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An illustration of a school bus. On the windows of the schools bus are three signs. The first sign says, "Face Coverings Required" with a picture of a mask on it. The second sign says "Delta Variant on the Rise" with a picture of the coronavirus. The third sign (below the second sign) says "Children 12 and Older Are Vaccine Eligible."
Credit: Tatiana Ayazo

It seems like you were just navigating remote versus in-person learning, carpools, and playdates for the back-to-school season in 2020. And yet here we are again: One year later, battling the same virus but in a very different landscape.

If you’re immunocompromised but around kids or grandkids who are heading back to school, you understand that the decisions never get any easier. Do you have your child wear a mask even when the other kids don’t — or opt for remote learning if it’s an option? Do you refrain from seeing your grandchildren during the school year, as painful as it may be?

There’s no one right answer, and it’s important to note that the COVID-19 landscape is constantly changing. The right decision today may not be the best one next month, or even next week for that matter.

“Things are rapidly changing, so we can’t make suggestions right now that will certainly be applicable a month from now when some schools are starting,” says Lynn Ludmer, MD, Medical Director of Rheumatology at Mercy Medical Center in Baltimore. That’s why it’s important to stay in touch with your doctor as questions arise about your risk level and mitigation efforts.

Here’s everything you need to know about the return to school this year — and what experts recommend you do to stay safe as an immunocompromised caregiver.

How This Back-to-School Season Is Different Than Last Year

Last year, we covered how you can stay safe if your kids are heading back to school and you’re high-risk for COVID-19 complications. While general mitigation efforts to prevent COVID-19 haven’t changed, two major things have:

  • This back-to-school season, there are COVID-19 vaccines. The vaccine dramatically reduces the risk of getting COVID-19 and severe complications from it, like hospitalization or death. The risk of severe disease or death is reduced 10-fold or greater in vaccinated people, and the risk of infection is reduced three-fold in vaccinated people, per new research published by the U.S. Centers for Disease Control and Prevention (CDC) and disseminated by the Washington Post. Yes, people who are immunocompromised because of immunosuppressant medications may have a lower response to the vaccine (more on this below) but the vaccines still offer protection and reduced risk of complications even in these groups.
  • This back-to-school season, the Delta variant is circulating. This strain is more contagious than the original SARS-CoV-2 strain. In fact, it’s more transmissible than MERS and SARS, Ebola, common colds, seasonal flu, 1918 “Spanish” flu, and smallpox, per the new research published by the CDC. It is as transmissible as chicken pox. The Delta variant may also cause more severe disease.

That said, the mitigation efforts we’ve learned over the past year and a half — which will keep you and your kids safe during back-to-school season — haven’t changed.

“Delta is more contagious but it’s the same virus, so the things that we’ve been doing all along still provide protection,” says Benjamin Linas, MD, an infectious disease doctor and Professor of Medicine at Boston University School of Medicine. “So in a lot of ways, it’s the same measures as last year, with the one major exception — go get vaccinated, because it really changes the entire picture.”

The Effects of Masking in Schools

The CDC recently updated its masking guidelines to note that all teachers, staff, students, and visitors to schools should wear masks indoors, regardless of vaccination status. However, whether this recommendation is actually followed will depend on your state and school district.

If your child’s school has universal masking, it will keep you and your child safer. Even if your school doesn’t require masks but your child still wears one, it will help reduce their risk.

“The mask mandates in school reduce risk for everyone, including parents and grandparents,” says Dr. Linas. “If you’re an immunocompromised parent and your child is going to school with a mask mandate, I think you can feel comfortable. And if they’re not, then you have to weigh having your child continue to wear a mask at school when nobody else is and personal safety at home.”

In other words, if you or others in your household are immunocompromised, having your child wear a mask at school is an important way to feel safer about COVID-19 exposure.

Now is a higher-risk time in the United States than even just a month ago. COVID-19 cases have surged, and the new research published by the CDC shows that even vaccinated people can spread the virus.

“The latest recommendations of masking are to make people aware that even though they are vaccinated, they may be able to transmit the virus unknowingly to other loved ones who might be immunocompromised,” says Ashlesha Kaushik, MD, Medical Director of Pediatric Infectious Diseases at UnityPoint Health in Sioux City and Clinical Assistant Professor of Pediatrics at the University of Iowa College of Medicine.

“That’s where this masking guidance comes into play. In the face of new, dangerous variants emerging variants, masking is a very, very important and valuable tool — especially for the immunocompromised,” adds Dr. Kaushik.

The Role Vaccines Play

Experts believe that even if you’re immunocompromised, you’ll get some degree of protection from the COVID-19 vaccine, which is why it’s so important to get vaccinated. And the more people around you who are fully vaccinated during the back-to-school season (including your children), the safer you’ll be.

But of course, not all children can get the COVID-19 vaccine yet: The vaccine is authorized only for those age 12 and up. Trials are currently underway to test the vaccine in children under 12, but results aren’t expected until later this fall. An FDA official recently said emergency authorization likely won’t come until early to midwinter, reports NBC News.

Even with the vaccine available for adolescents, not many have gotten the shot. Of kids ages 12 to 15, only 39.8 percent had received one dose and only 29.1 percent had received a full vaccination series as of August 6, per the CDC. Teens ages 16 to 17 have higher rates of 50.3 percent for one dose and 40.4 percent for a full vaccine series.

“The more unvaccinated population we have, the more mutations of the virus we’ll have — so the more variants will emerge,” says Dr. Kaushik.

You’ll be more protected if everyone in your household gets vaccinated if they’re eligible. Here’s how to talk to your loved ones about getting vaccinated.

“The large number of patients I see who are unvaccinated are not planning to get a vaccine and are not wearing masks,” says Dr. Ludmer. “Unfortunately, this means that those who are vaccinated still need to protect themselves. I am choosing to wear my mask in stores and around others whose vaccine status is unknown.”

And of course, don’t forget to get your other routine vaccinations to stay healthy during the back-to-school season. For instance, flu shots are already available for the 2021 to 2022 season.

Whether or Not to Consider Remote Learning

While some school districts like New York City will not offer remote learning this fall, others are offering remote options — especially in light of the Delta variant, reports TIME.

However, the CDC says that children should return to full-time, in-person learning this fall with proper prevention strategies in place (like universal masking). Meanwhile, the American Academy of Pediatrics (AAP) says: “The AAP believes that, at this point in the pandemic, given what we know about low rates of in-school transmission when proper prevention measures are used, together with the availability of effective vaccines for those age 12 years and up, that the benefits of in-person school outweigh the risks in almost all circumstances.”

“It has been shown that in-person learning is very important for overall development,” says Dr. Kaushik.

Still, decisions about potential remote learning will need to be made by your family individually and your risk level as an immunocompromised person. For some special health needs or immunocompromised family members, shared decision-making should be used with health care providers, educators, and your family to determine what the best learning environment would be for your children — whether it’s blended learning, in-person learning, or remote learning, depending on what’s offered and possible for your family.

“If your school is offering a remote option and you, your spouse, or someone other than the learner is immunocompromised, you are in a really unfortunate trade-off situation,” says Dr. Linas. “There’s no expert who can answer that for anyone. You can try to frame the numbers to find out what the trade-off is, but I can’t tell a parent what the right answer is, because it’s an extremely personal decision.”

Keep in mind that there are likely several other steps you can take to protect yourself this school year before considering remote learning for your child. For instance, there are many ways to mitigate risk by limiting or masking up during activities outside of school, such as group sports, carpooling, birthday parties, or group playdates.

“We learned last year that there’s exceedingly low COVID-19 transmission actually in school, in classrooms during the day,” says Dr. Linas. “Where we see COVID-19 in school-aged kids and clusters in schools tends to be outside of the classroom.”

Before pulling your child out of school for remote learning, it’s worth looking at all of the other potential areas of risk.

“People should remember that schools are neither a special protected environment, nor are they a particularly hazardous environment for COVID-19,” says Dr. Linas. “Arguably, you should try to reduce risk everywhere else in your life — and then take it to school as necessary. For instance, before anyone thinks about potentially keeping their learner home for remote learning, they absolutely should get vaccinated.”

The Takeaway: What Back-to-School Season Means if You’re Immunocompromised

Determining how to approach the back-to-school season and your child’s education is an extremely personal decision, but your doctor and your child’s pediatrician can help you determine the areas of risk and trade-offs of certain mitigation efforts.

And of course, “immunocompromised” can refer to a wide range of conditions and immunosuppressive drugs.

“Not all immunocompromised people are created equal,” says Dr. Ludmer. “There are certain drugs that put people at higher risk of not having made effective antibodies. That subgroup of patients may be at higher risk and that’s important for them to know about in terms of their choices.”

A lot will depend on your condition and what immunosuppressive medications you’re taking — some, like TNF inhibitors, seem to have little impact on vaccine efficacy.

One of the best things you can do to protect yourself is to get vaccinated, ensure your family members are vaccinated if eligible, and continue to follow standard mitigation efforts — and teach your children to, as well.

“If you model good mask wearing for children, they will follow,” says Dr. Kaushik. “A playful attitude can go a long way in preventing the spread of infection. With a mask, you can say, ‘You look like a superhero! This is your protective gear!’”

Also help your child practice washing their hands, covering coughs and sneezes properly, and refraining from germy habits like picking their nose when they’re at home so they can translate those habits to their time at school.

Throughout the school year, it’s also important to monitor any potential symptoms you might have carefully.

“Immunocompromised patients should keep a close eye out for symptoms — whether it’s fever, respiratory, coughing, or any other types of symptoms,” says Dr. Kaushik. “Once they’ve had any symptoms, they should definitely get tested.”

The CDC’s latest guidance recommends getting tested for COVID-19 if you’re exposed to someone who is infected, even if you’re vaccinated and don’t have any symptoms.

Specifically, the CDC states: “Fully vaccinated people who have a known exposure to someone with suspected or confirmed COVID-19 should be tested three to five days after exposure and wear a mask in public indoor settings for 14 days or until they receive a negative test result.”

If you do get infected with COVID-19 and are immunocompromised, monoclonal antibody treatment can have a significant impact in the course of your disease if administered immediately. In fact, the U.S. Food and Drug Administration recently revised the emergency use authorization (EUA) for the monoclonal antibody treatment REGEN-COV (casirivimab and imdevimab) to allow it to also be used as a preventive treatment for COVID-19 in adults and kids ages 12 and older who are at high-risk for poor outcomes from COVID-19.

And of course, in addition to getting vaccinated, the standard mitigation efforts for COVID-19 remain the same:

  • Maintain a social distance of six feet or more from people outside of your household whenever possible.
  • Wear face coverings when out in public and when you can’t be socially distant.
  • Wash or sanitize your hands frequently and disinfect commonly touched surfaces.
  • Avoid large groups or situations when it will be hard to be socially distant.
  • When spending time with others, being outdoors is safer than indoors.

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COVID-19 Guidance for Safe Schools. American Academy of Pediatrics. July 18, 2021. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools/.

COVID-19 Vaccination and Case Trends by Age Group, United States. U.S. Centers for Disease Control and Prevention. August 6, 2021. https://data.cdc.gov/Vaccinations/COVID-19-Vaccination-and-Case-Trends-by-Age-Group-/gxj9-t96f.

COVID-19 Vaccines for Children and Teens. COVID-19. U.S. Centers for Disease Control and Prevention. July 23, 2021. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/adolescents.html.

Edwards E. Covid vaccines for kids under 12 expected midwinter, FDA official says. NBC News. July 15, 2021. https://www.nbcnews.com/health/health-news/vaccines-kids-under-age-12-expected-mid-winter-fda-official-n1274057.

FDA authorizes REGEN-COV monoclonal antibody therapy for post-exposure prophylaxis (prevention) for COVID-19. U.S. Food & Drug Administration. July 30, 2021. https://www.fda.gov/drugs/drug-safety-and-availability/fda-authorizes-regen-cov-monoclonal-antibody-therapy-post-exposure-prophylaxis-prevention-covid-19.

Interview with Ashlesha Kaushik, MD, Medical Director of Pediatric Infectious Diseases at UnityPoint Health in Sioux City and Clinical Assistant Professor of Pediatrics at the University of Iowa College of Medicine

Interview with Benjamin Linas, MD, an infectious disease doctor and Professor of Medicine at Boston University School of Medicine

Interview with Lynn Ludmer, MD, Medical Director of Rheumatology at Mercy Medical Center in Baltimore

Katz R, et al. Are you happy or sad? How wearing face masks can impact children’s ability to read emotions. Brookings. April 21, 2020. https://www.brookings.edu/blog/education-plus-development/2020/04/21/are-you-happy-or-sad-how-wearing-face-masks-can-impact-childrens-ability-to-read-emotions/.

Read: Internal CDC document on breakthrough infections. The Washington Post. July 30, 2021. https://www.washingtonpost.com/context/cdc-breakthrough-infections/94390e3a-5e45-44a5-ac40-2744e4e25f2e/?_=1.

Reilly K. Schools Expected to Leave Virtual Learning Behind in the Fall, but the Delta Variant Is Forcing a Change in Plans. TIME. August 5, 2021. https://time.com/6087815/covid-delta-schools-reopening/.

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