A Case of Usefulness of Auto-Injectable Adrenaline as a Prophylactic Countermeasure Against Bee Sting for Forestry Workers

Introduction

Forestry work is usually performed in mountainous regions. In disaster situations in such regions, there can be difficulty communicating and obtaining emergency transportation, which might result in a fatal outcome. Fatal accidents in the field of forestry are often associated with fallen trees or rolling timber (Brodie & Ibrahim, 2010; Lilley et al., 2020; Springer et al., 2018; Struttmann & Scheerer, 2001), but anaphylaxis induced by bee stings can also result in fatal outcomes in this line of work (Ministry of Agriculture, Forestry and Fisheries; Nishio et al., 2020).

Anaphylaxis is described as a sudden-onset, immediate reaction that carries a risk of death. Fatalities can occur due to asphyxiation from laryngeal or oropharyngeal swelling, collapse from hypotensive shock, cardiac arrest, or acute severe bronchoconstriction that causes respiratory failure and arrest (Watts & Marie Ditto, 2019; Whyte et al., 2022). According to reports from the Ministry of Agriculture, Forestry and Fisheries, or Forestry and Timber Manufacturing Safety & Health Association in Japan, over 10 fatal bee sting accidents occur per year all over Japan, and over 200 bee sting accidents including 0–3 fatal accident occurred each year in the forestry field in Japan until 2006 (Forestry and Timber Manufacturing Safety & Health Association, 2022a; Ministry of Agriculture, Forestry and Fisheries, n.d.-b).

As a result, since 2015, the Ministry of Agriculture, Forestry and Fisheries in Japan has established national regulations for forestry workers with bee or wasp allergies, allowing them to carry auto-injectable adrenaline when they engage in forestry work (Forestry and Timber Manufacturing Safety & Health Association, 2022a; Watts & Marie Ditto, 2019). Employees are to arrange for workers with bee or wasp allergies to contact local medical facilities for the prescription of auto-injectable adrenaline. Adrenaline is a sympathomimetic catecholamine that increases blood pressure by inducing vascular smooth muscle contraction, an increased heart rate, bronchodilation, and mydriasis, and it is used as first-line management for anaphylaxis (Muraro et al., 2022; Watts & Marie Ditto, 2019; Whyte et al., 2022). Workers who are prescribed this medication then learn how to use the auto-injectable adrenaline from their health care provider. The auto-injectable adrenaline is a spring-loaded syringe that can act as an emergency medical treatment for severe allergic reactions and can easily be used by the worker if injected in a timely manner. To date, no concrete examples of cases supporting these measures have yet been recorded in the English medical literature.

We herein report a case concerning the usefulness of auto-injectable adrenaline as a prophylactic countermeasure against a bee sting in a forestry worker.

Patient Information

A 48-year-old man was diagnosed with bee allergy 4 years previously by an allergy test at the Ministry of Agriculture, Forestry and Fisheries office. Based on this finding, the worker was provided with an auto-injectable adrenaline prescription. He had experienced bee stings several times but never had an anaphylactic reaction. He always carried his auto-injectable adrenaline when he worked.

One month before the incident in question, the worker had suffered a bee sting to his forearm. In that instance, he had only experienced local pain and swelling at the sting site without any treatment. However, after suffering two bee stings to the head and face region, he felt generalized itching and headache followed by dyspnea for the first time. He used the auto-injectable adrenaline on himself. As he experienced difficulty walking, his colleagues transported him to a local clinic. The physician at the clinic was unable to treat such a patient, so an ambulance was summoned.

Clinical Findings

When emergency technicians assessed the worker, he presented with generalized urtication. His oxygen saturation was 95% at room air, and therefore, he received oxygen by facial mask at 5 liters per minute. Once stabilized, the worker was then transported to Numazu City Hospital, which had an acute critical care center.

Timeline

On arrival to the acute critical care center, he had clear consciousness, his blood pressure was 138/84 mm Hg, heart rate was 66 beats per minute, respiratory rate was 18 breaths per minute, and his oxygen saturation was 99% with an oxygen mask. He still had generalized urtication.

Diagnostic Assessment/Therapeutic Intervention

The admitting diagnosis was anaphylaxis. Upon admission, he received an intramuscular injection of 0.3 mg of adrenaline, followed by drip infusion of 100 mg of hydrocortisone, 10 mg of chlorpheniramine, and 20 mg of famotidine. Chest X-ray, electrocardiogram, cardiac echography, and results of a blood analysis were all negative for abnormal findings. Within 30 minutes, symptoms subsided.

Follow-up and Outcomes

The worker was admitted to the acute care center (hospital) for observation and discharged the next day without any symptoms after prescription of auto-injectable adrenaline.

Discussion

To our knowledge, this is the first report describing the efficacy of auto-injectable adrenaline as a prophylactic countermeasure against bee stings in forestry workers based on the results of a confirmed bee allergy, even though the worker had never experienced an anaphylactic reaction to a bee sting previously.

A previous Japanese report involving a questionnaire survey among Japanese forestry workers showed a high incidence of bee sting experiences (more than 90%), high positive ratio of allergy tests for beestings (more than 70%), and a reasonable number of experiences (9%) of being transported by an ambulance due to a severe condition after suffering a bee sting (Ministry of Agriculture, Forestry and Fisheries, n.d.-a). Based on preliminary research data from 2003 to 2006, there were no fatal cases involving auto-injectable adrenaline among 54 forestry workers (Ministry of Agriculture, Forestry and Fisheries, n.d.-a). In addition, based on a recent report from the Ministry of Agriculture, Forestry and Fisheries in January 2022, there were no fatal cases until 2020 among forestry workers due to a bee sting in Japan following the establishment of regulations in 2015 (Ministry of Agriculture, Forestry and Fisheries, n.d.-b). However, the data reported by the Forestry and Timber Manufacturing Safety & Health Association from 2017 to 2021 reported that the number of fatal casualties ranged from 30 to 40 per year, and the number of injured casualties ranged from 1,235 to 1,314 per year (Forestry and Timber Manufacturing Safety & Health Association, 2022b). The main causes of injuries during this period were being crushed by trees, followed by cuts or bruises sustained in the line of work, injury due to fallen branches or timbers, and falls themselves (Forestry and Timber Manufacturing Safety & Health Association, 2022b). Unfortunately, we were unable to find any data concerning the total number of anaphylactic reactions aside from those related to bee or wasp stings among forestry workers.

Forestry workers in Italy have also been reported to have a generic risk of experiencing wasp (hymenoptera) sting anaphylaxis (Ricciardi et al., 2018). A history of large, local reactions was a strong risk factor for developing a systemic reaction, thus representing a red flag for future anaphylaxis and meriting prescription of an adrenaline auto-injector (Whyte et al., 2022). As the immediate injection of adrenaline was vital for patients suffering from anaphylaxis, this advance effort from Japan involving prescription of auto-injectable adrenaline as a prophylactic countermeasure against bee sting among forestry workers based on a positive allergy test for bee sting may be used as grounds to help protect forestry workers around the world. In addition, this system would be useful if other groups who work outside (e.g., agriculture workers, environmental scientists, surveyors, remote construction workers [such as those involved in dam building]) and have similar risks adopted it as well. To promote this system among other industries, occupational health physicians or nurses who have the responsibility to manage and administer the total operation of occupational health services may play an important role in the future (Romero Saldaña et al., 2019).

The major limitation associated with case reports is the lack of generalizability, inability to establish a cause-effect relationship, danger of overinterpretation, publication bias, retrospective design, and unusual focus. Each one of these factors may inadvertently distract readers from the main findings (Nissen & Wynn, 2014).

Conclusion

The present study described the usefulness of prescribed auto-injectable adrenaline as a prophylactic countermeasure against bee stings for forestry workers known to have such allergies based on allergy tests in advance. This framework may be useful for protecting forestry workers around the world.