Epidemiologic and Clinical Features of Children and Adolescents Aged <18 Years with Monkeypox — United States, May 17–September 24, 2022
Weekly / November 4, 2022 / 71(44);1407–1411
Ian Hennessee, PhD1,2,*; Victoria Shelus, PhD1,2,*; Cristin E. McArdle, PhD1,2; Maren Wolf, MPH1,2; Sabrina Schatzman, PhD1,3; Ann Carpenter, DVM1,2; Faisal S. Minhaj, PharmD1,2; Julia K. Petras, MSPH1,2; Shama Cash-Goldwasser, MD1,2; Meghan Maloney, MPH4; Lynn Sosa, MD4; Sydney A. Jones, PhD4,5; Anil T. Mangla, PhD6; Rachel E. Harold, MD6; Jason Beverley, MS6; Katharine E. Saunders, DNP2,7; Jeremy N. Adams, PhD7; Danielle R. Stanek, DVM7; Amanda Feldpausch, DVM8; Jessica Pavlick, DrPH8; Megan Cahill, PhD2,9; Victoria O’Dell, MPH10; Moon Kim, MD11; Jemma Alarcón, MD2,11; Lauren E. Finn, MPH11; Maura Goss12; Monique Duwell, MD13; David A. Crum, DVM13; Thelonious W. Williams13; Katrina Hansen, MPH14; Megan Heddy14; Krystle Mallory14; Darby McDermott, DVM15; Mervin Keith Q. Cuadera, MS15; Eric Adler, MPH15; Ellen H. Lee, MD16; Amanda Shinall16; Carlen Thomas16; Erin K. Ricketts, MD2,17; Tammy Koonce, MSN18; Dana B. Rynk, MSN19; Kelly Cogswell, MPH20; Meagan McLafferty, MPH20; Dana Perella, MPH21; Catherine Stockdale22; BreeAnna Dell, DVM22; Mellisa Roskosky, PhD2,22; Stephen L. White, PhD23; Kenneth R. Davis, MPH23; Rania S. Milleron, PhD23; Skyler Mackey, MPH24; L. Anna Barringer25; Hollianne Bruce, MPH26; Debra Barrett27; Marisa D’Angeli, MD28; Anna Kocharian, MS29; Rachel Klos, DVM29; Patrick Dawson, PhD1; Sascha R. Ellington, PhD1; Oren Mayer, PhD1; Shana Godfred-Cato, DO1; Sarah M. Labuda, MD1; David W. McCormick, MD1; Andrea M. McCollum, PhD1; Agam K. Rao, MD1; Johanna S. Salzer, DVM1; Anne Kimball, MD1; Jeremy A. W. Gold, MD1; California Department of Public Health Monkeypox Pediatric Working Group; CDC Monkeypox Pediatric Working Group (View author affiliations)View suggested citation
What is already known about this topic?
Data on epidemiologic and clinical characteristics of monkeypox in persons aged ≤12 years (children) and adolescents during the ongoing 2022 monkeypox outbreak are limited.
What is added by this report?
During May 17–September 24, 2022, Monkeypox virus (MPXV) infections in children and adolescents aged <18 years were rare, representing 0.3% of all U.S. cases; none resulted in critical illness or death. Younger children typically acquired MPXV infection after skin-to-skin contact with a household member with monkeypox during caregiving activities; adolescents were most frequently exposed through male-to-male sexual contact.
What are the implications for public health practice?
Additional monkeypox cases in children and adolescents might be prevented through strengthened vaccination efforts and education around preventive measures and sexual health.
Views equals page views plus PDF downloads
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.
MPXV infections in children and adolescents during May 17–September 24, 2022, constituted a small percentage (0.3%) of total U.S. monkeypox cases, and no children or adolescents with monkeypox received ICU-level care or died. However, consistent with disparities observed during the ongoing monkeypox epidemic (3), which are likely related to longstanding inequities in the social determinants of health,*** monkeypox in children and adolescents occurred disproportionately among Black and Hispanic children and adolescents compared with U.S. race and ethnicity percentage distributions of persons aged <18 years.††† This finding underscores the continued need for public health efforts to ensure equitable access to monkeypox vaccination, testing, treatment, and information about prevention measures. Similar to findings reported from Spain (1), exposure characteristics differed between younger children and adolescents: younger children most often acquired infection after direct skin-to-skin contact with a caregiver or household member known to have monkeypox, whereas exposure characteristics among adolescents were similar to those most commonly reported among adults (i.e., sexual contact) (3). Adults with monkeypox who interact with children in the household setting should follow transmission prevention guidelines, which outline measures to prevent the spread of monkeypox in households (4), and caregivers who are symptomatic and believe they might have been exposed should try to limit skin-to-skin contact with children, including by covering lesions. In addition, health care providers caring for sexually active adolescents, particularly males who have male-to-male sexual contact, should consider offering vaccination, should provide education on prevention of monkeypox, and should provide testing for HIV and other STIs (5).
Limited data, based on infections involving Clade I MPXV rather than the Clade IIb virus causing the current epidemic, suggested that children aged <8 years might be at higher risk for severe disease than are older persons (6,7). However, the clinical signs and symptoms reported in children and adolescents in this report were broadly similar to findings from Spain and U.S. national surveillance data for cases overall (1,3), with most children experiencing a mild-to-moderate clinical course. Clinicians caring for children and adolescents should be aware of available clinical guidance for the diagnosis and treatment of monkeypox§§§ and of the potential for severe disease, particularly in persons with profound immunocompromise (e.g., those with advanced HIV disease or undergoing chemotherapy for cancer) (8).
No secondary transmission was identified during instances when children attended school or a child care facility while symptomatic, although incomplete case ascertainment and reporting might have limited detection of such events. The absence of known secondary transmission in schools and child care facilities despite the presence of symptomatic persons in these settings suggests that widespread child-to-child transmission might be unlikely.¶¶¶ Regardless of age, contacts of persons with monkeypox should be monitored, and JYNNEOS vaccination postexposure prophylaxis should be considered based on an exposure risk assessment and individual risk for severe disease (7,9).
The findings in this report are subject to at least three limitations. First, data regarding exposure characteristics were missing for one third (34%) of children and adolescents aged <18 years, potentially because of difficulty reaching caregivers or adolescents for interviews or interviewee reluctance to disclose potentially sensitive information because of fear of stigma. Second, exposure misclassification might have occurred because of recall or social desirability bias. Finally, this report could potentially underestimate the number of MPXV infections occurring if children and adolescents aged <18 years with monkeypox did not receive testing. Nonetheless, caution is needed when ordering monkeypox tests and interpreting laboratory results for persons with low pretest probability of infection, because false positive test results can lead to unnecessary or inappropriate medical treatment (10).
This analysis found that monkeypox in children and adolescents aged <18 years has been rare during the current outbreak and most infections were not severe. Public health messaging should emphasize transmission prevention guidelines for persons with monkeypox who interact with newborns, infants, and children in household settings (4,9). In addition, health care providers caring for sexually active adolescents, particularly male adolescents who have male-to-male sexual contact, should encourage vaccination for eligible persons and should provide testing for HIV and other sexually transmitted diseases.
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.
California Department of Public Health Monkeypox Pediatric Working Group
Rick Berumen, California Department of Public Health; Giorgio Cosentino, California Department of Public Health; Shiffen Getabecha, California Department of Public Health; Carol Glaser, California Department of Public Health; Kaitlin Grosgebauer, California Department of Public Health; Kathleen Harriman, California Department of Public Health; Monica Haw, California Department of Public Health; Amanda Kamali, California Department of Public Health; Chantha Kath, California Department of Public Health; Elissa H. Kim, California Department of Public Health; Linda S. Lewis, California Department of Public Health; Darpun Sachdev, California Department of Public Health; Maria Salas, California Department of Public Health; Cameron Stainken, California Department of Public Health; Debra A. Wadford, California Department of Public Health; Philip J. Peters, California Department of Public Health and CDC; Akanksha Vaidya, California Department of Public Health and University of California San Francisco.
CDC Monkeypox Pediatric Working Group
Susan Hocevar Adkins, CDC; ; Nicolle Baird, CDC; Lisa C. Barrios, CDC; Amy Beeson, CDC; Dawn Blackburn, CDC; Brian F. Borah, CDC; Eleanor Click, CDC; Whitni Davidson, CDC; Romeo R. Galang, CDC; Kaitlin Hufstetler, CDC; Helena J. Hutchins, CDC; Athena P. Kourtis, CDC; Maureen J. Miller, CDC; Sapna Bamrah Morris, CDC; Emily O’Malley Olsen, CDC; Nicole M. Roth, CDC; Emily Sims, CDC; Kevin Chatham-Stephens, CDC.
Corresponding author: Ian Hennessee, email@example.com.
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.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.
* These authors contributed equally to this report.
† https://www.cdc.gov/poxvirus/monkeypox/response/2022/us-map.html (Accessed October 4, 2022).
** https://www.fda.gov/news-events/press-announcements/monkeypox-update-fda-authorizes-emergency-use-jynneos-vaccine-increase-vaccine-supply; https://www.cdc.gov/poxvirus/monkeypox/clinicians/Tecovirimat.html; https://www.fda.gov/media/78174/download; https://www.cdc.gov/poxvirus/monkeypox/clinicians/ocular-infection.html
†† 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
§§ During the investigation period, CDC received notifications of 109 children and adolescents aged <18 years who received a positive PCR test result for MPXV, NVO, or OPXV, among whom 26 cases were ruled out after further investigation based on high Ct values on NVO, OPXV, or MPXV PCR testing, negative repeat testing, or absence of epidemiological risk factors.
¶¶ These children were aged <1 year. Both received oral tecovirimat, and both also received topical trifluridine as potential prophylaxis for ocular monkeypox. One received VIGIV because of their very young age (infant), their immature immune system, and certain other factors.
- Aguilera-Alonso D, Alonso-Cadenas JA, Roguera-Sopena M, Lorusso N, Miguel LGS, Calvo C. Monkeypox virus infections in children in Spain during the first months of the 2022 outbreak. Lancet Child Adolesc Health 2022;6:e22–3. https://doi.org/10.1016/S2352-4642(22)00250-4 PMID:36058226
- Saunders KE, Van Horn AN, Medlin HK, et al. Monkeypox in a young infant—Florida, 2022. MMWR Morb Mortal Wkly Rep 2022;71:1220–1. https://doi.org/10.15585/mmwr.mm7138e3 PMID:36136958
- Philpott D, Hughes CM, Alroy KA, et al.; CDC Multinational Monkeypox Response Team. Epidemiologic and clinical characteristics of monkeypox cases—United States, May 17–July 22, 2022. MMWR Morb Mortal Wkly Rep 2022;71:1018–22. https://doi.org/10.15585/mmwr.mm7132e3 PMID:35951487
- CDC. Monkeypox: isolation and infection control at home. Atlanta, GA: US Department of Health and Human Services, CDC; 2022. Accessed September 15, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-home.html
- CDC. Monkeypox: safer sex, social gatherings, and monkeypox. Atlanta, GA: US Department of Health and Human Services, CDC; 2022 Accessed September 26, 2022. https://www.cdc.gov/poxvirus/monkeypox/prevention/sexual-health.html
- Huhn GD, Bauer AM, Yorita K, et al. Clinical characteristics of human monkeypox, and risk factors for severe disease. Clin Infect Dis 2005;41:1742–51. https://doi.org/10.1086/498115 PMID:16288398
- CDC. Monkeypox: clinical considerations for monkeypox in children and adolescents. Atlanta, GA: US Department of Health and Human Services, CDC; 2022. Accessed September 15, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/pediatric.html
- Miller MJ, Cash-Goldwasser S, Marx GE, et al. Severe monkeypox in hospitalized patients—United States, August 10–October 10, 2022. MMWR Morb Mortal Wkly Rep 2022;71:1412–7. https://doi.org/10.15585/mmwr.mm7144e1
- CDC. Monitoring and risk assessment for persons exposed in the community. Atlanta, GA: US Department of Health and Human Services, CDC; 2022. Accessed September 15, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/monitoring.html
- Minhaj FS, Petras JK, Brown JA, et al.; CDC Monkeypox Emergency Response Team. Orthopoxvirus testing challenges for persons in populations at low risk or without known epidemiologic link to monkeypox—United States, 2022. MMWR Morb Mortal Wkly Rep 2022;71:1155–8. https://doi.org/10.15585/mmwr.mm7136e1 PMID:36074752
Suggested citation for this article: Hennessee I, Shelus V, McArdle CE, et al. Epidemiologic and Clinical Features of Children and Adolescents Aged <18 Years with Monkeypox — United States, May 17–September 24, 2022. MMWR Morb Mortal Wkly Rep 2022;71:1407–1411. DOI: http://dx.doi.org/10.15585/mmwr.mm7144a4.
MMWR and Morbidity and Mortality Weekly Report are service marks of the U.S. Department of Health and Human Services.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.
All HTML versions of MMWR articles are generated from final proofs through an automated process. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (https://www.cdc.gov/mmwr) and/or the original MMWR paper copy for printable versions of official text, figures, and tables.
Questions or messages regarding errors in formatting should be addressed to firstname.lastname@example.org.