FAQs for Return to School and COVID-19 Vaccinations among Pediatric Solid Organ Transplant Recipients in the United States, 2021

Resource Category: COVID-19, Other Helpful Resources

Resource Type: Info Sheet

Age of Child: 6-12, 13+

Years Since Transplant: <2, 3-5, 5+

The COVID-19 pandemic continues to create many questions about returning to school for pediatric solid organ transplant (SOT) recipients and their families. These recommendations from a team of pediatric infectious disease experts are focused on K-12th grade. When reviewing this document, it should be remembered that:

1) Information and knowledge about COVID-19 are constantly changing and being updated,
2) No single answer is going to be appropriate for every child after SOT,
3) These recommendations are not meant to replace advice from your transplant team. We recommend discussing individual details regarding your school plans with your child’s transplant provider.

What things should be considered when assessing individual risk/benefit associated with in-person school attendance?

Individual risk depends on numerous patient-, community-, and school-related factors:

  1. Patient factors include level of immune suppression, presence of medical conditions, and vaccine status. Because vaccines may not work as well in SOT recipients as in other people, we encourage all SOT recipients to continue to take steps to prevent infection regardless of vaccine receipt.
  2. Community factors include the level of transmission locally and vaccine rates in the community. See the CDC website for information in your area: https://covid.cdc.gov/covid-data-tracker/#datatracker-home
  3. School factors include strategies like masking, social distancing, cohorting, symptom screening, ventilation, and hand hygiene. Discuss with your school which measures will be in place.

What are considered the most important infection prevention measures to be in place in schools for a pediatric SOT recipient to safely attend?

We support universal masking for all staff and children 2 years of age or older in schools this year, as recommended by Centers for Disease Control and Prevention (CDC), American Academy of Pediatrics (AAP), and Pediatric Infectious Diseases Society (PIDS). A higher risk pediatric SOT recipient should wear a medical-grade mask (3-ply disposable mask, also called a “surgical mask”), if possible, at all times when in school, even if other students and staff have masks or cloth face coverings on. Masks are also encouraged for all SOT recipients during outdoor activities (recess, after-school sports) where prolonged close contact with other individuals is expected. In situations where universal masking does not occur, we recommend that all SOT recipients wear a medical-grade mask at all times, regardless of vaccination status.

Additional measures that have been helpful in containing the spread of COVID-19:

  • Physical distancing: Maintaining 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.
  • 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 practices that follow guidance from local health departments and the CDC.
  • Cohorting: using smaller and consistent groups/classes throughout the day, especially during higher risk activities such as lunch and gym class.
  • 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.
    • We suggest that families tell teachers that their child has had a transplant, as well as teachers of siblings, so that families can be quickly made aware of sick contacts in the classroom.
    • We encourage schools to implement policies about 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.

Is it safe for my child to go back to school if they are the only one masking?

There is no single right answer for all pediatric SOT recipients. There is a higher risk of transmission of the virus that causes COVID-19 if masks aren’t worn by everyone, but individual, community and school factors should be considered when making decisions about school attendance.

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:

  1. Having undergone transplantation in the last 3-6 months
  2. Receiving high doses of immunosuppression (such as for treatment of rejection)
  3. Having other medical problems such as cancer, obesity, or certain lung conditions

Discuss your child’s risk with your transplant provider to assess if he/she will be safe to return to in-person school, especially if universal mask requirements are not in place at the school.

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. Individualized Education Plans (IEPs), 504 plans, and/or Individual Health Plans (IHP) may also be helpful for some students. 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, if needed. These accommodations may also be beneficial for siblings of transplant recipients and should be discussed with schools, as well.

Should eligible SOT recipients receive COVID-19 vaccinations?

Absolutely. COVID-19 vaccination is strongly recommended for all eligible individuals, including SOT candidates and recipients. Ideally, eligible children awaiting transplant should complete COVID-19 vaccination at least 2 weeks prior to transplantation to maximize immunologic response. COVID-19 vaccination of household members and other close contacts around SOT recipients is also strongly recommended.

Should eligible SOT recipients receive additional (3rd) doses of COVID-19 vaccinations?

Recently, the FDA authorized administration of a 3rd dose of mRNA vaccines in people with compromised immune systems, which includes SOT recipients 12 years of age and older (Pfizer-BioNTech) and 18 years of age or older (Moderna). We encourage eligible pediatric transplant recipients to discuss this additional dose with their transplant team. This dose should be given no sooner than 28 days after the 2nd mRNA vaccine dose.

If a child had COVID-19 infection, does he/she still need a vaccination?

Yes. COVID-19 vaccination is recommended for all eligible SOT recipients, including those with a history of prior COVID-19 infection. The vaccine can be given once the child has recovered. If you received COVID-19 monoclonal antibodies as treatment, it is currently recommended that you wait 90 days to start vaccination.

Are mRNA COVID-19 vaccines safe for pediatric SOT recipients?

mRNA COVID-19 vaccines are well tolerated with similar safety in SOT recipients and the general population.

What serious side effects have been reported in children after receipt of mRNA COVID-19 vaccines?

Serious side effects, including heart muscle inflammation (myocarditis), have very rarely been reported after mRNA COVID-19 vaccination. The risk of serious side effects is low and the benefit of COVID-19 vaccination in individuals 12 years of age and older far outweighs the potential risk.

Should SOT recipients utilize antibody testing against SARS-CoV-2 when assessing personal risk for COVID-19?

Antibody testing following vaccination is not routinely recommended. Antibody testing should not be used to help decide if you should get a 3rd mRNA vaccine dose.

Helpful Resources:
American Academy of Pediatrics (AAP)
Center for Disease Control and Prevention (CDC)
• Considerations for schools: https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/k-12-guidance.html
• COVID-19 Vaccines in Immunocompromised People: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/immuno.html
• Delta variant: https://www.cdc.gov/coronavirus/2019-ncov/variants/delta-variant.html
• V-safe: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/vsafe.html
American Society of Transplantation
Action Learning Network

This document was created by:
Kevin J. Downes, MD, Children’s Hospital of Philadelphia
Rachel C. Orscheln, MD, St. Louis Children’s Hospital
Victoria A. Statler, MD, MSc, Norton Children’s Hospital
Melissa K. Cousino, PhD, C.S. Mott Children’s Hospital
Marian G. Michaels, MD, MPH, UPMC Children’s Hospital of Pittsburgh
William J. Muller, MD, PhD, Ann & Robert H. Lurie Children's Hospital of Chicago
Tanvi S. Sharma, MD, MPH, Boston Children’s Hospital
Michael Green, MD, MPH, UPMC Children’s Hospital of Pittsburgh
Monica I. Ardura, DO, MSCS, Nationwide Children’s Hospital
Lara A. Danziger-Isakov, MD, MPH, Cincinnati Children’s Hospital Medical Center