Monkeypox in children and elderly: correspondence

Dear Editor,

Monkeypox (MPX) is a viral zoonotic disease caused by the monkeypox virus as a part of orthopoxviruses belonging to the poxviridae family1. The disease has always been restricted in location and is mainly endemic to Central and West Africa2. The first case of MPX in humans was seen in 1970 in the Democratic Republic of Congo (DRC) in a pediatric patient3. Since then, the disease has remained restricted to endemic regions of Central and West Africa until in 2003, when it appeared as a major outbreak in the United States following importation of animals from Ghana4. Over the last 2 decades, sporadic cases of MPX have been reported from North America, Europe, and Middle East with most of the cases being linked to travelers from endemic regions. On May 4, 2022, the disease started to emerge outside of its endemicity with the first case being reported by WHO on the 7 of May. This case was of an individual who had a travel history to Nigeria in April and tested positive for MPX. The continuous surge in the number of cases all over Europe and subsequently in America prompted the WHO to finally declare it as a disease as a public health emergency of international concern on July 23, 20225. As on November 9, 2022 according to the Centre for Disease Control (CDC), a total of 78 599 confirmed cases of MPX have been reported from all over the world6.

The previous outbreaks of MPX in the DRC and other endemic countries in Africa have mostly been caused by the Clade I of the virus. Children were found to be the most high-risk group in all these outbreaks. Severe disease manifestations were observed especially in children under 8 years of age. In view of these findings from previous outbreaks, infants and children with skin conditions or if immunocompromised are considered to be a group with highest risk of acquiring MPX infection infection7,8. The case fatality rate is higher in children aged below 4 years (14%) in comparison to those between 4 and 5 years (8%)9.

The first case of MPX in children was reported on July 28, 2022. According to the CDC, these first cases were seen in two children who were symptomatic but stable at presentation to the hospital. Although they were not related to one another, the occurrence of disease was through means of household contact. Subsequently one more case was seen, when a male child aged below 10 years was admitted to the Emergency Department in Amsterdam, Netherlands with complains of sore throat. A day later he traveled to Turkey and on return, presented skin lesions on his jaw and cheek which tested positive for the MPX by PCR10.

According to the CDC weekly report in September, there were 27 pediatric MPX cases reported aged between 0 and 15 years old. It also included the youngest pediatric case of MPX in Florida, a young infant aged less than 2 months who was admitted to the Emergency Department with rash which was present since 5 days. The results of the primary investigation for bacteria, varicella, HIV, and herpes simplex were negative. The child returned back to the same hospital, this time with diffuse rash all over the body in form of papulovsicular lesions with central umbillication but after swabs from forehead and back lesions were taken which tested positive for MPX. The child was immediately treated with oral tecovirimat and intravenous vaccine immunoglobulin with a prophylactic ophthalmic trifluridine drops to prevent any ophthalmic compilations from the eyelid lesion11.

In Brazil, there were 38 children aged less than 4 years and two infants diagnosed with MPX from a total of 141 confirmed/probable pediatric MPX cases12. According to the CDC, the children cases in the age group from 1 to 15 years old were sorted out as follow, from 0 to 5 years (18 male and seven female), from 6 to 10 years (nine male and four female), from 11 to 15 years (11 male and five female). For the elderly age group from 61 to 65 years (279 cases), from 66 to 70 years (99 cases), from 71 to 75 years (35 cases), and over 67 years old (five cases) which shows that majority of the involvement is by children and elderly in the MPX outbreak13.

These cases highlight the importance of considering MPX in any pediatric case admitted with a rash and necessitate the surmount need to implement prophylactic measures of the disease as the children are infected from household contact besides other means of transmission. The disease treatment in pediatric patients should be considered in children below 8 years and those immunocompromised and with severe immune condition. The main management focus should be on supportive care in order to prevent dehydration, antibiotics for the secondary bacterial infection and antiviral drugs like tecovirimat and if suspected to be infected from the contact with another case, the child should be given postexposure prophylaxis with the immunoglobulins and antiviral drugs7.

The elderly are considered a special group of the disease as most of them have received a smallpox vaccine that can offer cross-protection against MPX, but this vaccine was stopped before 40 years so the age group that will take benefit from this is the patients over 50 years old14. The rate of MPX cases found in elderly in June 2022 was around 1.5% of all total cases which is considered to be low, but the cases started to increase as 715 cases in the age group (60–69 y old), 78 cases (70–79 y old), and 14 cases in the patients over 80 years old as shown in Fig. 1 15,16.

Figure 1.

The cases of monkeypox distributed over the different age groups and sex. Adapted from WHO15.

As the sexual transmission of the disease plays important role in the transmission methods, it is important to identify the contribution of other routes of transmission as shown in Fig. 2 which shows the MPX cases excluding men who have sex with men15.

Figure 2.

The cases of monkeypox distributed over the different age groups and sex excluding the men cases who have sex with men. Adapted from WHO15.

Elderly patients are suspected to have disease symptoms depending on the health status as most of this age group have other co-morbidities and chronic diseases, as was seen in the 710-year-old female Italian woman with co-morbidities including diabetes, hypertension, obesity, and bipolar disorders. She was admitted to the Emergency Department with rash besides other general symptoms such as fever and fatigue. Gradually the rash started to spread to different parts of the body and when swabs were taken from these sites, the patient tested positive for MPX. However, the patient was stable, did not receive any specific treatment and was eventually discharged after 3 days of the hospitalization with good health.

The infection is still ongoing and thus prevention is the cornerstone of controlling the spread of the disease in these two age groups. Covering skin lesions in order to limit the illness contagiousness, avoiding scratching the lesion and contacting the eye as the disease may be transmitted from the lesion to it, following infection control measures such as wearing masks during contacts with other people, continuous use of alcoholic gel, education on vaccines and the importance of their administration are crucial steps which may be considered in order to put an halt to the rapid propagation of the infection worldwide8.

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No funding received.

Author’s contribution

R.S. and A.S.: design and draw the original draft. A.M., M.A.R., T.A.A., and B.K.P.: review the literature, critically edit the manuscript. All authors read and approve for the final manuscript. All authors contributed equally.

Conflict of interest disclosure

Authors declare no conflict of interest.

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Guarantor

Ranjit Sah.

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Not commissioned, externally peer reviewed.