Epidemiologic and Clinical Features of Children and Adolescents Aged <18 Years With Monkeypox

United States, May 17-September 24, 2022

Ian Hennessee, PhD; Victoria Shelus, PhD; Cristin E. McArdle, PhD; Maren Wolf, MPH; Sabrina Schatzman, PhD; Ann Carpenter, DVM; Faisal S. Minhaj, PharmD; Julia K. Petras, MSPH; Shama Cash-Goldwasser, MD; Meghan Maloney, MPH; Lynn Sosa, MD; Sydney A. Jones, PhD; Anil T. Mangla, PhD; Rachel E. Harold, MD; Jason Beverley, MS; Katharine E. Saunders, DNP; Jeremy N. Adams, PhD; Danielle R. Stanek, DVM; Amanda Feldpausch, DVM; Jessica Pavlick, DrPH; Megan Cahill, PhD; Victoria O'Dell, MPH; Moon Kim, MD; Jemma Alarcón, MD; Lauren E. Finn, MPH; Maura Goss; Monique Duwell, MD; David A. Crum, DVM; Thelonious W. Williams; Katrina Hansen, MPH; Megan Heddy; Krystle Mallory; Darby McDermott, DVM; Mervin Keith Q. Cuadera, MS; Eric Adler, MPH; Ellen H. Lee, MD; Amanda Shinall; Carlen Thomas; Erin K. Ricketts, MD; Tammy Koonce, MSN; Dana B. Rynk, MSN; Kelly Cogswell, MPH; Meagan McLafferty, MPH; Dana Perella, MPH; Catherine Stockdale; BreeAnna Dell, DVM; Mellisa Roskosky, PhD; Stephen L. White, PhD; Kenneth R. Davis, MPH; Rania S. Milleron, PhD; Skyler Mackey, MPH; L. Anna Barringer; Hollianne Bruce, MPH; Debra Barrett; Marisa D'Angeli, MD; Anna Kocharian, MS; Rachel Klos, DVM; Patrick Dawson, PhD; Sascha R. Ellington, PhD; Oren Mayer, PhD; Shana Godfred-Cato, DO; Sarah M. Labuda, MD; David W. McCormick, MD; Andrea M. McCollum, PhD; Agam K. Rao, MD; Johanna S. Salzer, DVM; Anne Kimball, MD; Jeremy A. W. Gold, MD


Morbidity and Mortality Weekly Report. 2022;71(44):1407-1411. 

In This Article


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.