Monkeypox - American Academy of Pediatrics

Below are answers from AAP experts on some of the most frequently asked questions about how to prevent, recognize, test for and treat monkeypox. Additional resources, including details from Red Book Online, are listed below.

Is monkeypox a risk for children and adolescents?

The risk of children and adolescents getting infected with monkeypox virus is low. Monkeypox can spread to anyone through close, personal, often skin-to-skin contact and not through casual contact (eg, in school, child care settings). Risk of infection is more likely for household members and other close contacts of an infected person. As of August 21st, 17 pediatric cases have been reported in children 0-15 years old and 134 cases have been reported in adolescents/young adults 16 to 20 years old in the United States. The highest proportion of cases by race and ethnicity have been reported in people who are American Indian/ Alaska Native (30.6%), Hispanic or Latino (31.8%) and Black or African American (33.2%).

Are some children and adolescents at increased risk for monkeypox?

Infants, young children (under 8 years of age), children and adolescents with eczema and other skin conditions and children  and adolescents with immunocompromising conditions may be at increased risk of severe disease when they contract monkeypox.

What are the symptoms of monkeypox in children and adolescents?

Rash is the most common monkeypox symptom, and it can look similar to rashes seen more commonly in children and adolescents, including rashes caused by chickenpox, herpes, allergic skin rashes and hand, foot, and mouth disease.

The rash typically begins as maculopapular lesions and then progresses to vesicles, pustules and scabs. Other common symptoms include fever, lymphadenopathy, fatigue and headache, although these symptoms are not always present.

How is monkeypox spread?

Monkeypox spreads to others through close, personal, often skin-to-skin contact, including:

• Direct contact with monkeypox rash or scabs from a person with monkeypox, including sexual contact.
• Touching objects, fabrics (clothing, bedding or towels) and surfaces that have been used by someone with monkeypox.
• Contact with large respiratory secretions from prolonged face-to-face contact (this is more of a risk for health care workers, household members and other close contacts of an infected individual).

Unlike some other rashes, monkeypox remains contagious until the scabs fall off and new skin has formed.

Scientists are still studying whether the monkeypox virus can be spread in asymptomatic but infected individuals or through body fluids such as semen, vaginal fluids, urine and feces. Monkeypox is not believed to spread through casual conversations with an infected individual but rather through close contact, that can include sexual encounters.

When should I consider testing a child or adolescent for monkeypox?

If a child or adolescent has a suspicious rash, pediatricians and other pediatric clinicians should test their patients especially if there is a history of close, personal contact with someone who is a confirmed or probable case or travel that puts them at risk.

Testing is available through state public health authorities and at some commercial labs. Requirements for specimen collection and shipping may differ by laboratory and clinicians should confirm requirements before obtaining a sample from the skin lesions.

If I think a child or adolescent might have monkeypox, what precautions should I recommend to the family/caregiver?

Monkeypox remains contagious until the rash is fully resolved (scabs fall off and new skin has formed), which can take up to 2-4 weeks. While contagious, the following precautions should be taken:

• Individuals with monkeypox should cover their skin lesions.
• Parents/caregivers should encourage their children to avoid scratching their skin lesions and touching their eyes.
• Individuals with monkeypox should avoid contact with other people and pets. If possible, one person should be the caregiver of a child with monkeypox and should avoid skin-to-skin contact with the rash.
• Children who are at least 2 years of age who have monkeypox should wear a well-fitting mask when interacting with a caregiver, and the caregiver should wear a respirator or well-fitting mask and gloves when skin contact with the child may occur, and when handling bandages or clothing.
• Children and adolescents should not return to school or childcare while contagious. The decision to end isolation and return to school or childcare should be made in collaboration with local or state public health authorities.

Is there any treatment for monkeypox for children and adolescents?

Yes. Treatment is available, particularly for those who have severe disease, are at risk for severe monkeypox disease, (ie, those who are less than 8 years of age, those with immunocompromising conditions, those who have a history of certain skin conditions), those who have accidental implantation or lesions in certain anatomical areas (ie, eyes, mouth, genitalia, anus), and children and adolescents with complications from monkeypox.

Tecovirimat is the first-line treatment and is being used under an investigational protocol. The CDC recently streamlined the process to obtain it. It is available in both oral and intravenous forms.

Is there a monkeypox vaccine indicated for use in children and adolescents and how do I obtain it for my patients?

There is currently no monkeypox vaccine available for administration to children and adolescents. However, there is a vaccine available to individuals < 18 years who have been exposed to monkeypox (ie, JYNNEOS vaccine for post-exposure prophylaxis,) under expanded use authorization issued by the Food and Drug Administration. Jynneos is administered to individuals (age <18 years of age) subcutaneously. The vaccine should not be administered intradermally in individuals <18 years of age. Clinicians should discuss the use of vaccine in a child or adolescent as post-exposure prophylaxis with the state or local health department.

How can I protect myself and other members of the practice team from monkeypox?

Currently, vaccination is not recommended for most health care workers. CDC recommends that people whose jobs (clinical or research laboratories and certain health care and public health team members) may expose them to orthopoxviruses, such as monkeypox, receive either JYNNEOS or ACAM2000 vaccine.

Health care workers should utilize the following personal protective equipment (PPE) when caring for a patient with suspected or confirmed monkeypox infection: gown, gloves, eye protection and N95 (or comparable) respirator.

Is post-exposure prophylaxis recommended for health care workers who have been exposed to monkeypox?

Health care workers who have unprotected, high risk contact with patients with monkeypox may be eligible for post-exposure prophylaxis in consultation with public health authorities. Post-exposure prophylaxis involves receipt of vaccine, optimally within 4 days of exposure. Transmission of monkeypox virus from patients to health care workers has not occurred to date in this outbreak, lending support to the recommendation for post-exposure prophylaxis as the primary means for protecting health care workers.

What is the guidance for newborns in hospitals who may have been exposed to monkeypox during and after delivery?

Infants born to someone with suspected or confirmed monkeypox should undergo early bathing and post-exposure prophylaxis. While the optimal strategy for post-exposure prophylaxis of newborns has not been defined, Vaccinia Immune Globulin should be considered. Infants should also stay in a separate room and not have direct contact with parent (s) or caregivers infected with monkeypox. Breastfeeding should be delayed during the isolation period, and breastmilk should be pumped and discarded.

Additional Information: