The widening monkeypox outbreak is sparking concern that the virus could spread among a surprising cohort particularly prone to transmitting contagious infections: kids.
Experts at the World Health Organization said this week that they are watching the potential for spread among children “extremely closely.” Already, more than 80 kids across several countries have contracted monkeypox, largely through household contacts, the agency said in a media briefing.
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While that’s a tiny fraction of the more than 18,000 monkeypox cases around the world—with most concentrated among men who have sex with men—the prospect of community transmission is raising the specter that the virus could establish itself in other populations, such as women and children. The disease’s rapid spread has prompted WHO Director-General Tedros Adhanom Ghebreyesus to declare the outbreak a public health emergency of international concern.
“It’s likely that we will see an increasing number of cases transmitted in other social networks and settings” beyond male sexual relations, said Jay Varma, a professor of population health sciences at Weill Cornell Medicine in New York. “No social network is self-contained. They all ‘bridge’ to other networks.”
Anyone can get the virus, which is characterized by raised sores and sometimes causes swollen lymph nodes or other flu-like symptoms. Though its primary mode of transmission has been sexual networks, it can spread through other forms of contact. Once someone has it within a household, it’s especially easy for the virus to infect others through sharing clothes or towels, by touching sores or prolonged skin-to-skin contact like hugging.
Kids, constantly interacting at schools and day-care centers, may be especially vulnerable. As it is, they pick up dozens of viruses each year, including contagious rashes such as hand, foot and mouth disease, eliciting some fear that if monkeypox were to start spreading in child-centric settings, it could be hard to contain.
“It is inevitable that some kids will become infected and attend school while infected,” Varma said. “What we don’t know is how likely it is that kids will transmit to other kids while in school, and, if transmission occurs, whether it will be limited to a few cases or cause a large outbreak.”
Health officials from the US Centers for Disease Control and Prevention said last week that they’re aware of two pediatric cases in the country. Another case has been identified in a pregnant woman who recently gave birth, said John Brooks, the CDC’s chief medical officer for monkeypox.
The good news is that there have been no deaths in the US outbreak so far. And by targeting the virus’s primary routes of transmission and getting treatments to the groups most affected—right now, men who have sex with men—it’s possible to prevent further spread within the community.
Still, US Health and Human Services Secretary Xavier Becerra on Thursday stressed the importance of being ready for a wider outbreak, including by securing more access to vaccines.
“Every American should pay attention on monkeypox,” he said during a call with the media. “Monkeypox is not Covid, but it is contagious. It is painful. And it can be dangerous.”
Historically, in parts of west and central Africa where monkeypox is considered endemic, pediatric cases weren’t unusual. The first human case of the virus was a child in the Democratic Republic of the Congo in 1970, and past outbreaks have spread primarily through contact with infected animals. And in those instances, severe cases occurred more commonly among children, according to the WHO.
During a 2003 monkeypox outbreak in the US, which stemmed from rodents imported from Ghana, pediatric patients were more likely to be hospitalized in an intensive-care unit than adults, according to a study published in the journal Clinical Infectious Diseases. Almost a third of the 37 confirmed patients were younger than 18, the study showed.
But in another large outbreak in Nigeria in 2017, only a handful of cases were found in kids. And according to one systemic review of case data from outbreaks that occurred between 1970 and 2019, the median age of monkeypox patients has actually increased from 4 to 21 over the last five decades.
The 2022 outbreak looks a bit different than past situations, with the virus mostly spreading by people touching infectious lesions or fluids during intimate encounters. Symptoms are also distinct from the medical literature, with more cases presenting with sores that look similar to common sexually transmitted infections or rashes, according to a study recently published in the New England Journal of Medicine.
The changing nature of the virus is making it more difficult to recognize cases, along with the potential effects for kids.
“Our experience with children is small, so we’ll be learning, unfortunately, as children do become infected,” the CDC’s Brooks said on a July 23 call with clinicians. “Those reported so far have been doing fine.”
Anyone at Risk
Rosamund Lewis, the WHO’s technical lead on monkeypox, said that so far most of the children with monkeypox globally have shared a home with other infected people, such as parents or guardians. But a few appear to have no epidemiological links, indicating infection from elsewhere in the community.
Regardless of age, “the message remains the same: Anyone who has household contact or direct contact with someone who has monkeypox may be at risk,” Lewis said.
Another concern is that monkeypox can be transmitted through the placenta during pregnancy and has been known to cause complications for a baby, including stillbirth. Brooks, from the CDC, said the pregnant US woman with the virus doesn’t appear to have passed it to her child. The infant was given antibodies prophylactically and is doing fine, he said.
The commonly used treatments for monkeypox—Bavarian Nordic’s vaccine Jynneos, and Siga Technologies Inc.’s smallpox antiviral medication, Tpoxx—can be used to treat kids when necessary, such as when they are at high risk of exposure. In June, the CDC said it was figuring out the best way to use Jynneos in kids exposed to the virus. Health officials also told reporters last week that they were clarifying how to use Tpoxx in pediatric patients.
The US, however, currently has limited supplies of Jynneos available for use, and clinicians have had difficulty prescribing Tpoxx to patients since it is only approved for smallpox.
That makes it especially important for health officials to develop a plan for what should happen if infections spread rapidly among kids, Varma of Weill Cornell said.
“Any situation in which an infected child visits school or day care will generate a high level of concern from administrators and families,” he said. “It is critical that public health agencies develop protocols now for how they plan to investigate such cases, including contact tracing and testing.”