Children at high risk for monkeypox complications, review finds
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Children aged younger than 8 years are at an elevated risk for monkeypox complications and should be considered a high-risk group, according to a review article published in The Pediatric Infectious Disease Journal.
Few children have been diagnosed with monkeypox in the current outbreak, with just 83 out of the more than 25,000 U.S. cases reported as of Sept. 24 occurring in people aged younger than 18 years, according to data published this week in MMWR.
The review article was authored by Petra Zimmermann, MD, PhD, a pediatrician and infectious diseases specialist at the University of Fribourg in Switzerland, and Nigel Curtis, PhD, chair of pediatric infectious diseases at the University of Melbourne and Royal Children’s Hospital in Australia, who noted that the global outbreak has included nearly 47,000 laboratory-confirmed cases, but only 211 in children.
This does not mean the disease hardly effects pediatric patients, they said.
“Children are reported to have an increased hospitalization rate, even in high-income countries, and an increased mortality,” they wrote. “Children under 8 years of age are particularly at higher risk of complications, including bacterial superinfection such as cellulitis, abscesses, pneumonia, and sepsis.”
According to the MMWR report, among 20 American children aged 0 to 12 years with available exposure data, 19 were exposed in the household setting. For 17 patients, the reported exposure was direct skin-to-skin contact between a child and an adult caregiver. Among 55 adolescents aged 13 to 17 years, an overwhelming 89% were male, and male-to-male sexual contact was noted as the most likely route of exposure.
In terms of treatment, 22% were treated with the antiviral tecovirimat and 11% were hospitalized. The authors also noted that monkeypox occurred disproportionately among Black and Hispanic children and teens.
Zimmerman and Curtis also noted that no authorized monkeypox vaccination exists for children in the U.S., with only Jynneos and the smallpox vaccine ACAM2000 available for use.
“Although [Jynneos] is the only vaccine currently approved by the FDA for the prevention of monkeypox, it has not been licensed or rigorously evaluated in children,” they wrote. “However, since August 2022, the standard vaccine dosing has been authorized for the prevention of monkeypox in children and adolescents down to 1 year of age in the United States under an emergency use authorization.”
The authors said young children should be considered among those most vulnerable to severe illness due to monkeypox.
“Children (especially those under 8 years of age and those with underlying skin conditions), pregnant women and immunosuppressed individuals are considered high-risk groups for whom antiviral treatment with tecovirimat as first-line treatment should be considered,” they continued.
“With increased easing of restrictions because of the COVID pandemic, the paucisymptomatic nature of the current clade, it is possible that the [monkeypox] outbreak could become uncontrolled and spread to more vulnerable patient groups, including children. ... Should the current outbreak spread to children, authorities should be prepared to rapidly implement vaccination of this age group.”
References:
CDC. Monkeypox cases by age and gender race/ethnicity, and symptoms. https://www.cdc.gov/poxvirus/monkeypox/response/2022/demographics.html. Updated Nov. 2, 2022. Accessed Nov. 4, 2022.
Hennessee I, et al. MMWR Morb Mortal Wkly Rep. 2022;doi:10.15585/mmwr.mm7144a4.
Zimmerman P, et al. Pediatr Infect Dis J. 2022;doi:10.1097/INF.0000000000003720.
Perspective
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To date, most pediatricians in the United States have not seen a case of monkeypox. Of the more than 28,000 cases reported to the CDC as of Nov. 2, only 55 have occurred in children aged younger than 16 years. That doesn’t mean that we haven’t worried or even tested children who had a low likelihood of infection. How could we not? As Drs. Zimmerman and Curtis highlight in their comprehensive review, the differential diagnosis for monkeypox includes common childhood infections, including varicella zoster virus, herpes simplex virus infection, staphylococcal skin infection, molluscum contagiosum and hand-foot-mouth disease.
Zimmerman and Curtis do not include data about the pediatric cases from the current outbreak in their paper; aside from an occasional case report, these have not been published. Understanding how these patients were likely infected, how they were treated and clinical course will improve our care of patients in the future. This summer, the U.S. FDA authorized the use of Jynneos vaccine as post-exposure prophylaxis in individuals aged younger than 18 years, while acknowledging that safety and effectiveness have not been assessed in children. Information about the numbers of children treated during this outbreak and their outcomes are needed to inform future vaccination efforts.
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