). However, implementation of these laws requires training personnel in recognizing symptoms, in administering medication, and in following best practices, and the laws are not monitored by any government agency. According to the nonprofit Asthma and Allergy Foundation of America (AAFA), school settings lag in prompt recognition of allergic reactions and anaphylaxis, treatment of reactions, and extension of these goals to address previously undiagnosed children. This is especially problematic in early care and education settings and schools that lack access to a medical provider, such as a school nurse. It is estimated that 25 percent of schools have no school nurse (AAFA, 2015), and the number of early care and education settings that have access to a nurse is unknown.

Since 2008, the AAFA has identified U.S. states with the best public policies for children and youth in elementary, middle, and high schools who have asthma, food allergy, related allergic diseases, or who have experienced anaphylaxis. All states and the District of Columbia are assessed for 23 standards that are grouped into three broad categories (medications and treatment, awareness, and school environment). In the 2015 report, 14 states met the standards for being a State Honor Roll of Asthma and Allergy Policies for Schools (AAFA, 2015).

The Centers for Disease Control and Prevention School Guidelines

In 2011, Congress passed the FDA Food Safety Modernization Act⁴ in an effort to improve food safety in the United States by focusing on prevention. Section 112 of the act calls for the Centers for Disease Control and Prevention (CDC) to develop voluntary guidelines for schools and early care and education settings to help them manage the risk of food allergy and severe reactions in children. Accordingly, in 2013, the CDC, in consultation with the U.S. Department of Education and others, developed the Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs (CDC, 2013). (Box 8-2 lists the complete set of topics that are included in the CDC guidelines.)

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⁴ Public Law 353, 111th Cong., 2d sess. (January 4, 2011).

The Voluntary Guidelines for Managing Food Allergies calls for Food Allergy Management and Prevention Plans (FAMPPs) to

• Meet the requirements of federal, state, and local laws and regulations;
• Reflect clear goals, purposes, and expectations for food allergy management that are consistent with the school’s or early childhood education program’s mission and policies;
• Be clear and easy to understand and implement;
• Be responsive to the needs of any child with food allergy by taking into account the different and unique requirements of each child; and

• Be adaptable and updated regularly on the basis of experiences, best practices, current research and changes in district policy or state or county law.

The Guidelines recommendations include five priority areas that should be addressed in each FAMPP. These are (1) ensure the daily management of food allergy in individual children, which includes the child’s Emergency Care Plan⁵ (see Chapter 6), (2) prepare for food allergy emergencies, (3)

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⁵ Emergency Care Plan for Anaphylaxis or Allergy and Anaphylaxis is a plan written by the physician or health care provider and the patient and family that serves to notify the school about a potentially life-threatening food allergy and about a management approach. These plans come in many forms, but, to date, none is standardized. Key features include the child’s name, weight, identifying information (child’s picture, if provided), specifics about the food

provide professional development on food allergies for staff members, (4) educate children and family members about food allergy, and (5) create and maintain a healthy and safe educational environment. To help with dissemination and adoption of the guidelines, the CDC has developed a tool kit for schools and early care and education programs (http://www.cdc.gov/healthyschools/foodallergies/toolkit.htm [accessed January 6, 2017]). The extent of implementation of the Guidelines is unknown. However, it has been documented that the use of emergency care plans is less than desirable. For example, in a study of the Chicago Public School district, the third largest public school district in the United States, only half of students with food allergy had filed a health management plan with their school (Gupta et al., 2014). In the same study the authors found that Black and Hispanic and low-income students were less likely to have a school health management plan than Caucasian and higher income students.

Unlike the United States, Australia mandated in 2014 that all schools (including private schools) must comply with Ministerial Order 706⁶ if they have a student enrolled who is at risk of anaphylaxis. This law requires schools to

• Develop a school Anaphylaxis Management Policy;
• Develop and review Individual Anaphylaxis Management Plans for affected students, which include an individual Australasian Society of Clinical Immunology and Allergy (ASCIA) Action Plan for Anaphylaxis;
• Identify and train school staff in anaphylaxis management;
• Purchase backup adrenaline auto-injectors for general use;
• Complete an annual Anaphylaxis Risk Management Checklist;
• Develop a Communication Plan that ensures that all school staff (including volunteers and casual staff), students, and parents are provided with information about anaphylaxis and the school’s Anaphylaxis Management Policy;
• Identify prevention strategies to be used by the school to minimize the risk of an anaphylactic reaction; and
• Develop School First Aid and Emergency Response Procedures that can be followed when responding to an anaphylactic reaction.

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allergy or allergies, medications and doses, descriptions of possible symptoms and related treatment instructions, advice to activate emergency services, and family contact information (see also Chapter 6).

⁶ Victorian code 706. Anaphylaxis management in Victorian schools. See http://www.education.vic.gov.au/Documents/school/teachers/health/Anaphylaxis_MinisterialOrder706.pdf (accessed June 26, 2016).

Other Federal Policies

Meanwhile, other federal laws, such as the FDA Food Code (explained in more detail above), Section 504 of the Rehabilitation Act of 1973,⁷ the Americans with Disabilities Act (ADA)⁸ and the Richard B. Russell National School Lunch Act⁹ as well as state laws in 15 states, pertain to children with food allergy and need to be considered when schools or early care and education settings create management prevention plans, such as FAMPPs. While it is duly noted that the management prevention plans are voluntary, if an individual plan is developed for a child with food allergy, by law it is considered an education record for the purposes of Section 444 of the General Education Provisions Act (better known as the Family Educational Rights and Privacy Act).¹⁰ In addition, if a school or early care and education setting participates in the School Nutrition Programs (i.e., National School Lunch and School Breakfast Programs, the Special Milk Program, and the Fresh Fruit and Vegetable Program), then the U.S. Department of Agriculture (USDA) nondiscrimination regulation (7 CFR 15b) and the Richard B. Russell National School Lunch Act must be followed. These policies state that accommodations to program meals must be made for children who are determined to have a food allergy disability. Furthermore, USDA Food and Nutrition Service (FNS) guidance requires that accommodations must be made at no additional cost to the student, that a food allergy or intolerance impacting a major bodily function (i.e., digestive or respiratory system) must be considered a disability, and that a medical statement from a state-licensed health care professional authorized to write medical prescriptions should be provided to school administrators in certain situations. FNS issued a memorandum in September 2016 (SP 59-2016) that clarifies these requirements. FNS is currently conducting training on the requirements and revising guidance so that current versions of the ADA, Section 504 of the Rehabilitation Act of 1973, and the Individuals with Disabilities Education Act (IDEA)¹¹ are incorporated.

In addition, FNS has developed food safety guidelines specifically targeted at school nutrition directors. These guidelines include a section on managing food allergies with references to many resources (USDA, 2016).

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⁷ Public Law 112, 93rd Cong., 1st sess. (September 26, 1973).

⁸ Public Law 336, 101st Cong., 2d. sess. (July 26, 1990). The ADA defines a person with a disability as “a person who has a physical or mental impairment that substantially limits one or more major life activity.” Major life activities include eating and therefore individuals with food allergies have a disability as defined by the ADA, particularly those with more severe responses, such as difficulty swallowing and breathing, asthma, or anaphylactic shock.

⁹ Public Law 396, 79th Cong., 2d sess. (June 4, 1946).

¹⁰ Public Law 380, 93rd Cong., 2d sess. (August 21, 1974).

¹¹ Public Law 142, 94th Cong., 1st sess. (November 29, 1975).

Also, FNS has funded other initiatives related to food allergies through the Institute of Child Nutrition,¹² which offers resources in many formats and conducts training and research. For example, it offers a 4-hour online course on “Managing Food Allergies in School Nutrition Programs” directed to district school nutrition directors and supervisors, managers, and food service assistants and technicians. Many of the resources also are available in Spanish. FNS is updating these resources so that they reflect the requirements included in SP 59-2016.

The FDA Food Code

Like other food establishments, school cafeterias must comply with the version of the FDA Food Code adopted by the local or state government. As mentioned above, as of October 2015, only seven states have adopted the 2013 versions of the FDA Food Code dated after the implementation of the Food Allergen Labeling and Consumer Protection Act (FALCPA) in January 1, 2006, which includes new provisions regarding food allergens. The Annex to this chapter includes some highlights of the 2013 FDA Food Code relevant to food allergy, including some of the new provisions. The 2013 FDA Food Code recognizes the importance of restaurant and retail food service managers by adding a provision to ensure that the food safety training of employees includes food allergy awareness. FALCPA also requires that the FDA works in cooperation with the Conference for Food Protection to pursue revision of the Food Code to provide guidelines for preparing allergen free foods in food establishments, including elementary and secondary school cafeterias.

HIGHER EDUCATION INSTITUTIONS

As Chapter 6 argues, adolescents are particularly at risk when it comes to food allergy. As adolescents continue from high school into higher education, they are increasingly less dependent on guardians or parents to remain safe, and the physical separation that often occurs by leaving home coincides with their desire for independence. Perhaps for this reason, young adults may prefer to manage their food allergy on their own as they enter institutions of higher education. It appears that fewer regulations govern the management of food allergy in higher education institutions.

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¹² The Institute of Child Nutrition at the University of Mississippi was established by Congress in the Child Nutrition and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Reauthorization Act of 1989 and funded by a grant administered through the U.S. Department of Agriculture (USDA), Food and Nutrition Service (FNS). The Institute’s mission is to provide information and services that promote the continuous improvement of child nutrition programs.

Some of the obvious policies and resources that help students with managing food allergy at a college or university are described in this section. Schools vary considerably in their food service structure but their facilities generally include various cafeteria-style facilities and fast-food restaurants. In addition to the role of food service in preventing food allergy, other staff influence aspects of college life that have a potential impact. These staff also have a responsibility to work with students and families to ensure the proper management of food allergy and adequate quality of life and well-being for the students. Campus health centers, for example, are important institutions as they offer diagnostic services, and tools and management approaches for individuals (see Chapter 6 for a discussion of the health care system, which includes campus health centers). In addition, campus housing has a role in working with students who have food allergy and determining their needs. This section briefly refers to these diverse areas in a higher education setting where policies and procedures need to consider the needs of individuals with food allergy.

Federal and State Policies

Cafeterias or restaurants, when defined by the local and state governments as a food establishment, need to follow the version of U.S. Food Code adopted by the relevant state or local government. However, as explained above, not all states have adopted the most recent version of the Food Code, the 2013 Food Code, which includes new important provisions related to food allergy, such as training of personnel and food labeling (see above and the Annex for details on these provisions).

Although no other specific federal or state policies cover higher education in regard to food allergies, some broader policies apply. For example, as noted earlier, food allergy might be considered a disability under the ADA. In fact, in 2009, the U.S. Department of Justice (DOJ) received a complaint about violations of the ADA public accommodations provision at Lesley University in Cambridge, Massachusetts, related to students with celiac disease and/or food allergy. After concluding that violations had occurred, the DOJ entered into an agreement with the university “to ensure that its students with celiac disease and other food allergies can fully and equally enjoy the university’s meal plan and food services” (DOJ, 2012). This was a key decision that will guide any future decision regarding implementation and enforcement of the ADA public accommodations provision.

Other Policies

Until recently, no specific guidelines had been developed on recommended practices to manage and prevent food allergy in higher education.

With this goal in mind, the Food Allergy Research Education College Food Allergy Program¹³ was launched in 2014. The program provides the first guideline with details about processes that must be in place at a college or university to ensure safety. The guideline helps officials develop uniform policies to successfully manage food allergy in this setting. It addresses all aspects of college life that are relevant to food allergy, including dining services, health services, resident life, social well-being, disability accommodations, and emergency services. It emphasizes the need for comprehensive policies (e.g., a clear process for requesting accommodations), emergency response plans, process transparency and documentation, individual confidentiality, effective outreaching, staff training, and methods for assessment. The program is very flexible, being sensitive to the varying resources among colleges and universities. The program is being tested in 12 colleges and universities with the hope that others will join.

As a pilot program, some barriers have already been identified (Haas, 2015), such as the challenges of gathering accurate information about food allergens in food and food ingredients from food manufacturers, gathering adequate resources for implementation of the guideline, and identifying practical measures of success.

FOOD ALLERGIES AND THE TRAVEL INDUSTRY

Flying with Food Allergies¹⁴

Patients with food allergy can have serious reactions to small quantities of an allergen and, as previously discussed, allergen avoidance is currently the only management approach to minimize the risk of an allergic reaction. When flying, avoidance might appear more difficult because spending hours in a closed environment might increase the risk of contact with a food allergen when food is served or other passengers bring food. This perceived higher risk can exacerbate anxiety in passengers with food allergy. Although peanut has become a center of focus in research and in the media, any food allergy can be a concern to a flyer.

Few data are available on the percentage of food allergy reactions

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¹³ The Food Allergy Research Education College Food Allergy Program was developed in partnership with other organizations (the National Foundation for Celiac Awareness; the National Association of College & University Food Services) and food allergy experts, college and university representatives, and industry representatives. The program, including the guidelines and other resources for prospective and current students with food allergy, can be found at http://www.foodallergy.org/resources-for/colleges-universities/college-food-allergy-program (accessed January 6, 2017).

¹⁴ Considerations while traveling on other modes of transport should be the same, especially if food is served to travelers.

among those with food allergies while flying. In a 2008 study, Comstock et al. reported that in a sample of 471 individuals with peanut, tree nut, or seed allergy, approximately 9 percent (41 individuals) reported an allergic reaction to food while on board an airplane. Six of these reactions were serious and potentially life-threatening (Comstock et al., 2008). Similar findings emerged from an earlier study that interviewed participants in the National Registry of Peanut and Tree Nut Allergy. Within a total of 3,704 registry participants, 62 reported a reaction associated with airline travel, with reaction severity correlating with exposure route (i.e., ingestion led to the most severe reaction, with inhalation and skin contact resulting in progressively less severe reactions) (Sicherer et al., 1999). In 2008, Greenhawt et al. tracked 150 self-reported reactions to peanut or tree nut on an airline. Of these reactions, 33 percent were reported with symptoms consistent with anaphylaxis but only 10 percent (15 individuals) of the total number of individuals that reported a reaction were treated with epinephrine (Greenhawt et al., 2009). And 48 percent of individuals in the study reported changing flying behavior in response to their reaction. In a survey of 850 physicians who had been asked to provide medical assistance during in-flight medical episodes, no cases relating to peanut allergy were reported (Rayman, 2002). One case report also has been published. In this report, a woman age 19 years experienced anaphylaxis during a transcontinental flight after eating a meal that was reported to have been cooked in peanut oil (Brady and Bright, 1999). Because this individual had a past medical history of asthma, allergic rhinoconjunctivitis, and urticaria related to peanuts, she had medications with her to treat allergic reactions.

Environmental Exposure to Food Allergens

In addition to the risk of exposure through accidental ingestion of an allergen, travelers on airplanes also may worry about being exposed to an allergenic food through contact with particles through skin or by breathing aerosolized allergens. Although no studies have addressed the risk of exposure and reaction on an actual commercial airline flight, studies have been completed to determine whether contact by skin exposure or inhalation can cause an allergic reaction in individuals with a peanut allergy (see Box 8-1).

Based on these limited studies and reported cases on environmental exposure to food allergens, the risk of a severe reaction from aerosolized food allergens appears to be very low, except for children with both asthma and food allergies.¹⁵ Likewise, the risk from skin exposure is low. However, similar to other settings, individuals still need to be cautious about the

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¹⁵ Occupational exposure to food allergens is not included in this report.

potential for severe reactions in an airplane environment in the case, for example, of accidental transfer from the hand to the mouth if the seats or other contact areas are not carefully cleaned.

Current Management of Food Allergies During Air Travel

Relevant Federal Policies on Flying with Food Allergy

The Americans with Disabilities Act and the Air Carrier Access Act The Federal Aviation Act of 1958¹⁶ was intended to ensure “safe and adequate service” on airlines, but it primarily addressed fair prices and did not address disabilities. In 1986, the Supreme Court found that Section 504 of the Rehabilitation Act, the first U.S. protection for people with disabilities that led to the 1990 ADA, applies only to accommodations in the airport, not on airlines, as airlines do not receive federal funding.¹⁷ Subsequently, the court found that the ADA also does not apply to airlines (Francoeur, 2015). The Air Carrier Access Act¹⁸ (ACAA) of 1986 covers all domestic and most international flights and instituted much stricter regulation regarding serving passengers with disabilities. The ACAA uses the same definition of disability as the ADA, and the U.S. Department of Transportation (DOT) was given authority¹⁹ to make regulations enforcing the ACAA. Applying the ACAA to passengers with a food allergy could imply the following:

• The cost of accommodating special needs of passengers with food allergy will not be passed on by the airlines to passengers.
• Epinephrine is allowed on board in a medical kit, but flight attendants may not use this without a doctor on board or without calling down to a doctor on the ground.
• Passengers are allowed to bring epinephrine on the airplane as long as it had been prescribed.
• Medical certificates are not necessary to prove that an individual has a food allergy.

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¹⁶ Public Law 726, 85th Cong., 2d sess. (August 23, 1958).

¹⁷ The Paralyzed Veterans brought a case under Section 504 of the Rehabilitation Act, arguing that paralyzed veterans were entitled to certain rights when traveling on an airline (U.S. Department of Transportation v. Paralyzed Veterans, 477 U.S. 597 [Supreme Court, 1986]).

¹⁸ Public Law 435, 99th Cong., 2d sess. (October 2, 1986).

¹⁹ Nondiscrimination on the Basis of Disability in Air Travel, 14 CFR Part 382, 2003.

However, passengers can actually do very little if they feel discriminated against for having a food allergy. The contract of carriage²⁰ limits passengers from filing a lawsuit against an airline for failure to make accommodations. Even if a passenger can file a complaint with a Complaint Resolution Officer or with the DOT, the DOT is able to fine an airline or take it to court only if there is a pattern of discrimination. Passengers cannot receive any compensation in such cases (Francoeur, 2015). Data pertaining to disability-related complaints filed to the DOT for all United States and foreign air carriers are helpful for passengers to determine which airlines have the most allergy-related complaints against them.²¹ In 2014, a total of 968 allergy-related complaints were filed with the DOT. However, these complaints are not separated by allergy, so it is likely that some allergy complaints were not food-related.

Department of Transportation and Related Agencies Appropriations Act of 2000 and Buffer Zones In 1998, to deal with an increasing concern over food allergic reactions on planes, the DOT suggested that airlines create buffer zones. As a result of backlash followed this suggestion, Congress passed the Department of Transportation and Related Agencies Appropriations Act of 2000²² which states that no federal funds can be used to require airlines to provide peanut-free buffer zones or limit the distribution of peanuts on airlines until a peer-reviewed study could show that peanut protein circulating in the air could cause harm (Francoeur, 2015). In 2010, the DOT issued a new proposal to the public in which they offered three suggestions regarding peanuts on flights:

1. Ban peanuts completely on flights.
2. Ban peanuts on flights with a peanut allergic passenger.
3. Create buffer zones.

The DOT soon backed down from this 2010 proposal when reminded about the 2000 Appropriations Act. Until the 2000 Appropriations Act is modified, airlines will be legally allowed to make their own policies regarding food allergy without any instructions from the DOT. As a result, each

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²⁰ The contract of carriage is an agreement that passengers automatically enter any time they purchase a ticket from an airline. The contract of carriage is often either printed in fine print on the paper ticket or is found on the airline’s website. This agreement limits a passenger’s right to sue a carrier for damages, and courts have held that this is a binding contract whether or not a passenger has read it in its entirety.

²¹ These data can be found on the DOT’s website: https://www.transportation.gov/airconsumer/2015-report-disability-related-air-travel-complaints-received-2014 (accessed January 6, 2017).

²² Public Law 69, 106th Cong., 1st sess. (October 9, 1999).

airline has developed its own policies.²³ As examples, some airlines warn passengers that they are unable to guarantee no nut dust in the air but they will attempt to accommodate them by not serving nut-containing snacks when a passenger at risk of an allergic reaction is on board. Some also recommend that passengers with nut allergies take precautions by flying early in the day and reading the labels. Other airlines have implemented buffer zones whereby peanuts are not served within two rows of a passenger with food allergies.

Food safety policies Airlines, similar to railroads and other transportation services, are managed under the Interstate Travel Program, which governs Interstate Conveyance Sanitation and is authorized by the Public Health Service Act. It is enforced by the FDA, not by the states.²⁴ However, in airplanes, with the more recent practice of receiving prepackaged food, rather than preparing food on board, informing the consumers about allergens in foods is no different than it is in a retail stores. In that way, firms (caterers and commissaries) who provide food for these transportation services are not subject to FALCPA or the FDA Food Safety Modernization Act²⁵ (FSMA), the federal laws regulating food safety and food allergy labels, unless they prepared and distributed food that was packaged and sold in interstate commerce and need to carry a label. As a result, airline menus (which are typically prepared 1 year in advance) and meals are required to be labeled for allergens on U.S. carriers, but this requirement is not currently being enforced. Policies enforcing the labeling of food allergens for meals served on airplanes are only currently being finalized. The FDA Food Code (see above and Annex) also applies to airline caterers. Finally, these U.S. regulations pertain only to flights that depart from the United States jurisdiction. For example, an U.S. carrier on a flight from Germany to the United States would not have to comply with FALCPA.

In contrast, European Union Allergen Legislation Regulation No. 1169/2011 on The Provision of Food Information to Consumers,²⁶ which was published in October 2011 and became effective in December 2014, requires labeling information for prepacked food to include an ingredients list, including allergens, and a quantitative indication of ingredients. This regulation applies “to all foods intended for the final consumer, including foods delivered by mass caterers” and applies to “catering services provided by transport undertakings when the departure takes place on the territories

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²³ See www.dot.gov/airconsumer/nuts-airlines-policies (accessed January 6, 2017).

²⁴ Interstate Conveyance Sanitation. Code of Federal Regulations, Title 21, Part 1250.

²⁵ Public Law 353, 111th Cong., 2d sess. (January 4, 2011).

²⁶ See http://eur-lex.europa.eu/legal-content/EN/ALL/?uri=CELEX%3A32011R1169 (accessed July 2, 2016).

of the Member States to which the Treaties apply.” This regulation also covers crew food and requires that allergens be labeled on catered and nonprepacked foods as well. When allergens are present, they must either be listed on the packaging information or available by asking a crew member. If this information is available verbally, it must be indicated on a label attached to the food, or on a menu, ticket, or label that is readily discernible by an intending purchaser at the place where the intending purchaser chooses that food (FSA, 2015).

The World Food Safety Guidelines²⁷ from the International Flight Services Association has information on allergen labeling and management, and some airlines may require caterers to report allergens to airline staff but it is unclear whether this is mandatory or optional guidance.

Policies about medical emergencies training of personnel As already mentioned, epinephrine is indicated if a person has an anaphylactic reaction due to a food allergy. The Federal Aviation Administration (FAA) has required an emergency medical kit in domestic passenger planes since 1986. Under the current rule, the kit must contain two single-dose vials of epinephrine injection (1:1,000 dilution) or the equivalent, and two single-dose vials of epinephrine injection (1:10,000 dilution) or the equivalent. The 1:10,000 vials are labeled for the treatment of cardiac arrest. However, the 1:1,000 vials, which would be typically used for severe food allergic reactions, are not labeled specifically for this use. In addition, the FAA does not mandate that epinephrine auto-injectors be available on board. In response, the American Academy of Pediatrics is currently advocating the FAA to require the inclusion of epinephrine auto-injectors in the medical kits on aircrafts and to work with the FAA on procedures for the use of auto-injectors, recommendations for doses, and replacement of old medication. In addition, in July 2015, bipartisan legislation²⁸ was introduced to require the FAA to initiate rule-making to update the emergency medical kits contents with appropriate pediatric medications and equipment, including an epinephrine auto-injector.

Flight attendants and other crew members have first-aid training. However, the airlines do not mandate that a crew member respond to an emergency, such as anaphylaxis, occurring on a plane. As mentioned above, they are not allowed to use medical kits (including epinephrine) unless a doctor is on board or they have received permission from a doctor on the ground. The Aviation Medical Assistance Act of 1998²⁹ protects persons

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²⁷ See http://www.ifsanet.com/?page=World_Guidelines (accessed July 2, 2016).

²⁸ Airplane Kids in Transit Safety Act of 2015 or Airplane KITS Act of 2015, HR 3379, 114th Cong., 1st sess. (July 29, 2015).

²⁹ Public Law 170, 105th Cong., 2d sess. (April 24, 1998).

providing assistance in the case of an in-flight emergency as long as they are medically qualified. As mentioned above, however, the epinephrine vials in a plane’s emergency medical kit are not labeled for allergic use and so it is possible that a person who is unfamiliar with allergy would not know that epinephrine can and should be used in the case of anaphylaxis.

Another approach to managing emergencies is to divert the plane. Although pilots have broad discretion to divert an airplane in an emergency, they have to consider cost (which can range anywhere from $3,000 to $100,000 [Gendreau and DeJohn, 2002]), proximity to an airport, advice of medical team, and the ability to land safely. One study analyzed the records of in-flight emergency calls from five domestic and international airlines from January 2008 to October 2010. This study found that in total 11,920 in-flight medical emergencies resulted in calls to medical professionals on the ground and 265 of these calls were related to an allergic reaction (Peterson et al., 2013). Of the 265 calls, 12 required aircraft diversion, 40 required transportation to a hospital upon landing, 8 required hospital admission, and no deaths occurred. The authors did not indicate how many of these reactions were food-related.

Research on Mitigating Risk

The committee did not find any studies on approaches to mitigate risk conducted in an airplane setting, although one study, which assessed the effectiveness of cleaning agents for allergen removal (Perry et al., 2004), could apply to airlines. The researchers found that on a flat surface such as a table, dish soap does not remove peanut protein Ara h 1. However, other cleaners did effectively remove peanut protein Ara h 1 from a table surface. Soap and water were able to remove Ara h 1 from hands, but hand sanitizer was not adequate for this purpose. The authors were not able to detect airborne allergen in a simulated environment, suggesting that the risk from contact and airborne exposures to peanut protein is very small. Although the findings were promising, the Enzyme-Linked Immunosorbent Assay (ELISA) test used to identify the peanut protein was specific for Ara h 1 protein; other peanut allergenic proteins could have been present but not detectable. In addition, some detergents and sanitizers can interfere with ELISA detection of allergen residues, for example, by denaturing the proteins. Therefore, the findings from this study, although interesting, would need to be re-evaluated under a different study design to ensure that the ELISA method does not interfere with the results.

Greenhawt et al. studied international in-flight experiences to determine the efficacy of risk-mitigation behaviors by food-allergic passengers (Greenhawt et al., 2013). They found that the following contributed to lower odds of risk of reaction: requesting a buffer zone, requesting an

announcement to not eat peanut items, request for a peanut-free meal, wiping tray table, bringing own food, and avoiding airline blanket/pillow. No association was reported for preboarding; sitting in a particular area; wiping the seat belt, arm rest, or seat back; or asking the airline to not distribute snacks containing peanut.

OTHER SETTINGS

Many settings where food is served in any community present health risks for consumers with food allergies, but only a few are presented in detail here because of their particular relevance: food service and retail, day care centers and educational institutions, and air travel (and other modes of transportation). However, in other settings, food is prepared and served for specific populations. These include camps, social gatherings, prisons and jails, military bases, hospitals, and senior homes. The committee did not explore these settings but, just like other cafeterias, it is reasonable to suggest that they also are considered food establishments under the U.S. Food Code and therefore should meet its food allergy provisions.

OVERALL CONCLUSIONS

In general, tools that can assist in achieving safety in settings of concern relate to policies (either implemented and enforced by the individual setting or by federal, state, or local government) combined with precautionary behaviors from the side of those at risk of having an allergic reaction. In general, however, only a few federal policies directly or indirectly apply to food allergies at the settings of concern described in this chapter (e.g., a recent federal policy allowing schools to stock epinephrine to manage severe allergic reactions). For the most part, however, oversight of places where food is prepared or served is left to the state and local government, such as the voluntary adoption of the FDA Food Code for food establishments. Unfortunately, many states follow Food Code versions before 2013, which do not include important provisions relevant for food allergies that are now in effect.

In regard to individual settings, such as schools or restaurants, studies showing internal policies, knowledge, and practices to manage food allergies are scarce. The data available would indicate that many improvements are feasible that would likely contribute to preventing and managing severe allergic reactions. For example, studies about food service settings suggest that staff may not have a good understanding of the nuances of food allergy management or how to prepare a safe meal. The 2013 FDA Food Code suggests the need for awareness and training, but this is not mandated. Only a few states have laws regarding approaches to food allergy and very few

mandate training of employees. Training programs are available but have generally not been grounded in evidence. High employee turnover, varying education levels, and language barriers represent additional challenges.

Another example of needed improvements that are feasible is in educational settings. In early care and education and school settings, U.S. Food Code regulations could be followed. Also, voluntary guidelines exist for K-12 schools (i.e., the CDC Guideline, FAMPP), and some federal and state laws are specific to children participating in federal nutrition programs and those who have an individualized education program (IEP).³⁰ However, gaps in managing food allergies exist. First, because schools are not reporting in a systematic fashion the occurrence of severe reactions or the number of children with IEPs due to a food allergy diagnosis, the scope of the problem in schools is unknown. Second, it is also clear from reviewing the literature and policies, that schools and other educational settings do not have sufficient staff trained in first aid and, in particular, in food allergy anaphylaxis first aid training, which creates a serious problem for being capable of managing severe food allergy reactions. Finally, the degree to which states adhere to laws that allow stocking of epinephrine is not monitored, which hinders the ability to develop best practices and evaluate their effectiveness.

As children begin to transition into adulthood and may engage in risk-taking behaviors, it is critical to have policies in place to help ensure that their food allergies can be managed. No specific federal or state policies for higher education campuses directly address food allergies. Several policies, however, such as the ADA are important for college and university students and indirectly support food allergy prevention and management.

In all settings where food is prepared or served, most severe reactions will occur by oral exposure and not from exposure to dust particles. Therefore, the committee concluded that policies, such as mandating a buffer zone or prohibiting serving allergens in airplanes or in schools, are not based on current knowledge. Patients and caregivers can take precautions to minimize the risk, such as making sure those in charge (e.g., teachers, restaurant servers, flight crew) are informed about a person’s food allergy, wiping tray tables, or requesting an allergen-free meal as appropriate. However, other policies that could be effective at preventing or treating the rare severe reactions do not exist in those settings of concern. For example, policies enforcing the labeling of food allergens for meals served on airplanes are only currently being finalized. Also, although epinephrine vials

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³⁰ An individualized education program is a plan that lays out an educational program designed to meet the needs of a child with special needs. Ideally, it is developed collaboratively among the parents and school staff. See http://www.parentcenterhub.org/repository/iep-overview (accessed January 6, 2017).

are included in an airplane first aid kit, the availability of epinephrine in a dose to treat food anaphylaxis is not required. Likewise, medically trained personnel in these settings need to be able to recognize signs and symptoms of a severe food allergic reaction and treat with epinephrine.

Policies are not the only approach to food safety. Students in particular, but also those with risk of food allergy and their caregivers in general, need to be provided with the information that empowers them to make their own appropriate decisions about safety. For students, given the nature of campus life, institutions of higher education have the potential to be key providers of information about food options and nutrition and available resources (e.g., dietitians, health care service, or on-campus accommodations) that can help to meet their food allergy needs. In practice, health care providers offer food-allergic individuals variable advice about avoidance diets and the need to avoid completely the specific allergenic food(s) (Turner et al., 2016). Moreover, advice from food allergy advocacy groups, the Internet, and other sources also may be inconsistent. Therefore, health care professionals (see Chapter 6), public health authorities (see Chapter 5), and food allergy advocacy groups should be trained to offer consistent, evidence-based advice on allergen risks, including allergen avoidance diets.

In response to its task, the committee developed specific recommendations for ways to assure that appropriate guidance and education is in place to create a safe public environment for individuals with food allergy. In doing so, the committee recognized that its task did not include recommendations for therapeutic intervention or clinical management of food allergies.

RECOMMENDATIONS

Training Food Industry Personnel

RESEARCH NEEDS

Allergic reactions occur among children attending early care and education settings, schools, camps, or college, as well as among children and adults while traveling or eating at a food establishment and may include persons without a prior diagnosis. Although anecdotal reports describe severe reactions, well-documented estimates of such reactions in each setting are not available. Also, although federal and local policies exist, such as the FDA Food Code, no studies have been conducted on the extent to which regulatory policies have been implemented and the impact of those policies on management or prevalence of food allergy.

The obstacles for consumers with food allergy in restaurants, food establishments, and during travel include lack of communication between the consumer and staff and lack of knowledge about ensuring safety for consumers with food allergies. Limited programs exist for education and more studies are needed to create and validate food allergy educational materials and programs.

Best practices for managing food allergies in settings of concern where food is served have not been studied. For example, management plans for food allergy in early care and education settings, schools, camps, or other places where children are served food include providing instructions for safe meals, recognizing and managing reactions, and assigning roles and responsibilities. These plans require different strategies according to age of the child, skill level of the supervising adults, and cultural or socioeconomic context, but these factors have not been extensively studied and a paucity of data exist upon which to base best practices.

To fill gaps in knowledge in this area, studies should be conducted to accomplish the following objectives:

• Monitor the number of food allergic reactions that occur in various settings where food is served, particularly in early care and education settings, schools, camps, and food establishments, and in additional settings of concern, including restaurants, cafeterias, grocery stores, and commercial airliners (or other commercial means of travel).

• Monitor the degree to which states adhere to the FDA Food Code and other laws and regulations with a food allergy component (e.g., the number of children with IEPs³¹ due to food allergy) so that best practices are developed and their effectiveness in the prevention of severe reactions and management of food allergies is evaluated.
• Define best practices regarding food allergy management (e.g., epinephrine storage) at settings where food is served, particularly in early care and education settings, schools, camps, and food establishments in additional settings of concern, including restaurants, cafeterias, grocery stores, and commercial airliners (or other commercial means of travel). The experiences of other countries where management practices have been standardized should be considered.
• Develop and implement evidence-based, effective training programs for relevant personnel at settings where food is served, particularly in early care and education settings, schools, camps, and food establishments in additional settings of concern, including restaurants, cafeterias, grocery stores, and commercial airliners (or other commercial means of travel). The experiences of other countries where effective training programs have been standardized should be considered.
• Identify and explain risks associated with environmental exposures to food allergens through skin contact or inhalation.

REFERENCES

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Ahuja, R., and S. H. Sicherer. 2007. Food-allergy management from the perspective of restaurant and food establishment personnel. Ann Allergy Asthma Immunol 98(4):344-348.

Bailey, S., R. Albardiaz, A. J. Frew, and H. Smith. 2011. Restaurant staff’s knowledge of anaphylaxis and dietary care of people with allergies. Clin Exp Allergy 41(5):713-717.

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Bock, S. A., A. Munoz-Furlong, and H. A. Sampson. 2001. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol 107(1):191-193.

Bock, S. A., A. Munoz-Furlong, and H. A. Sampson. 2007. Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol 119(4):1016-1018.

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³¹ In public schools, students with a disability may qualify for an IEP, under federal special education funding through the Individuals with Disabilities Education Act (IDEA) of 1975, and may receive special education and related services. See more at http://www.foodallergyawareness.org/civil-rights-advocacy/schools-2/individualized_education_program_(iep)-2/#sthash.F4dKKnbV.dpuf (accessed January 6, 2017).

Boros, C. A., D. Kay, and M. S. Gold. 2000. Parent reported allergy and anaphylaxis in 4173 South Australian children. J Paediatr Child Health 36(1):36-40.

Brady, W. J., Jr., and H. L. Bright. 1999. Occurrence of multiphasic anaphylaxis during a transcontinental air flight. Am J Emerg Med 17(7):695-696.

Brough, H. A., K. Makinson, M. Penagos, S. J. Maleki, H. Cheng, A. Douiri, A. C. Stephens, V. Turcanu, and G. Lack. 2013a. Distribution of peanut protein in the home environment. J Allergy Clin Immunol 132(3):623-629.

Brough, H. A., A. F. Santos, K. Makinson, M. Penagos, A. C. Stephens, A. Douiri, A. T. Fox, G. Du Toit, V. Turcanu, and G. Lack. 2013b. Peanut protein in household dust is related to household peanut consumption and is biologically active. J Allergy Clin Immunol 132(3):630-638.

CDC (Centers for Disease Control and Prevention). 2013. Voluntary guidelines for managing food allergies in schools and early care and education programs. Washington, DC: U.S. Department of Health and Human Services.

Comstock, S. S., R. DeMera, L. C. Vega, E. J. Boren, S. Deane, L. A. Haapanen, and S. S. Teuber. 2008. Allergic reactions to peanuts, tree nuts, and seeds aboard commercial airliners. Ann Allergy Asthma Immunol 101(1):51-56.

DeSantiago-Cardenas, L., V. Rivkina, S. A. Whyte, B. C. Harvey-Gintoft, B. J. Bunning, and R. S. Gupta. 2015. Emergency epinephrine use for food allergy reactions in Chicago Public Schools. Am J Prev Med 48(2):170-173.

DOJ (U.S. Department of Justice). 2012. Justice Department and Lesley University sign agreement to ensure meal plan is inclusive of students with celiac disease and food allergies. https://www.justice.gov/opa/pr/justice-department-and-lesley-university-sign-agreement-ensure-meal-plan-inclusive-students (accessed July 15, 2016).

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Gendreau, M. A., and C. DeJohn. 2002. Responding to medical events during commercial airline flights. N Engl J Med 346(14):1067-1073.

Gold, M. S., and R. Sainsbury. 2000. First aid anaphylaxis management in children who were prescribed an epinephrine autoinjector device (EpiPen). J Allergy Clin Immunol 106(1 Pt 1):171-176.

Gonzalez-Mendiola, R., C. Martin-Garcia, J. Carnes, J. Campos, and E. Fernandez-Caldas. 2003. Asthma induced by the inhalation of vapours during the process of boiling rice. Allergy 58(11):1202-1203.

Greenhawt, M. J., M. S. McMorris, and T. J. Furlong. 2009. Self-reported allergic reactions to peanut and tree nuts occurring on commercial airlines. J Allergy Clin Immunol 124(3):598-599.

Greenhawt, M., F. MacGillivray, G. Batty, M. Said, and C. Weiss. 2013. International study of risk-mitigating factors and in-flight allergic reactions to peanut and tree nut. J Allergy Clin Immunol Pract 1(2):186-194.

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Lee, Y. M., and H. Xu. 2015. Food allergy knowledge, attitudes, and preparedness among restaurant managerial staff. J Foodsrv Bus Res 18(5):454-469.

Leitch, I. S., M. J. Walker, and R. Davey. 2005. Food allergy: Gambling your life on a takeaway meal. Int J Environ Health Res 15(2):79-87.

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Sicherer, S. H., T. J. Furlong, J. DeSimone, and H. A. Sampson. 2001. The US Peanut and Tree Nut Allergy Registry: Characteristics of reactions in schools and day care. J Pediatr 138(4):560-565.

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ANNEX 8: 2013 FOOD CODE (FOOD ALLERGY PROVISIONS)

1.1 Definitions

Major Food Allergen. (1) “Major food allergen” means: (a) Milk, EGG, FISH (such as bass, flounder, cod, and including crustacean shellfish such as crab, lobster, or shrimp), tree nuts (such as almonds, pecans, or walnuts), wheat, peanuts, and soybeans; or (b) A FOOD ingredient that contains protein derived from a FOOD, as specified in Subparagraph (1)(a) of this definition. (2) “Major food allergen” does not include (a) Any highly refined oil derived from a FOOD specified in Subparagraph (1)(a) of this definition and any ingredient derived from such highly refined oil; or (b) Any ingredient that is exempt under the petition or notification process specified in the Food Allergen Labeling and Consumer Protection Act of 2004 (Public Law 108-282).

Chapter 2 Management and Personnel

2-1 Supervision

Responsibility

2-101.11 Assignment

(A) Except as specified in ¶ (B) of this section, the PERMIT HOLDER shall be the PERSON IN CHARGE or shall designate a PERSON IN CHARGE and shall ensure that a PERSON IN CHARGE is present at the FOOD ESTABLISHMENT during all hours of operation.

Knowledge

2-102.11 Demonstration

Based on the RISKS inherent to the FOOD operation, during inspections and upon request the PERSON IN CHARGE shall demonstrate to the REGULATORY AUTHORITY knowledge of foodborne disease prevention, application of the HAZARD Analysis and CRITICAL CONTROL POINT principles, and the requirements of this Code. The PERSON IN CHARGE shall demonstrate this knowledge by:

(C) Responding correctly to the inspector’s questions as they relate to the specific FOOD operation. The areas of knowledge include:

(9) Describing FOODS identified as MAJOR FOOD ALLERGENS and the symptoms that a MAJOR FOOD ALLERGEN could cause in a sensitive individual who has an allergic reaction

Duties

2-103.11 Person in Charge*

The PERSON IN CHARGE shall ensure that:

(M) EMPLOYEES are properly trained in FOOD safety, including FOOD allergy awareness, as it relates to their assigned duties;

Chapter 3 Food

3-6 FOOD IDENTITY, PRESENTATION, AND ON-PREMISES LABELING

Labeling

3-602.11 Food Labels

(B) Label information shall include:

(5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient.

Chapter 4 Equipment, Utensils, and Linens

4-602.11

(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned:

(1) Except as specified in ¶ (B) of this section, before each use with a different type of raw animal FOOD such as beef, FISH, lamb, pork, or POULTRY;

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^* “Person in charge” means the individual present at a FOOD ESTABLISHMENT who is responsible for the operation at the time of inspection.

(2) Each time there is a change from working with raw FOODS to working with READY-TO-EAT FOODS;

(3) Between uses with raw fruits and vegetables and with TIME/TEMPERATURE CONTROL FOR SAFETY FOOD;

(4) Before using or storing a FOOD TEMPERATURE MEASURING DEVICE;

(5) At any time during the operation when contamination may have occurred

(B) Subparagraph (A)(1) of this section does not apply if the FOOD-CONTACT SURFACE or UTENSIL is in contact with a succession of different types of raw MEAT and POULTRY each requiring a higher cooking temperature as specified under § 3-401.11 than the previous type.*

* 4-602.11(B) was amended in the 2013 Food Code. It changes the cleaning and sanitizing frequency for food contact surfaces or utensils that are in contact with a raw animal food that is a major food allergen such as fish, followed by other types of raw animal foods. With this change, the exception to existing subparagraph (A)(1) found in ¶ (B) now applies only to raw meat and poultry.

Annex 3 Public Health Reasons/Administrative Guidelines

Restaurant and retail food service managers need to be aware of the serious nature of food allergies, including allergic reactions, anaphylaxis, and death; to know the eight major food allergens; to understand food allergen ingredient identities and labeling; and to avoid cross-contact during food preparation and service. The 2008 Conference of Food Protection (CFP) passed Issue 2008-III-006 which provided that food allergy awareness should be a food safety training duty of the Person in Charge. Accordingly, the Person in Charge’s Duties under paragraph (M) were amended to assure the food safety training of employees includes food allergy awareness in order for them to safely perform duties related to food allergies.