Epidemiologic and Clinical Features of Children and Adolescents Aged <18 Years with Monkeypox — United States, May 17–September 24, 2022

Data on monkeypox in children and adolescents aged <18 years are limited (1,2). During May 17–September 24, 2022, a total of 25,038 monkeypox cases were reported in the United States,^† primarily among adult gay, bisexual, and other men who have sex with men (3). During this period, CDC and U.S. jurisdictional health departments identified Monkeypox virus (MPXV) infections in 83 persons aged <18 years, accounting for 0.3% of reported cases. Among 28 children aged 0–12 years with monkeypox, 64% were boys, and most had direct skin-to-skin contact with an adult with monkeypox who was caring for the child in a household setting. Among 55 adolescents aged 13–17 years, most were male (89%), and male-to-male sexual contact was the most common presumed exposure route (66%). Most children and adolescents with monkeypox were non-Hispanic Black or African American (Black) (47%) or Hispanic or Latino (Hispanic) (35%). Most (89%) were not hospitalized, none received intensive care unit (ICU)–level care, and none died. Monkeypox in children and adolescents remains rare in the United States. Ensuring equitable access to monkeypox vaccination, testing, and treatment is a critical public health priority. Vaccination for adolescents with risk factors and provision of prevention information for persons with monkeypox caring for children might prevent additional infections.

During May 17–September 24, 2022, children and adolescents who received a positive polymerase chain reaction (PCR) test result for MPXV, nonvariola Orthopoxvirus (NVO), or generic Orthopoxvirus (OPXV) were identified through national surveillance or during CDC clinical consultations. Demographic and exposure characteristics and clinical features of children and adolescents aged <18 years with monkeypox-compatible symptoms^§ who received a positive NVO, OPXV, or MPXV PCR test result were analyzed. In cases for which PCR test cycle threshold (Ct) results were available, persons whose specimens had NVO, OPXV, or MPXV PCR Ct values ≥34 (potentially indicating a false positive test result) and who had atypical clinical features or no known epidemiologic risk factors^¶ were excluded.

Data collected included age; sex; gender identity (among adolescents); race and ethnicity; exposure setting and risk behaviors; monkeypox symptoms and lesion distribution; receipt of JYNNEOS vaccine postexposure prophylaxis, tecovirimat (Tpoxx; SIGA Technologies), topical trifluridine (Viroptic; Pfizer Inc.), or vaccinia immune globulin intravenous (VIGIV; Cangene Corporation)**; and hospitalization status. Data were stratified by age group (0–4, 5–12, and 13–17 years). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.^††

During May 17–September 24, 2022, 83 MPXV infections were identified among children and adolescents aged <18 years, including 16 (19%) in children aged 0–4 years, 12 (14%) in children aged 5–12 years, and 55 (66%) in adolescents^§§ (Table 1). Among 28 children aged 0–12 years, 18 (64%) were boys, and 10 (36%) were girls. Most adolescents were male (48; 89%), six (11%) were female, and information on sex was missing for one. Overall, 38 (47%) children and adolescents were Black, 28 (35%) were Hispanic, 10 (12%) were non-Hispanic White, and five (6%) were of another race and ethnicity; data on race and ethnicity were missing for two.

Among 20 (71%) children aged 0–12 years with available exposure data, 19 were exposed in the household setting; for 17 of these children, the reported exposure was direct skin-to-skin contact that routinely occurs between a child and an adult caregiver. In another instance, fomite transmission (e.g., towels shared with a caregiver with monkeypox) was the suspected route of exposure because the index patient and the child had shared a living space without direct skin-to-skin contact. In the remaining instance, further information about the exposure was unavailable. One nonhousehold exposure occurred when an adult with monkeypox held a child outside the household setting. In two instances, adult caregivers contracted monkeypox after caring for children with monkeypox in household settings; the suspected exposure routes were skin-to-skin contact during diapering and other routine child care activities.

Among 35 (64%) adolescents with available exposure data, 32 were males with direct skin-to-skin sexual contact as the presumed mode of spread: 23 (72%) reported male-to-male sexual contact, four (13%) reported male-to-female sexual contact, and five (16%) reported sexual contact with a person whose sex was not specified. One female adolescent reported recent sexual contact with a male adolescent, but further details were unavailable; another adolescent who identified as a transgender male reported recent sexual contact with a male adolescent. One female adolescent had shared a bed with another adolescent who had a rash, but further details were unavailable.

Among the 28 children aged 0–12 years with monkeypox, lesions most commonly occurred on the trunk; no child had anogenital lesions; 10 (36%) received tecovirimat, one (4%) received VIGIV, and three (11%) received topical trifluridine (Table 2). Two children aged 0–4 years were hospitalized with diffuse rash and eyelid involvement; both recovered without complications and were discharged.^¶¶ One child aged 5–12 years was hospitalized for periorbital cellulitis and conjunctivitis; this child received oral tecovirimat and topical trifluridine and recovered.

Among the 55 adolescents, lesions most commonly occurred on the trunk (33, 60%) and the genitals or perianal area (33, 60%). Eight (15%) received tecovirimat. Six (11%) adolescent patients were hospitalized. For five adolescent patients, reasons for hospitalization included pain management, treatment of secondary bacterial infections, and systemic symptoms with rash; three of these adolescents received oral tecovirimat, and whether the other two received tecovirimat is unknown; one adolescent received a new diagnosis of HIV infection during hospitalization. Another adolescent was hospitalized to ensure adequate isolation but had mild symptoms and did not receive monkeypox-directed therapies. All adolescents were discharged and recovered.

Overall, no children or adolescents received ICU-level care or died. No reported case during the investigation timeframe was known to be associated with sexual abuse.

Ten distinct instances were investigated in which a child or adolescent with monkeypox attended a child care facility (two) or school (eight) while symptomatic; no instance of secondary transmission in these settings was identified. JYNNEOS vaccination was offered to close contacts in at least four situations, and in one instance more than 15 other students and staff members received JYNNEOS postexposure prophylaxis.

Acknowledgments

Summer Adams, Matthew Bacinskas, Cynthia Bernas, Brandon Brown, Teal Bullick, Alex Espinosa, Maria Uribe Fuentes, Bianca Gonzaga, Ydelita Gonzales, Deidra Lemoine, Adrienne Macias, Nichole Osugi, Will Probert, Alexa Quintana, Serena Ting, Kristen Wendorf, Cindy Wong, California Department of Public Health; Sarah Gillani, Michelle Lee, Christina Willut, District of Columbia Department of Health; Vonda Pabon, Denise Smith, Guilford County Department of Health and Human Services; Kris K. Carter, Cassidy VanWarmerdam, Idaho Department of Health and Welfare; Jessica McClenahan, Sarah Wright, Central District Health; Susan Hathaway, Amy Marutani, Steve Moon, Los Angeles County Department of Public Health; Marcia Pearlowitz, Maryland Department of Health; Stephanie Locke, Ryan M. Tannian, New Hampshire Department of Health & Human Services; Joel Ackelsberg, Karen A. Alroy, Nanette Bracero, Renee King, Rachel Paneth Pollak, Brenda Robinson, Kit Voit, New York City Department of Health and Mental Hygiene; Justin P. Albertson, Molly Deutsch-Feldman, North Carolina Department of Health and Human Services; Kaira Carter, Mercedes White, Philadelphia Department of Public Health; Jennifer Lenahan, Sargis Pogosjans, Public Health – Seattle & King County; Denise C. Sockwell, Virginia Department of Health; Ashley Caesar Cuyler, Virginia Beach Department of Public Health; Kim Carlson, Nailah Smith, Washington State Department of Health; Suzanne Gibbons-Burgener, Christopher Steward, Wisconsin Department of Health Services; Monkeypox response teams from state and local health departments; State of Connecticut Public Health Laboratory monkeypox testing team; Wisconsin local and tribal health agencies.

Corresponding author: Ian Hennessee, ihennessee@cdc.gov.

¹CDC Monkeypox Emergency Response Team; ²Epidemic Intelligence Service, CDC; ³Laboratory Leadership Service, CDC; ⁴Connecticut Department of Public Health; ⁵Division of State and Local Readiness, Center for Preparedness and Response, CDC; ⁶District of Columbia Department of Health, Washington, DC; ⁷Florida Department of Health; ⁸Georgia Department of Public Health; ⁹Idaho Department of Health and Welfare; ¹⁰Central District Health, Boise, Idaho; ¹¹Los Angeles County Department of Public Health, Los Angeles, California; ¹²Maine Center for Disease Control and Prevention, Augusta, Maine; ¹³Maryland Department of Health; ¹⁴New Hampshire Division of Public Health Services; ¹⁵New Jersey Department of Health; ¹⁶New York City Department of Health and Mental Hygiene, New York, New York; ¹⁷North Carolina Department of Health and Human Services; ¹⁸Guilford Department of Health and Human Services; ¹⁹Mecklenburg County Public Health, Charlotte, North Carolina; ²⁰Oregon Health Authority; ²¹Philadelphia Department of Public Health, Philadelphia, Pennsylvania; ²²Public Health – Seattle & King County, Seattle, Washington; ²³Texas Department of State Health Services; ²⁴Alexandria City Health Department, Alexandria, Virginia; ²⁵Virginia Beach Department of Public Health, Virginia Beach, Virginia; ²⁶Snohomish Health District, Everett, Washington; ²⁷Grays Harbor County Public Health, Aberdeen, Washington; ²⁸Washington State Department of Health; ²⁹Wisconsin Department of Health Services.

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* Percentages were calculated using nonmissing data.
^† Reported as sex assigned at birth. Gender identity was known for 25 (45%) adolescents. One adolescent whose assigned sex at birth was female identified as a transgender male.
^§ For these persons, all of whom were aged ≥15 years, direct skin-to-skin sexual contact was the presumed mode of spread. Among 48 male adolescents, 23 (48%) reported male-to-male sexual contact, four (8%) reported sexual contact with a female, and five (10%) reported sexual contact with a person whose sex was not specified. One female adolescent reported recent sexual encounters with a male, but further details were unavailable; another adolescent who identified as a transgender person or teen reported recent sexual contact with a male adolescent.
^¶ In 17 cases among children aged 0–12 years, direct skin-to-skin contact occurred between the child and an adult with monkeypox who was caring for the child in the setting of routine caregiving activities. In one instance, no direct skin-to-skin contact was noted, but the child shared a living space with the index patient, likely with frequent contact with shared materials (e.g., towels). In the remaining instance, further details about the exposure were unavailable.
** In one instance, direct skin-to-skin contact occurred with an adult with monkeypox who held the child, but the exposure occurred outside the household setting. In another instance, an adolescent shared a bed with another adolescent who had a rash, but further details were unavailable.

* Percentages calculated using nonmissing data.
^† Two adolescents had recently received a diagnosis of HIV infection; one received this diagnosis while hospitalized with monkeypox, and the other received the diagnosis in an outpatient setting.
^§ Rash was part of the case definition and is typically required for monkeypox testing.
^¶ Lesions could occur on more than one body site.
** Included two children aged 0–4 years who had eyelid involvement and received topical trifluridine as potential prophylaxis for ocular monkeypox and one child aged 5–12 years who received topical trifluridine for conjunctivitis.
^†† Eighteen persons received oral tecovirimat, including six of the nine persons who were hospitalized; one hospitalized adolescent aged 13–17 years initially received intravenous tecovirimat before being switched to oral tecovirimat.
^§§ One adolescent received JYNNEOS as postexposure prophylaxis 6 days before the onset of monkeypox symptoms; the timing of JYNNEOS receipt was unknown for the other adolescent.