This webinar was recorded on Wednesday, March 22, 2023

How can we assure all people are treated with equity in healthcare? Join us as we explore disparities in asthma and allergy care and how to best help under-resourced communities.

Vivian Hernandez-Trujillo, MD


CNE for nurses, and CRCE’s for Respiratory Therapists is available through Allergy & Asthma Network’s Online Learning HQ

CME is available through ACAAI for this webinar.

Sponsored by the American College of Allergy, Asthma and Immunology

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Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.

Andrea: Hello everyone, we are waiting for a few more people to join us. Just a few more seconds and we will get going on the webinar. Thank you for joining us we have a few housekeeping items before we start. All participants will be on mute for the webinar. We will be recording today’s webinar and we will post that on our website in a few days. You can listen to it again and you are welcome to share that with one of your colleagues. You can find all recorded webinars on our website at allergy asthma We will also have a common webinars there. This webinar will be about an hour and will include time for questions. We will take those questions at the end of the webinar. You can put those into the Q&A tap at the bottom of your screen on the left side at any time. We have someone monitoring the chat if you have questions or need any help, Chris will be there to help you. It will get to as many questions as we can before we can conclude today’s webinar. We offer cbce’s for individuals attending this webinar. Instead of downloading this certificate during the webinar which you may be used to doing in the past we will — you will receive an email in a few days. It will have resources for everything that we talk about, a link to download your certificate, and we will also have links you can access with the American — link you can access with links to getting cme’s. Today’s webinar addresses how we can ensure all people are to do with equity in health care. Let us go to the next slide. Allergy and asthma network is a grassroots organization that was started over 35 years ago by a mother who knew the other moms like her needed resources and support. Our mission is to end the needless death and suffering through allergies, asthma, and related conditions through outreach, education, advocacy, and research. Today it is my pleasure to introduce our Dr.. She graduated from the allergy and immunology fellowship training program at the University of Tennessee, Memphis in collaboration with Saint Jude children’s research Hospital. She has been director of the division of immunology at Miami Torres hospital, Nicholas Jordan Hospital since January of 2008. She is also the fellowship training program Director for the allergy immunology fellowship program I Nicholas Children’s Hospital. She is a clinical professor at the school of medicine at Florida international University. She found allergy and immunology care center at South Florida and has been board certified in pediatrics as well as allergy and immunology. She has conducted clinical research on asthma, food allergies, and anaphylaxis and conducted basic laboratory research on HM. She is in health care disparities especially in box on Hispanic patients and the impact on asthma, food allergy and diesel and T cell immunodeficiency disorders. With a special interest in 2q11 patients. She was active during covid-19 pandemic sharing information in Spanish throughout efforts with the immune deficiency foundation and webinar series. For the Hispanic land next — Latinx patients. She was a recipient of the American College of allergy asthma and immunology women in immunology and water for contributions to — immunology for her contributions. Thank you for joining us.

Dr. Hernandez-Trujillo: It is better to talk about a topic that is near and dear to my heart. As far as my disclosures I will ensure that none of this comes and affects what I say today. I am a consultant and spokesperson, I have been on advisory boards for the U.S. world meds and Regeneron and a consultant for Amgen. A speaker for CSL. And an ad board and speaker for enzama. It will not interfere with today’s presentation. To give you a different view and overview of the talk we will talk a little bit about disparities in Hispanics and Leatinos. Depending on the different studies I present, some of them are about the Hispanic population as opposed to the Latino population. I am sticking with whatever terminology that they use because in some cases they may include other patients, example, from Brazil. I will not use the same — I will use the same terminology as I did throughout the studies. We will talk about asthma in adults and the Unidos Hablemos presentation. We will talk about disparities in Hispanics as far as food allergies and talk about food insecurity which really affects all patients. Particularly those with food allergies. What is a disparity? The definition by the American Medical Association, health care disparities are differences in medical care that are not due to different clinical needs, patient preferences, or the appropriateness of the intervention. Disparities in health care for racial and ethnic minorities in the U.S. are long-standing, well documented, have complex origins both historic and contemporary. One of the reasons why it is so important to have the opportunity to meet today and talk about this is who we are not talking about it we are not aware of what we can do and what is necessary I want those patients may actually need to address the disparities and improve equity in our health care system. — necessary and what those patients may actually need to address disparities to improve equity in our medical health system. Over 4145 — 4,145 deaths annually, and it is 83% higher in black adults. 13.8 million missed school days. This is very concerning. Especially because it is the number one reason the children miss school. 14.2 million workdays that are missed. Three in five patients have limited physical activity. Almost three quarters of patients will misuse inhalers. One in five cannot afford their medications. When we talk about pediatric asthma it is one of the most common and chronic conditions that affect over 7 million children in the U.S.. Severe pediatric asthma is difficult only to manage but utilizes a large part of resources that are available for our patients. There is a need that exist to improve the treatment of these patients with severe asthma. I have different signs from the CDC that gives sobering statistics. This is asthma severity among children with current asthma patients with persistent asthma as we all know it requires a long-term controller medications to control the symptoms. Almost 60 percent of children with current asthma have persistent asthma. That is more than half of all children with children who have persistent asthma. They need to be controlled using long-term medications, sadly, many are poorly controlled due to the lack of response to medications or lack of medications not being available or not being used as prescribed. The prevalence of persistent asthma does vary by state. You can see here 45% in Oregon and up to almost three quarters of patients in Mississippi. These are sobering statistics. Looking at prevalence in children among children under 18 years of age, 8% of all Hispanics are affected by asthma and of this group of this 8%, 17 percent have Puerto Rico as the country of origin and 7% as Mexico. Asthma cases in Puerto Rico represent twice as many asthma cases compared to other Hispanics and children of Puerto Rican origin suffer three times more than white children of non-Hispanic origin. We need to help address that. This is the current asthma among children under the age of 18 and as you can see, this is looking at the total numbers at the very bottom, by race and Hispanic origin, 8% of the patients who are affected are Hispanic. As far as asthma prevalence in our population, in 2018 2.3 million Hispanics reported asthma, the prevalence of asthma is 100% higher in patients who are Hispanic or Latinx as compared to Caucasian. Here, it is 15% of the 6.4% are from Puerto Rico as a country of origin and 5% from Mexico as a country of origin. Unfortunately, the prevalence rates increase and in particular, they are saying in underserved areas or those were having difficulty accessing medical resources. You can see asthma president — asthma prevalence. It shows Hispanics and Puerto Ricans and Mexicans and other Hispanic country of origins. As far as health care disparities again, looking here at the year 2019 as compared to 2020, the blue line is Hispanic or Latino and you can see it is increasing, the greenline is Mexican or Mexican-American come Hispanics were 6.9% in increasing to 7.9%. This is from 2019 through 2020. Looking at asthma attack prevalence, these numbers are more concerning, 50% of all of the Hispanics reported having asthma attacks. This was looking at a time period from 2016 through cap as an 18. Puerto Ricans it was around 50% and Mexicans were over 40% and other Hispanics again, somewhere between 40 and 50%. As far as prevalence of the ER and urgent care visits and again, this is concerning. Hispanics overall, it was somewhere close to 18% of patients for Puerto Rican origin patients it was 20%. Mexican was under 15% and other Hispanics were close to the 20% of prevalence of using ER and urgent care visits. This is a similar table as I showed earlier for pediatrics. This is an adult, 2019 from the CDC. 60% of adults with current asthma had uncontrolled asthma. It was higher among females, 63 percent compared to males, almost 85% and in Hispanics it was 75%. Ages 55 through 64 and 65% and then it was higher than 18 through 54 years of a root in the prevalence of asthma does vary by state. When we look at health indicators, Hispanic adults ranked worse across all racial and ethnic groups for access to health care during the 20 year period. This was published in JAMA network. Despite experiencing lower chronic disease burden the black adult, Hispanic men and women of all ages reported worse perceptions of their general health of all three groups. This is obviously concerning because when asked, how they felt their health was, there reported as poor. — they reported as poor. They had health challenges, suboptimal insurance coverage, physical inactivity, and other factors including self management of chronic diseases that are likely involved in this. Looking specifically at health care disparities in the Latinx community, Latinos who prefer to communicate in Spanish received fewer asthma diagnoses compared to those who communicated in English. When they presented with these exact same symptoms and they were also receiving a diagnosis of asthma less frequently the first day they presented with symptoms as compared to white and non-Latino patients. I love this figure on the right because it is just a reminder. What are the different factors that need to be addressed in order to achieve health equity? Health is affected by different factors. Discrimination and minority stressors, housing, educational opportunities, quality, affordable health care, neighborhood conditions, food security and access to healthy foods, a stable income and job security, and an environmental quality. There is all important to address in order to ensure that everyone has a full and equal access to opportunities that will enable them to lead a healthy life. Again here, looking at different factors that are important. Respiratory infections are in the first two years of life and the increased the chances of recovering asthma in patients. The ER visits and hospitalizations related to asthma in Hispanics was double those in Caucasians and the number of free hospitalizations was 50% higher. As a pediatric successor list — pediatric subspecialist, this is concerning, and only are they being hospitalized, they are pre-hospitalized — they are re-hospitalized 50% higher. This has long-term side effects. We have many other treatment options nowadays that can help to mitigate this. Looking again, factors that can lead to asthma disparities on the right, access to care, no having the transportation that is needed, not every city and not everyone lives in the city, they may not have the transportation to get to where they need to be seem to be receive the health care that they deserve or that they need. Income, poverty does affect access to health care and health insurance. Environmental allergies, people have asthma who live in urban areas with a substandard housing are exposed to more of the asthma triggers that can include mold, dust mites, cockroaches, mice, exposure to cigarette smoke. Exhaust from vehicle from nearby highways and looking at what neighborhoods people live in are important because they affect asthma and the control of asthma. As far as education inequality, the lack of knowledge and the lack of understanding disease can lead to problems such as using their asthma inhalers incorrectly which I alluded to earlier or not understanding that there are controller medications and rescue medications and when to use each. Languages and cultural differences, people who speak Spanish as a primary language may struggle to get appropriate health services. I live in South Florida, there is a high population of Spanish-speaking people. During the pandemic I was really disheartened and it was really a wake-up call for me. I had a patient who was on the West Coast of Florida who I had followed for a long time and of the family reached out to me desperate because their older child was dying of COVID in the ICU. They do not have anybody who could communicate with them in Spanish. They did not know what was going on. Even when you think people should have access to someone who speaks their primary language, they may not. You never know, the importance of advocating. I was so happy that the family reached out to me because I was able to help and be a liaison because there is more frustrating in a situation that is an emergency and you cannot receive information and know what is going on in your primary language. It is not just about the language, it is at a level that they understand. We talk about literacy also, we need to make sure that resources are at a level that can be understood by the patients and their families. Shifting now and talking about mortality. Mortality for asthma is higher among Latinos, especially from origin of Puerto Rico. It is 75 through 200% higher than in Caucasians. The Latino school age children from Puerto Rico, Mexico, and Central and South America, the use of rescue medications is greater than other groups. Controller medications may not be used or available, they are not receiving proper treatment. I children have a 40% higher risk of dying from asthma compared to non-Hispanic whites. You can see to the right to asthma health disparities in general, African-American children have 4.5 times higher ER visits, African-American adults is 2.8 times higher and Hispanic children is 2.1 times higher visits to the emergency room and looking at sobering statistics, seven times higher risk of death from asthma in African-American children and two times higher in Hispanic children. How can we address these disparities? Different efforts to exist to increase participation levels of minority patients in different educational programs and research and patient engagement programs that can help to address the many barriers. The distrust and fear of influencing immigration status I can honestly speak to because I’ve had patients who are undocumented and they are concerned about being deported. Creating a place where they can come and they know I am just here to take care of you and your child and I’m not here to report you or talk about your immigration status at all. That is not my purpose. Earning their trust is something that is very important. Education and at a level that is appropriate for the patient out of the family. Overcoming the language barrier, we were talking about Hispanics and Latinos, having a translation service available is important. In some patients there is a lack of interest. As they learn more it is likely that they will become more interested in this. I want to take a moment to talk about Unidos Hablemos. Thanks to a grant, key stakeholders and faith leaders worked together to establish trust within the Hispanic and Latino community and engage the community in patient centered outcomes research and clinical effectiveness research. The project convene Hispanic people with asthma, patient advocates, patients, researchers, leaders in the Hispanic community to develop a robust agenda to participate in a series of virtual, live sessions to introduce the attendees to PC OR/CER, to share and learn how to share the needs of researchers, caregivers, those who have COVID or their caregivers. I parted advisory group was comprised of six Latino patients diagnosed with covid-19 and/or asthma, a faith-based Leader, health care providers, researchers, and a problem evaluator. — program evaluator. They identified the theme of the ritual series, determined the agendas, selection of presenters, review of objectives and titles of the sessions and all sessions were delivered using the zoom language interpretation features of the attendees could hear that presentation in either English or Spanish. They were offered the following in English or Spanish, the pre-and post-knowledge surveys, polling questions, and decision evaluations. Each project advisory group member, the fake leader and guest presenters and consultants or compensated after each session. It was very interesting what we found. On average 700 people registered. 382 unique people participated in discussions. Between October and January there was a 6% increase in attendees identifying as Hispanic patients or caregivers and a 20% increase in the attendees requesting handouts in Spanish. I hope that was amazing. It gave me the hope that people were actually referring back to them and using the information that we shared. When asked if they would be willing to be a research subject in an asthma study, 66.4% agreed. That is incredible. 15% did not agree and 18% would depend on whether their doctor thought it was a good idea. This is going back to the trust. The relationship between the physician and the patient or the medical team and the patient and the trust that they have. We found that over three quarters would be willing to be a patient partner or advisor for an asthma study while only 3.2% did not agree. The remaining 20% were unsure of the persist station — of the participation or wanted to know it their doctor thought it was a good idea. — if their doctor thought it was a good idea. This is a good idea for health professionals, and biannual reconvening virtual conference for those who participated in the virtual series. FA Facebook group was created for a patient centered outcomes research and sharing experiences, future events, our work, poems or readings, we are looking for funding for capacity building to draw upon the Hispanic and Latino community and develop a patient research expert or ambassador who will provide education about all expects of resorts from developing the research question to being involved in research as a subject or advisory for the project. Hasn’t is a patient is to share with researchers about the pool of experts and encourage them to involve them in their research program. In order to increase the numbers of patients who are a Latino or Hispanic origin in research which is really necessary. The virtual series engaged patients in their native language and invited them to not only learn about asthma and covid-19 but more importantly provided them information and tools to participate in patient centered outcomes research and clinical effectiveness research. It was an honor to be part of this is a primary investigator. I will shift and talk about disparities in food allergies. I think it is important to say that not only in asthma but also in food allergies there is just a lack of data across the board. I’m using the term Hispanics or Latinos, I’ve spoken to people with different countries of origin out of the same way you cannot lump all locations together, you cannot lump all Hispanic or Latinos together. Unfortunately, that is the information that we have. Ideally, depending on where you are from, we are all different and dependent on your country of origin, it is different. It is important to increase the number of patients in research so we can improve the equity in health care to improve the disparities that exist and address the needs of different patients. Looking at race and ethnicity, it was associated with sensitization to one of one of the food allergens Hispanic children had higher odds of allergies to corn, fish, or shellfish. The prevalence of physician diagnosed food allergy in urban children was 3.4 or lower than schoolchildren in New York City. Physician diagnosis of food allergy was higher in private’s correspondence 17.5% as compared to public school respondents, 7.4%. There may be something due to a lack of proper medical access or equity in the health care that is provided. Even when there was a history of severe reaction, half of the children in public schools lacked a physician diagnosis of food allergies. Food allergies in the U.S. has increased in recent years. It has been seen amongst all groups and looking at the increase of food allergy per decade by race or ethnicity, you can see here non-Hispanic Blacks was 2.1%, Hispanics was 1.2%, and non-Hispanic whites was 1.7. — was 1%. National data on food allergies from plane 21, food allergy overall except between wheat are greater in Blacks compared to whites. Whites had a lower chance of food allergies and Hispanics and Asians and minority pediatric patients and those in high poverty towns were less likely to see allergists or receive diagnostic testing. It is important to be able to address the disparities that exist in order for the patients to be properly diagnosed and receive proper management. I will shift and talk about disparities in the food allergy management. Minority patients were less likely to have a food allergy action plan and shorter time for — shorter specialist follow-up over time. That is a concern. And Hispanic parents were less likely to identify signs of food allergy reactions and less likely to identify triggers. Fewer epinephrine autoinjector as were associated with a higher prevalence of Hispanic children and those with limited English proficiency in low social economic schools. There are fewer autoinjector’s available. Massachusetts school nurse survey showed white children were five has more likely to have epinephrine autoinjector’s dispensed. My references are on the bottom. Looking at health care utilization in food allergy, whites come Hispanic, and other races had lower medical costs with increasing household income. Hispanics had higher rates of ED visits for food into his anaphylaxis than other children. Medicaid enrolled children presented to the emergency room for food induced anaphylaxis are less likely to receive epinephrine before arrival to the emergency department and what children were more likely to have the early epinephrine treatment. As we know in anaphylaxis, minutes matter. The sooner you receive the proper treatment which is epinephrine, the more likely it is going to work and the quicker it will work. I think that is important to keep in mind. They need exist to improve food allergy management so the lowest income children have the greatest cause for emergency department visits and hospitalizations with lower spending on social daycare and out-of-pocket expenses. That indicates that costs are different for these patients. I want to talk about food insecurity. Households that were at times unable to acquire adequate food for one or more household members because they had insufficient money and other resources for food. Limitations for food allergic patients include the higher cost of allergen free foods, an estimated 21% of children with food allergy in the U.S. experiencing food insecurity. Food deserts are actually areas with limited access to nutritious and affordable food. You can actually have a food desert in a large city. I will show you a picture in a few minutes. It really — it is not only interesting but it is important to be aware of. If you live in an area where there are many supermarkets and food markets, he would think that food insecurity is less likely to exist. That may not be true. Looking particularly at now at food insecurity and race, in a study clinics at Arkansas children, African-Americans have significantly higher food and security rights compared to Caucasians. When 85 children from the center with food allergy and cap food insecurity. — had a food insecurity. Occasions had a higher overall health literacy rate rate. That also is related to allergic reactions and epinephrine autoinjector use. I would like to restate the importance of when we give resources and giving information, we need to be sure that it is at a level where the patient side the families can understand them. Everyone can read, everyone can read at a high school level. It is important to keep this in mind and be cognizant of it so that you can address it. Health literacy was also higher in patients with food security as compared to those with food insecurity. It is a reminder of the need for support for these families and they need to better understand these disparities that do exist among different patient populations with food allergies. There was a study that was done in Hartford, Connecticut that looked at low income Republican — Puerto Rican families. Latino families were 22.8% more likely than non-Latino whites to live under poverty level. Attending cultural event or church was an indicator of a stronger social network and food security. In Spanish-speaking only households, this was considered a risk factor for food insecurity. Food stamps appear to be a major proportion of monthly household expenditure, as opposed to supplemental, likely education on management of food stamps would be helpful for these patients. Referral to so four is also likely to be helpful — referral to social work is also likely to be helpful. Survey of low income brain at Latina, and what would you Puerto Rican women, almost 2/3rds participated in the WIC program. One third was uninsured, and one half was bilingual and one there had food insecurity prior to the survey. All symptoms of depression when the household experienced food and security. Medical team can ensure that information regarding support is available. Offering materials in their native or preferred language is important. Talking a little bit about food insecurity and different groups. Latin X, Native Americans, and Blacks are disproportionately affected by food insecurity. As we know the pandemic has really resulted in many people experiencing food insecurity for the first time. 50 million people were affected. The majority of allergists do not screen for food insecurity and of the 59 allergists responding they said they do not have the staff or resources to optimize their help for their patients. This is a map I wanted to show you. At the bottom is the USDA website you can actually put in — this is a map of the whole U.S.. You consume in — zoom into different areas and see different areas of a food desert. This is the actual map of the U.S. with food deserts. As an interactive tool and it looks a little income and low access by mileage. I encourage everyone to do this because I was surprised. Even living in South Florida, a very big city and there are different parts of it, there are definitely food deserts in our area. Resources like the emergency food assistance program which is a program that help families during the pandemic often did not have food allergy friendly foods great our patients — friendly foods. Our patients often had no friendly foods. One food bank offered food through the Postal Service and another what’s in gift cards as they can make online purchases of allergen say foods. I now, I this because the cost of food, we do not think about this often. It is very difficult for patients who are economically or socially disadvantaged. Especially nowadays going to the grocery store and the cost of food is high and the cost of food alternatives is even higher. We really need to be aware of the cost differences, however there may be resources, it is important to help our patients with this. Went to the grocery store and looking at ice cream that is based on how milk — cow milk. You can get two of those for seven dollars versus 599 each for the nondairy alternative — $5.99 each for the nondairy alternative. Land O Lakes was $2.37 as compared to the alternatives which is much higher. Up to $5.59. Having a multidisciplinary approach is important. If somebody is not allergic to a food, delabelling is important and can positively impact the family not only emotionally and a lack of distress of living with a food allergy. It will save them money as well. In summary, a need exists to improve the medical care of patients with asthma. Reese was to improve the understanding of the disease and improve treatment in Latino communities is also needed. Outreach is needed to improve the outcomes of our asthmatic patients and our communities. Improve health equity, and decrease health inequities. Recognize differences exist in patients of different races or ethnicity with food allergy. Remembering we have a responsibility to advocate for our patients with food allergy, especially those experienced in despair is in health care, working with primary care, and referring to social work. Allergists can help to screen and identify patients at risk of food insecurity. Some of the following are some resources, the allergy and asthma network website. There are resources in Spanish and English. Communication with the medical team is important. Remembering only the primary language whether it is spoken or read, but also be health literacy lelve. I would like to thank the allergy and asthma network or the use of slides and graphics that I would like to thank the Eugene wash and engagement award for the engaging asthma and asthma patients in the PCORI grant.

>> I was such fantastic information. We have a steady stream going for the chat of people who are really enjoying this. We have a few questions. If you have questions, please put those into the Q and A and I will start with some of these now. Lynn says offering to help enroll families in food programs like SNAP/Wic or connecting them to someone who can is more important than providing the information. Many families actually struggle with the actual implication due to the language, literacy, technology. Do you have anyone in your clinic like social workers or anyone else like that that is able to help your patients enroll in WIC or SNAP?

>> Are the children’s hospital

–Dr. Hernandez-Trujillo: At the children’s hospital we have people who can help. Finding information is not enough. Sometimes we need to actually help them. The way I told you about my patient that needed help with a translation. I felt like that was an important opportunity. Providing the information is not enough and helping them walk through it and obviously social work when it is available, it is not available everywhere. Having someone. It is not had to be social work, it may be a coordinator. Everybody’s setting is a little bit different. Providing the information is not going to be enough. They need someone to advocate for them.

>> We know how fun it can be to fill out forms. If there was someone you could refer them to, the local with offices could help with that. I used to run an asthma home visit program. Who would help people with paperwork for different things as well. That may be an option. If you have an asthma home visit program. They have a wealth of information. Let us see the next one. Interesting findings for the food allergy inequalities. Some of the policy solutions that my work to reverse these trends include universal access to epinephrine in school. Better screening for food allergies by pediatricians. Patient counseling/health education to be covered by Medicaid. What if that be a dream? — wouldn’t that be a dream?

Dr. Hernandez-Trujillo: Those are very important. I think in an ideal world and we are talking about schools. I have had many patients who come to me and their first reaction was in a restaurant. Having access the same way we have AEDs, the dream would be to have epinephrine autoinjector available or epinephrine available wherever there is NAED. Not every plane may have available epinephrine. If someone has epinephrine that needs to be drawn up and there is no one who has it drawn up, that is an issue as well. Having access in many different settings. Restaurants, that is where we eat. Having it available whether there is an AED would be imported because the same way that someone can have an emergency on the athletic field, the same thing happened great you can have anaphylaxis from food during exercise or competitive athletic event. Having it available, that would actually be incredible.

Andrea: We know that there are a lot of people who have anaphylaxis for the first time to food that they have not been allergic to. Epinephrine on airplanes and one of our staff members for the asthma network is a physician’s assistant, she has to review and make sure that she has written down how much you would have to draw for an adult and a child because she knows the flight attendants cannot do that on the flight. That is an area that needs a lot of work to do. To know that there are autoinjector is on the plane. A perfect world. We have another person out of their asking about can you explain the difference between allergy friendly versus allergy free?

Dr. Hernandez-Trujillo: I think the term allergen friendly is a better term. It has more to do with the cost and contamination. — the cross-contamination. I partnered with faire and the Miami Dolphins and we were working with small business owners who — it is a owners talking about cross contact — it is business owners talking about cross contact. Allergy free, there would be wonderful to be able to say that. I think it is a struggle because we list for example on labels the top nine allergens. There are many, many patients who have other allergies. I think it is difficult. Allergy friendly I think is a better term overall. Allergy free may not be the best term or realistic for everybody.

Andrea: There are so many other things that people can anaphylax to them may not be allergy free. Someone is asking when a food desert is.

Dr. Hernandez-Trujillo: Food deserts or areas, I was using — are areas, I live in a suburban area, food desert is an area where people just cannot get the access that they need to the food that they need. These food deserts and again that USTA website I think is really an eye-opener for everyone. You can see in your particular location and look in a different part of the U.S. or the whole U.S., the map I showed. It is areas where there is a lack of food for people. I think again, that is important because I was not even aware of the term at all. Honestly, until a few years ago. That was not something I was even aware of. I think it is important. We can assume a lot of things but the reality that people live in is different.

Andrea: Agreed. This can be common in areas, my daughter when she was in college it was the same thing. There were no grocery stores, there was a gas station and that was it. Luckily she had a car but a lot of people around her did not. It would have been a round-trip for them to walk to go to the grocery store and get back to their apartment. At rural areas as well.

Dr. Hernandez-Trujillo: Someone in the checkbox, Native American reservations, they are often located in food deserts. It is important to know. I talked about the Latinos and Hispanics but there are such needs to address this and help improve disparities that exist and improve equity in health care. I think that programs like this, the reason they are so important is not only are we talking about it. If we never talk about it, we cannot fix it. We come up with solutions. This is not something that one or two groups can do. This is something that we need to work on together.

Andrea: Let us get these kids fat an — let us keep these kids healthy and happy. Connect these people and food agencies, in Massachusetts we have project bread that can help our community health workers. Fantastic resource. We need that everywhere.

Dr. Hernandez-Trujillo: That is an awesome example. I was at a health fair about a week and a half ago. It was an amazing opportunity. I was there to talk about immunodeficiency food allergies. They had a truck that was giving out food. It was amazing to see the families and we had such a great attendance and they had told me I went with the medical students and they told me we had never seen it. I said that is because there is a real need. They went from place to place. They were there not only to get the food but they wanted to learn and hear about what we did and hear about food allergies and asthma. Immunodeficiency’s. Any opportunities like that and working within your local community, you can make a big difference.

Andrea: Feel free to connect with each other, someone has a program and it is not available in your area, there is no reason to reinvent the wheel. Look for these other programs and model what they are doing already in your area. Thank you everyone for sharing some of the things that you had. Someone says I am adjusted in collaborative and allergy providers, demonstration projects that lead us toward a value-based care approach. People living with food allergies, do you have recommendations for models that focus on health equity?

Dr. Hernandez-Trujillo: I do not but I commend you for that, for your work. As we learn more and I said this in the middle of the talk and I should have opened the talk with the fact that we do not have enough information. We do not have information in place. We do not know enough about different populations and we just need more and more research and we need to increase the different participation reasons. That is why I thought it was such an important opportunity. I come up myself, does not have any recommendations for models that focus on health equity. Work like yours will obviously lead us to that. I not aware of any myself.

>> There are so many things that are out there and coming back to what you talked about with the grant, I was lucky enough to participate in 110 years ago and it is the patients who are leading the research. Saying what about this? Have you thought about that? For those of you are thinking about being in research, it is invaluable. Oftentimes the researchers may not have asthma or food allergies or eczema or something like that they are studying. Get your voice out there and let them know what is important to you. I think we have another question here. Public and private schools have diverse students and school nurses providing health care for students with food allergies and food insecurity. What or how can school nurses activat–actively decrease inequality between students?

Dr. Hernandez-Trujillo: Particularly in the asthma world there have been different — looking at control of asthma specifically, low income school populations. The importance of the school nurse. I can actually be set as well because I mentioned some studies that talk about if you are in a school that is lower income it will be less epinephrine that is available. It does not mean that there is less food allergies. There is an opportunity and I had always said the school nurses are integral to the care of our patients. Particularly the young pediatric patients with asthma. In our populations, the parents, I talked about that, they may not identify that the child is having an asthma attack. He has been congested and he is coughing. There have been studies that have shown that in programs for that children are a minister of the medications at school the control of asthma improves. Their outcomes improve and those are the types of programs, that is Mono example. With food allergy and maybe access to epinephrine. Again, getting the opportunity to talk to the schoolteachers and for many years, I had once a year’s to the school nurses about anaphylaxis and food allergies and epinephrine and the use of epinephrine. I think it is important to include our school nurses because they are vital and for many patients they may be the most important person that can help get that child adequate care. They may be the one who sees them coughing when they are on the playground or coming in because they have shortness of breath. They can really raise the flag and say your child needs to be seen by their pediatrician or by someone in the medical community to help address this. I think that is final and I am so happy that you address that. They are the unsung heroes, they have been vital. For me, I love to partner with the school nurses and I have for many years. Thank you because I did not put that into my talk.

Andrea: I see hearts coming up on the screen. I wholeheartedly agree. I have three children with asthma and food allergies and they are adults now. I do not know what I would have done without the school nurse. It was terrifying even go to the grocery store when my kids were in school because I would get a call that one of them was having an asthma attack. Thank you school nurses, you are underpaid and overworked. We love all of you. Thank you so much. We have subjugated the chart — we have something in the chat thing that we have the installation of roundabouts. Adding around about two intersections can limit the street for buses if the terms are too tight. A bus cannot take people from their neighborhood to the nearest grocery store.

Dr. Hernandez-Trujillo: Thank you for that comment because that is a great example. Depending away patient lives if there is more exposure to exhaust, when we are talking about food deserts, if you cannot get to the store because of that, that is a perfect example. I was not aware of that. Thank you for sharing.

Andrea: Someone says dollar stores take over where grocery stores used to be. I actually saw something online that there is a woman and she runs a blog or whatever people do these days but she actually makes recipes from the dollar store because she knows that is all that people cannot afford. Sometimes you have to be creative. One thing I want to ask about when we are talking about food insecurity in your area or other areas of the country with your work with quad ai. Have you seen an increase in food pantries in colleges and the high school level?

Dr. Hernandez-Trujillo: I have not seen it. I will — I will need to go back and look. I cannot say that I have looked recently. What I can say especially during the pandemic, the food pantries, so many people were in need that they were short of food. We know that. I will need to look specifically to answer your question. I’m not aware of that at all.

Andrea: That might be something that people are on the line may see. I see my local university started a food pantry and even some of the high schools in my state have started food pantries. If you are in need or if there is patients or whoever you are helping, it sounds strange but take your schools and see if there may be something there. Someone in the chat has a question, of children with asthma, what is the percentage of those with food allergies? This may be tricky to answer.

Dr. Hernandez-Trujillo: I cannot answer that directly. I cannot. I will be happy to give that and get that information to you and we can email you. I do not know that off the top of my head.

Andrea: We know that you can develop a new food and allergy at any time as adults. My food allergy developed as a n adult. Just checking, someone says the many times I’ve been the parents throughout the year for an update to their food allergy plan and EpiPen or epinephrine autoinjector but I never get one. Epinephrine pens are expensive for these kids to get.

Dr. Hernandez-Trujillo: That is something, one of the things that when I talk to school nurses, if a child, if you know a child has anaphylaxis, it is a challenge working with her parents. It is so important when you are actually able. With some persistence they are able to get the proper medication. They tell school nurses if it is not clear, if your plan is not clear, please ask for clarification. The whole purpose of an action plan is for you to look at it and no when it is necessary. When to put into action. — went to put it into action. The action plan, if you have a child with an autoinjector or epinephrine available, the action plan is key.

Andrea: One thing is to keep checking back because insurance and prices change all the time. I remember paying $600 for my epinephrine and a few months ago I went to get refills. The generic version was $10. Can you give people less — can you give people an idea of what is coming down the line.

Dr. Hernandez-Trujillo: there has been interest in intranasal, epinephrine, sublingual epinephrine, there is a lot of hope for all of our patients, with anaphylaxis and food allergy.

Andrea: That is also great for people who have needle phobia. We will see with the prices are like when that comes out eventually. I’m so sorry to have taken so much of your time. We have plenty going on in the chat. We have two more webinars to give, thank you everyone for joining us, keep an eye out for that that will have information and links to everything you will have a link to get your certificate for attendance. If you need CE’s or any of that, please join us for our next webinar, let us clearly error — let us clear the air. Thank you again, I could chat with you all day about all of this.

Dr. Hernandez-Trujillo: It is Mike pleasure — my pleasure. Thank you all for attending and participating. Thank you and have a great day.

Andrea: Thank you everybody.