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Q&A: Returning to school, post-transplant

As schools reopen for in-person learning, what should bone marrow transplant recipients do?
photo inside an elementary school classroom showing teacher and a few physically distanced children
Students and teachers participate in a physically distanced classroom session at Medora Elementary School on March 17, 2021 in Louisville, Kentucky. Photo by Jon Cherry / Getty Images

Editor’s note: This story was first published on March 29, 2021. It’s been updated to reflect the researchers’ recent publication of peer-reviewed research on pediatric transplant recipients return to school during the COVID-19 pandemic and other updates related to vaccination, new guidelines and more.

As schools across the country grapple with what a safe reopening looks like, many families are also struggling to weigh the risk of virus exposure at school with the benefits of being in the classroom.  

While research in the general population points toward relatively low risks from in-person learning, the risk/benefit balance can look different for families of kids with compromised immune systems — such as those recovering from bone marrow transplants — compared to other families. 

Each year, around 3,000 children in the U.S. receive bone marrow or blood stem cell transplants, in which their diseased blood and immune systems are suppressed or destroyed and then replaced with new blood-forming stem cells. As those new cells rebuild the immune system from scratch, these children are severely immune-compromised. Even a cold can kill. So schools — and their notorious germiness — can pose serious risks. 

We spoke with two experts at Fred Hutchinson Cancer Research Center about what parents of these kids should think about as they weigh their options for school. 

Dr. Neel Bhatt cares for children and young patients during and after bone marrow transplant and studies ways to improve their quality of life. In her patient care and research, Dr. Alpana Waghmare focuses on treating and preventing infectious diseases in immunocompromised groups, including children who’ve undergone transplant.  

“We’re encouraging whoever is eligible among the family members to get vaccinated as soon as possible. That's the best way to protect pediatric transplant recipients right now."

Their top messages: 

“We’re encouraging whoever is eligible among the family members to get vaccinated as soon as possible. That's the best way to protect pediatric transplant recipients right now,” Waghmare said. 

Bhatt added: “If families are considering in-person schooling, they should definitely reach out to their primary bone marrow transplant team and think through all the pros and cons of returning, and make a shared decision based upon that.” 

We’ve edited this transcript lightly for conciseness and clarity. 

Even in non-coronavirus times, it’s standard to keep kids out of school for some time after transplant. Can you talk a little about that?

Bhatt: We typically ask patients to stay out of school for at least six to 12 months after transplant because they’re at risk for infection, especially as they are recovering their immune system and are on immune suppression. Patients are often being treated for graft-vs.-host disease, which can also put them at higher risk of infection. [In graft-vs.-host disease, transplanted immune cells attack the patient’s healthy cells.]

In normal times, how do parents and doctors make the decision to send the kid back to school after transplant?

Bhatt: It’s a very variable practice across the U.S. We are trying to understand the variation in return-to-school practices across different transplant centers in the U.S. with a survey project we started before COVID. We found that some centers have a standard operating protocol that they follow to decide when kids should go back. And for some other programs, the decisions are made on a case-by-case basis. 

Usually transplant centers look at whether a patient is on immune-suppression, and/or has any evidence of graft-vs.-host disease. The other parameters are their CD4 counts, and T-cell proliferation to specific antigens. [These refer to how well specific white blood cells are recovering in number and in disease-fighting activity.] They also see if the children have started receiving their vaccinations. In addition, centers often look at patients' physical readiness for going back to school.

Fred Hutch physician-scientists Drs. Neel Bhatt (left) and Alpana Waghmare (right) weighed in on decisionmaking for children to go back to school after bone marrow transplant during the COVID-19 pandemic.
Fred Hutch physician-scientists Drs. Neel Bhatt (top) and Alpana Waghmare (bottom) weighed in on decisionmaking for children to go back to school after bone marrow transplant during the COVID-19 pandemic.

Photos by Robert Hood / Fred Hutch News Service

Waghmare: I would add that even in non-COVID times, I think there is some consideration about circulating respiratory viruses, particularly flu and RSV, in making those decisions about when the right time is to go back to school.

For me, one of the small comforts of this pandemic is that little kids are at relatively lower risk of serious illness from COVID-19. What do we know about the risk from COVID-19 for kids who’ve undergone transplant? And are they more at risk than they would be from other circulating respiratory viruses?

Waghmare: Overall, children tend to have more mild or asymptomatic disease than adults, but given the high transmissibility of the delta strain and the high rates of community transmission, we are seeing an increase in both the number of cases and hospitalizations in children. I think the challenge is still really understanding what happens in a transplant recipient. The cases even reported to the national database are fairly low — Neel can speak to this — and the outcomes that are reported from COVID-19 in children who’ve undergone transplant don’t seem to be as severe as in the adults. That being said, this was also in the context of most kids being out of school in most of the country. So it’s a little hard to know how widespread school reopenings will affect these numbers. Based on what we know from other respiratory viruses, I think that there is fair enough reason to be cautious with bone marrow transplant recipients. 

Bhatt: As Alpana mentioned, we published in January 2021 the largest study so far looking at the outcomes of stem cell transplant recipients with COVID, using the CIBMTR data — the Center for International Blood and Marrow Transplant Research. There were 318 total transplant recipients reported in this data set; however, there were less than 30 pediatric recipients in the data set, but we’ve since collected data on more and hope to publish our results soon. A paper that came out in August from the St. Jude global registry of COVID-19 in Childhood Cancer had 81 young transplant recipients, and they found that receipt of transplant and time from transplant were not associated with severity of COVID-19. However, children with cancer who were receiving intensive treatment or had lower neutrophil or lymphocyte counts [numbers of certain immune cells in their blood] were more likely to have severe COVID-19. Given the dynamic nature of this pandemic, it will be important to continue conducting such analyses periodically. Another analysis in next few months might help understand the impact of school reopening and delta variant on number and severity of COVID-19 cases among children.

What are some of the concerns and questions you’ve heard about this from your patients’ families?

Bhatt: Returning to in-person school is definitely an important milestone for any of our patients, who are usually out of school for so long. It’s important for their quality of life and their self-esteem. So that’s why both patients and parents do care about in-person schooling during this time and have several questions about returning to school. 

The ones that I have heard are basically, when can they go back? And not only from the child’s perspective — like, where they are in the post-transplant course — but also from a community transmission perspective, is it safe enough to go back to school? And the other questions are about whether the patient’s siblings can go back to school — they’re worried that it could put the transplant recipient at a higher risk of catching COVID from the sibling. I’ve also heard questions about vaccination and antibody testing.

“If families are considering in-person schooling, they should definitely reach out to their primary bone marrow transplant team and think through all the pros and cons of returning, and make a shared decision based upon that.” 

Waghmare: One of the questions that people are asking us infectious disease doctors about is vaccine efficacy in transplant recipients, where there are a lot of unknowns. We now have some preliminary results that kids aged 5 to 11 have good antibody responses to the Pfizer vaccine; additional data from this study and studies using the Moderna vaccine are forthcoming. None of these vaccine trials, as far as I know, have enrolled immunocompromised children, so all of the data on immunogenicity [the ability of the vaccine to stimulate an anti-coronavirus immune response] has been outside of our population. There are now studies planned that will enroll immunocompromised children, including transplant recipients, to evaluate how they respond to the vaccine. This will help us answer questions about the timing of vaccines, and the need for boosters in our population.

As you counsel families about this, what are some of the considerations that you’re talking about with them?

Bhatt: The survey that we did about returning to school, in normal times without COVID, also included a brief survey about how physicians across the U.S. are recommending patients go back to school during the COVID pandemic. We received responses from 122 transplant physicians across 32 U.S. states. What we heard was that 76% of physicians recommend that patients should consider hybrid or remote school options at this time, if possible. Or, if not possible, in-person school should wait until patients are at least 12 months post-transplant and/or off immune-suppression drugs, while also taking school safety measures and local COVID-19 cases into account. So that is what I would also recommend: Don’t send patients who are early post-transplant and are on immune suppression. And the decision also needs to be made on a case-by-case basis, if anybody has any other comorbidities. So, for example, from the literature we know that patients with cardiopulmonary comorbidities [heart/lung diseases] are at higher risk of developing more severe COVID. So it all depends on how high the patient is at risk, for deciding whether or not they should go back to in-person school. 

Other considerations, in terms of safely going back to school, are following guidance from the American Society of Hematology/American Society for Transplantation and Cellular Therapy regarding getting the COVID-19 vaccination. And obviously making sure that the school has adequate provisions about physical distancing, universal masking, hand hygiene, and also strict policies for symptom assessment and staying at home. So these are some of the things I am recommending to my patients.

Currently the return-to-school guidelines we have are from the CDC and from the American Academy of Pediatrics, which are not transplant-specific. They are helpful in terms of guiding schools to ensure appropriate safety measures, but it’s difficult to extrapolate information from them for our population.

Would community vaccination rates factor into your counseling on return-to-school?

Looking for easy-to-understand, science-based information about the coronavirus vaccines? Visit PreventCovidWA.org, a joint effort of Fred Hutch, the COVID-19 Prevention Network and the Washington State Department of Health. 

Waghmare: Yes, I think community vaccination rates would be a consideration, in addition to community incidence. 

What research questions are the two of you pursuing on this issue right now?

Waghmare: Our group at Seattle Children’s is part of a couple national registries. Certainly we contribute to CIBMTR, and there’s also a registry out of St. Jude’s which we’ve contributed all of our cases to. A couple of our faculty here are more involved in the analysis of that data. More data is really key at this point in pediatrics, so we’ll be able to really look at what those outcomes are. We are also interested in immune responses to vaccination in immunocompromised children and plan to participate in clinical trials to address this question.

Bhatt: We are currently analyzing the data from the CIBMTR to specifically describe severity, treatment approaches and outcomes of children who developed COVID-19. This will be an extension of our previous work using this registry. Since March 2020, the CIBMTR has been collecting data on COVID-19 among patients who have received blood stem cell transplant or cellular therapy and has information on outcomes of more than 100 young transplant recipients who have developed COVID-19. Since the majority of studies focusing on transplant recipients with COVID-19 so far have included only a small number of children, this will likely be the largest study on this topic and provide valuable information to our community. We hope to publish the results in near future.

Waghmare: I would like to just mention a couple of things that we’re doing from an advocacy standpoint. I am part of the American Society for Transplantation and Cellular Therapy’s Infectious Disease Special Interest Group, and we’ve been putting out guidance for both adult and pediatric transplant recipients with COVID including FAQs about vaccine recommendations. These FAQs are updated frequently to address questions about timing of vaccination, booster doses and the need for revaccination. We will incorporate more recommendations for younger children when the vaccines are approved for additional age groups.

On Aug. 11, 2021, Fred Hutch President and Director Dr. Tom Lynch led a conversation with Waghmare, Dr. Trevor Bedford and Dr. Joshua Hill about viral variants, vaccines and kids, new treatments, considerations for cancer patients, and more.

Video by Fred Hutch

Susan Keown is an associate editor at Fred Hutchinson Cancer Research Center. She has written about health and research topics for a variety of research institutions, including the National Institutes of Health and the Centers for Disease Control and Prevention. Reach her at skeown@fredhutch.org or on Twitter @sejkeown.

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Last Modified, September 29, 2021