FAQs: Children Returning to School After Solid Organ Transplant Amidst COVID-19
The coronavirus disease 2019 (COVID-19) pandemic has created many questions about returning to school for pediatric solid organ transplant (SOT) recipients and their families. While the risk of getting COVID-19 in school will never be zero when COVID-19 cases are present in a community, a team of pediatric transplant infectious diseases experts have provided information to help families make decisions with their transplant teams about school attendance for their child who has received a SOT (liver, lung, kidney, heart, or pancreas). These recommendations are focused on K-12th grade. When reviewing this document, it should be remembered that:
- Currently there are many unknowns about COVID-19, so this document will be revised as we learn more.
- No single answer is going to be appropriate for every child after SOT.
- State and local officials will ultimately make decisions about when or whether schools are in-person or virtual.
- These recommendations are not meant to replace advice from your transplant team. While we hope that this document will be helpful, we would recommend discussing individual details regarding your school plans with your child’s transplant provider.
Are pediatric SOT recipients at higher risk for getting COVID-19 compared with other children?
Children of any age can get COVID-19, but they seem to have milder disease than adults. Pediatric SOT recipients do not seem to get COVID-19 more often than other children.If infected with COVID-19, are pediatric SOT recipients at higher risk for developing severe disease or complications?
Severe disease means that the infected person is admitted to the hospital and may require admission to the intensive care unit, or need a ventilator to help them breathe.
Based on experience with other viruses, and from reports of COVID-19 in adult SOT patients, there are a few things that may increase the risk of severe COVID-19. These include:
- Having undergone transplantation in the last 3-6 months
- Receiving high doses of immunosuppression (such as for treatment of rejection)
- Having other medical problems such as diabetes, obesity, or certain lung conditions (refer to CDC website under Helpful Resources for more details)
It is not known if the above factors also put children with SOT at risk. In fact, of all the reports among pediatric SOT recipients with COVID-19 published so far, the majority have had mild symptoms and recovered.
It is not known if getting infected with SARS-CoV-2 increases the chance of rejection. Although some pediatric kidney transplant recipients with COVID-19 have had mild graft dysfunction that resolved, most have not had rejection.
Does COVID-19 present similarly in pediatric SOT recipients as in other children?
Based on what we know so far, the types of symptoms seen in pediatric SOT recipients are the same as reported in other children. In fact, many children have no symptoms. When they occur, symptoms most often include fever, cough, sore throat, and diarrhea.Are some pediatric SOT recipients at such high risk that they should not return to school this fall?
There is no single right answer for all pediatric SOT recipients. The decision will depend primarily on how many active COVID-19 cases there are in your school and community, in combination with specific details about your child. If the school is opening, then we encourage all SOT recipients and families to speak with their transplant team about whether their child should return to school. Children who have had a recent transplant, are receiving high doses of immune suppressive medications, or who have other serious medical conditions may want to consider other learning options. This is particularly important if living in an area where there are increasing rates of active COVID-19 cases in the school or community. The way rates are calculated may vary by districts and may be different in schools vs the community. Some experts suggest that high community spread is defined when more than 10% of tests are positive (10 positive tests out of 100 tested over a 7 day period). Given possible changes in community COVID-19 rates, it will be important for parents to discuss options with their child’s transplant team and medical provider.Can a sibling of a high-risk pediatric SOT recipient return to school?
Most siblings are encouraged to return to school with infection prevention measures (face masks or coverings, physical distancing, proper hand hygiene) practiced and reinforced. Siblings of higher risk SOT recipients should practice the same infection prevention measures outlined below.Is there value in antibody testing for pediatric SOT recipients prior to return to school?
No. Currently, COVID-19 antibody testing is not of benefit in helping to decide about going back to school. Even when a SOT recipient has antibodies, we do not know how well they are protected from a new infection or how long protection lasts.What are considered the most important infection prevention measures to be in place for a pediatric SOT recipient to safely return to school?
Parents are encouraged to ask what procedures are in place to help ensure the safety of both children and staff during school hours. Experience from other countries where children have returned to school are reassuring in regard to safety, if appropriate measures are taken. However, these reports do not comment on pediatric SOT recipients specifically. The following measures have been helpful in containing the spread of COVID-19.- Physical distancing: All pediatric SOT recipients should maintain a safe distance (ideally 6 feet, but at least 3 feet or more) from other people at school at all times if they will be spending more than 15 minutes with the other person.
- Masking: If a student cannot stay at least 6 feet away and will be around other students or staff for more than 15 minutes, a face covering should be worn by the pediatric SOT recipient.
- If all students and staff are wearing cloth face coverings, then a cloth covering is enough for the SOT recipient, too.
- If other students and staff do not have face coverings on, the SOT recipient should wear a surgical mask (3-ply disposable mask) or a cloth face covering with a plastic face shield.
- A higher risk pediatric SOT recipient should wear a surgical mask (instead of a cloth covering) at all times when in school, even if other students and staff have cloth face coverings on.
- It is not known if the use of a face shield without a mask provides the same protection. If used in certain situations (needing to read lips, child unable to wear/remove mask), then the shield should fit properly, including wrapping both cheeks and below the chin.
- Hand hygiene: Frequent hand hygiene should be encouraged and available for all students. This can be done by washing hands with soap and water for 20 seconds or using hand gel containing at least 60% ethanol.
- Cleaning and disinfection: Schools should ensure regular cleaning and disinfection practices that comply with guidance from local health departments and the Centers for Disease Control and Prevention (CDC).
- Sick day policies: It is important that students and staff who are sick stay home. Staff or students who have been exposed to a person with known COVID-19 should also stay home. Schools should screen for possible symptoms or exposures. The type and extent of screening will vary by school and may include symptom and exposure screening or temperature checks. We encourage schools to implement policies that define who needs to stay home, what happens if a student or staff member gets sick while at school, and in communication with local health authorities, when a person can safely return to school after illness.
Should families of SOT recipients discuss learning and health accommodations with the school?
We suggest that families tell schools that their child has had a transplant. Although not needed for all pediatric SOT recipients, Individualized Education Plans (IEPs), 504 plans, and/or Individual Health Plans (IHP) may be helpful to identify specific supports or accommodations that will benefit the student’s education in the setting of the ongoing pandemic. We encourage schools to permit SOT recipients increased excused absences, flexible learning, opportunities to make-up missed work, and access to learning materials for at-home instruction.Are there other preventative measures that a pediatric SOT recipient should take in advance of return to school?
- Vaccines: It is very important that pediatric SOT recipients and their household contacts get all of their recommended immunizations, including the inactivated influenza vaccine (ie, flu shot). Currently, science is advancing to develop a safe and effective COVID-19 vaccine; however, it will likely be some time before we know whether pediatric SOT recipients can receive these vaccines.
- Safe living: We encourage parents and siblings to role model safe living behavior when educating their children about the importance of wearing a mask, and performing good cough etiquette (cover your cough) and hand hygiene, so that it becomes a more ‘normal’ part of their child’s daily routine.
- Immune suppression: No changes to immune suppressing medications are needed because of the COVID-19 pandemic in stable pediatric SOT recipients. As always, SOT recipients and caregivers should discuss a plan with their transplant provider of what to do should their child get sick.
