Food allergy is a common problem in children as well as in adults, and its prevalence is well discussed and estimated in developed countries [1Gupta RS, Springston EE, Smith B, et al. Food allergy knowledge, attitudes, and beliefs of parents with food-allergic children in the United States. Pediatr Allergy Immunol 2010; 21(6): 927-34.
[http://dx.doi.org/10.1111/j.1399-3038.2010.01005.x] [PMID: 20492544] ]. There is a significant gap in estimating the prevalence of food allergy in developing countries and particularly in Middle East Arabian Countries [2Boye JI. Food allergies in developing and emerging economies: need for comprehensive data on prevalence rates. Clin Transl Allergy 2012; 2(1): 25.
[http://dx.doi.org/10.1186/2045-7022-2-25] [PMID: 23256652] ].

Food allergy is an abnormal immune body reaction to some food contents, the symptoms of reaction usually present as an immediate presentation, but some time can be late. Skin rash and hives usually are the main presentations [3El-rab MOG, Arabia S, El-rab MOG, Arabia S. Foods and food allergy : The prevalence of IgE antibodies specific for food allergens in Saudi patients CAP classes and interpretation. 1998;(Class 1):4–5.]. When two systems are involved in the reaction (skin, cardiovascular, respiratory or gastrointestinal) then it is termed as anaphylaxis [4Aba-Alkhail BA, El-Gamal FM. Prevalence of food allergy in asthmatic patients. Saudi Med J 2000; 21(1): 81-7.
[PMID: 11533756] ]. Anaphylaxis is a serious medical problem leading to food allergic reactions [5Cianferoni A, Muraro A. Food-induced anaphylaxis. Immunol Allergy Clin North Am 2012; 32(1): 165-95.
[http://dx.doi.org/10.1016/j.iac.2011.10.002] [PMID: 22244239] ] and requiring a prompt treatment [6Fitzharris P, Sinclair J. Food allergy. BMJ (Clinical research ed.). England;2011; 342: d933.
[http://dx.doi.org/10.1136/bmj.d933] ].

Food allergy can be a serious and fatal illness [7Lieberman P, Nicklas RA, Oppenheimer J, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010; 126(3): 477-80.e1, 42.
[http://dx.doi.org/10.1016/j.jaci.2010.06.022] [PMID: 20692689] ]. Severe fatal food allergy reaction at school is rare but have been reported [8Bock SA, Munoz-Furlong A, Sampson HA. Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol 2007; 119: 1016-8.]. Safety and management of food allergy reaction is an issue that is gaining increasing attentions [9Hay GH, Harper TB III, Moore TG. Assuring the safety of severely food allergic children in school. J Sch Health 2006; 76(9): 479-81.
[http://dx.doi.org/10.1111/j.1746-1561.2006.00145.x] [PMID: 17026642] ] and mainly the problem of school preparedness [10Portnoy JM, Shroba J. Managing Food Allergies in Schools. Curr Allergy Asthma Rep 2014; 14: 1-7.]. Nearly all schools in developed countries are supplemented with food allergy guidelines [11Sheetz AH, Goldman PG, Millett K, et al. Guidelines for managing life-threatening food allergies in Massachusetts schools. J Sch Health 2004; 74(5): 155-60.
[http://dx.doi.org/10.1111/j.1746-1561.2004.tb08212.x] [PMID: 15283495] , 12Vale S, Smith J, Said M, Mullins RJ, Loh R. ASCIA guidelines for prevention of anaphylaxis in schools, pre-schools and childcare: 2015 update. J Paediatr Child Health 2015; 51(10): 949-54.
[http://dx.doi.org/10.1111/jpc.12962] [PMID: 26428419] ].

To our knowledge there is no written policy or guideline existing at our schools in Saudi Arabia about food allergy precaution and management. There is no previous study estimating the prevalence of food allergy either in Jazan region or in Saudi Arabia. Some studies estimate the rate of food allergy in other atopic diseases [3El-rab MOG, Arabia S, El-rab MOG, Arabia S. Foods and food allergy : The prevalence of IgE antibodies specific for food allergens in Saudi patients CAP classes and interpretation. 1998;(Class 1):4–5., 4Aba-Alkhail BA, El-Gamal FM. Prevalence of food allergy in asthmatic patients. Saudi Med J 2000; 21(1): 81-7.
[PMID: 11533756] ] but not for general population. The current study aims to assess the knowledge of schoolteachers about food allergy and to determine the need for urgent strategic plan in order to set up a policy and procedure for ensuring wellbeing of children in their schools.

The response rate was estimated at 72% (360 out of 500). The distribution of study participants according to gender showed 13% were males and 83% were females. Some of the subjects (nearly 4%) did not reveal their gender. The distribution of the subjects according to different age categories showed that majority of them 81.1% belong to the age group 25-44 years. Nearly 95% of the study populations were Saudi nationals indicating a homogenized study sample (table not provided).

The total scores were computed and classified, as mentioned in the methodology section. Moreover, the overall mean score of food allergy was presented. As shown in Table 2, most teachers (59.7%) have intermediate food allergy knowledge (overall mean = 57.2, SD = 17.6). No significant difference was found between food allergy scores of the study participants according to age groups, years of education past years of experiences with food allergy and or college type (p = 0.186, and 0.166 and 0.818 respectively). The mean scores are significantly higher for female than in males (58.5± 17.2 and 51.8± 16.0 respectively p = 0.017).

Table 2 presents itemized knowledge of schoolteachers about food allergy. According to the table More than half of responders either do not know or they disagree that the food allergy is a serious problem and can lead to death. One third of study participants reported that food allergy means food is harmful. The majority of teachers do not have much idea about the common food are causing allergy. Around 60% of responders were able to recognize the immediate reaction from food allergy, 80% of them were aware about the skin rashes as a common presentation of food allergy.

Table 2
Itemized knowledge of tutors in relation to known subjects suffering from food allergy.

Table 3 displays itemized attitude of schoolteachers towards food allergy. According to the table around 60% of study participants disagree that Children with food allergies are teased at school, while 83.4 agree that It is difficult for people with food allergies to safely eat at restaurant. Regarding the School should have plans for keeping children with food allergies safe at school majority or 99% of them agree with this statement. Majority of study participants 82.8% stated that Special places for food allergic students might be good practice for children with food allergy. Moreover 61.7% of schoolteacher agree that it is unfair to band a food because some student allergic to it (Table 4).

Table 3
Itemized attitude of tutors towards food allergy.

Table 4
Itemized practice of tutors in relation to known subjects suffering from food allergy.

Table 5 illustrates the results of the logistic regression analysis. The analysis shows that participant level of knowledge is significantly associated with school teacher’s attitudes (OR= 0.06, 95% CI; 0.39 – 0.92, p = 0.01), practice (OR =1.68 95% CI: 1.11- 2.56 p = 0.01), and years of experiences (OR= 1.8, 95% CI; 1.15-2.98 p = 0.011).

Table 5
Relation between participant’s knowledge and some selected factors.

To our knowledge this is the first study in Saudi Arabia conducted on food allergy knowledge, attitudes, and beliefs among school teachers. We believe that the schoolteachers are an important population segment in any country, and we proposed that the assessment of their awareness about food allergy would weigh the magnitude of problems and help students suffering from food allergy.

We found that schoolteachers have a significant poor knowledge in most of food allergy domains. More than half of responders either do not know or they disagree that the food allergy is a serious problem and can lead to death. The majority of teachers do not have much idea about the common food causing allergy and as we know that peanut and nuts are known to be the top listed foods that cause fatal reaction [13Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol 2001; 107(1): 191-3.
[http://dx.doi.org/10.1067/mai.2001.112031] [PMID: 11150011] ] but, here in our study 100% responded nut as not a food allergy causing substance. 65% of responders felt the same for peanut, and that could highlight the rarity in knowledge of these food causing allergy substances in our community. Around 60% of responders were able to recognize the immediate reaction from food allergy, 80% of them aware about the skin rashes as a common presentation of food allergy. However, a frequent misconception that food allergy is a cause of chronic nasal congestion was a finding in our study [14Gupta RS, Kim JS, Springston EE, et al. Food allergy knowledge, attitudes, and beliefs in the United States. Ann Allergy Asthma Immunol 2009; 103(1): 43-50.
[http://dx.doi.org/10.1016/S1081-1206(10)60142-1] [PMID: 19663126] ].

Milk allergy is related to milk proteins [15Solinas C, Corpino M, Maccioni R, Pelosi U. Cow’s milk protein allergy. J Matern Neonatal Med 2010; 23(sup3): 76-9. Available from: http://dx.doi.org/10.3109/14767058.2010.512103] and 70% of participants responded incorrectly to low fat milk causing food allergy. 80% considered lactose intolerance as a form of food allergy. There is a significant lack of knowledge about incidence and daily treatment of food allergy in face of a lot of hope in finding a cure. Our major concern is the poor knowledge about the main stay of treatment of severe form of food allergy which is the Epinephrine auto-injector [16Cheng A, Farrell C, Friedman J, Gauthier M, Mikrogianakis A, Ortiz-Alvarez O. Emergency treatment of anaphylaxis in infants and children. Paediatr Child Health 2011; 16(1): 35-40.
[PMID: 22211074] , 17McIntyre CL, Sheetz AH, Carroll CR, Young MC. Administration of epinephrine for life-threatening allergic reactions in school settings. Pediatrics 2005; 116(5): 1134-40. Available from: http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2004-1475
[http://dx.doi.org/10.1542/peds.2004-1475] [PMID: 16264000] ].

To the best of our knowledge there is no policy to keep Epinephrine auto-injector in the school in Saudi Arabia, having this treatment in the school and training on how to use it, mandate a clear legislation [18Grouhi M, Alshehri M, Hummel D, Roifman CM. Anaphylaxis and epinephrine auto-injector training: who will teach the teachers? J Allergy Clin Immunol 1999; 104(1): 190-3.
[http://dx.doi.org/10.1016/S0091-6749(99)70134-X] [PMID: 10400860] ], and we hope that this study will bring a positive change leading to such action. School teachers agree on having a safety plan for children with food allergy, but 70% of them do not believe that students with food allergy can be teased because of this problem [19Lieberman JA, Weiss C, Furlong TJ, Sicherer M, Sicherer SH. Bullying among pediatric patients with food allergy. Ann Allergy Asthma Immunol 2010; 105(4): 282-6.
[http://dx.doi.org/10.1016/j.anai.2010.07.011] [PMID: 20934627] ]. The participants were mostly aware about the avoidance as the only prevention of food allergy [20Syed A, Kohli A, Nadeau KC. Food allergy diagnosis and therapy: where are we now? Immunotherapy 2013; 5(9): 931-44.
[http://dx.doi.org/10.2217/imt.13.93] [PMID: 23998729] ] and they feel in 65% how difficult is staying away from offending food, there is a current food labeling law in Saudi Arabia [21Ahmed HF, Embassy US, Mousa H, Embassy US. Saudi Arabia food and agricultural import regulations and standards - Narrative FAIRS Country Report. 2015; (May 2012).], but more than half of responders are not aware of it. Majority of teacher felt worry about having student with food allergy in their class, with some concern of inability to recognize early reaction of incidental ingestion of the offending food.

This study has several limitations, first, is the ratio of male responders to females are not reflecting the actual school teacher’s population, this was due to the high non-response among male teachers compared to female teachers. The web-based survey is a valid and reliable means of data collection, but it has some limitations like high nonresponse rate [1Gupta RS, Springston EE, Smith B, et al. Food allergy knowledge, attitudes, and beliefs of parents with food-allergic children in the United States. Pediatr Allergy Immunol 2010; 21(6): 927-34.
[http://dx.doi.org/10.1111/j.1399-3038.2010.01005.x] [PMID: 20492544] ]. Second the study was based on a cross-sectional study design, so study results should be understood in this context.

In conclusion, participants of our study showed significant poor basic knowledge of food allergy, there is a major concern of fatal reaction recognition as result of incidental ingestion of food causing allergic reaction, importance of epinephrine auto-injector as the main treatment of sever food allergy is not well acknowledged by school teachers, our finding put safety of children with food allergy in the school as a top urgent topics to be discuss with authorities to introduce a policy regarding food allergy in the schools along with educational intervention and action plan that ensure the optimal treatment of food allergy in case of severe and fatal reaction. We recommend keeping epinephrine auto-injector in the school with teaching on how and when to use it [22Rhim GS, McMorris MS. School readiness for children with food allergies. Ann Allergy Asthma Immunol 2001; 86(2): 172-6.
[http://dx.doi.org/10.1016/S1081-1206(10)62687-7] [PMID: 11258686] ].