The U.S. monkeypox outbreak continues to spread, infecting more than 3,500 people to date, according the CDC. Now, cases are cropping up in kids too.
Last Friday, the agency announced two cases in young children on U.S. soil: A toddler in California and an infant from the U.K. whose family was traveling through the Washington, D.C. area. Both infections were likely a result of household transmission, the CDC said.
“We have seen now two cases that have occurred in children,” said CDC Director Rochelle Walensky, MD, in an interview with the Washington Post. “Those children are doing well.”
The current outbreak has been driven predominantly by a viral strain known as the West African clade. Thus far, it has spread primarily among men who have sex with men (MSM), according to the CDC. Currently, 99% of U.S. cases are in the MSM population.
Vandana Madhavan, MD, MPH, clinical director of pediatric infectious disease at Mass General Hospital in Boston, said while it is important for parents and clinicians to understand the risk of monkeypox in children, it is not a major concern to see a small number of cases in kids at this point. Prevention will be key, she added, encouraging families to continue to share information about symptoms observed in their household to avoid potential transmission.
“I want caregivers of children to be aware of these considerations,” she stated, but emphasized that COVID remains a more pervasive risk to kids at this point.
There are still many unknowns about how the current monkeypox outbreak will impact kids. Although some experts say there is potential for monkeypox to be more severe in younger patients, pediatric infection has remained rare during the outbreak, and more information about the current viral strain is needed to determine risk.
As more cases spread globally, it is likely that providers will continue to see cases in children and other populations outside of the MSM community, experts warned.
Karen Acker, MD, assistant professor of clinical pediatrics at Weill Cornell Medicine in New York City, told MedPage Today that it is not surprising to see some monkeypox cases in children because “contagious infections often are not contained within the community they started in.”
Based on the current understanding about how monkeypox is spread — through close physical contact of someone with lesions or the spread of respiratory droplets — and how quickly the virus has spread, “it was only a matter of time before we saw cases in children,” Acker added.
There have been reports of pediatric monkeypox cases out of Spain and the Netherlands. Dutch researchers recently documented a case report in a boy, age 10, who presented to the emergency department in June with 20 skin lesions all over his body, including on the shoulder, forearm, and cheek. He did not have signs of a rash in his oral cavity or in the genital region. The researchers determined that the source of infection was unknown.
“With this case description we wish to raise awareness among clinicians that [monkeypox] can develop in children and be present in the general population,” the researchers wrote. They recommended prompt diagnostic testing to stop the spread of the virus in the community, and vaccinations for those at risk.
Aaron Glatt, MD, a spokesperson for the Infectious Diseases Society of America, said that pediatric infections may result from children hugging a parent, or being in close physical proximity to someone who is infected. Contaminated towels or bedding could also pass along the virus. But Glatt cautioned that other avenues of transmission are less likely.
“This is not something that the public should be concerned about, that kids picked it up from outside on the playground, at school or at camp or anything like that,” added Glatt, who is chair of the department of medicine at Mount Sinai South Nassau.
Previous outbreaks in Africa have revealed that children under 8 years of age have a higher risk of complications from monkeypox, according to Madhavan. But whether those findings can be extrapolated to the U.S. population, and to the current viral strain, is hard to say, she noted.
“Generally, monkeypox causes mild or moderate infection, but can cause more severe disease in immunosuppressed individuals,” Acker explained, adding that children may be at risk for more severe disease, but their susceptibility to severe illness during the current outbreak is unknown.
And more data are needed on how current vaccines and treatments can be used in pediatric populations. The vaccine Jynneos is FDA approved for prevention of smallpox and monkeypox in adults, but has not been tested in children, although the CDC says it is available to kids under special expanded access protocols.
As for treatments, they can be considered for children on a case-by-case basis, Madhavan said. Tecovirimat (Tpoxx), an FDA-approved drug to treat smallpox in adults and children, is eligible as a monkeypox therapy under CDC protocols. The agency states that tecovirimat should be considered for all monkeypox patients, particularly kids under age 8 years.
Sallie Permar, MD, PhD, chair of the department of pediatrics at Weill Cornell Medicine, said that tecovirimat “is mainly recommended for use in severe cases or for those at risk of severe disease, such as very young children or those with exfoliative skin or immunocompromising conditions.”