Monkeypox in children: Update on the current outbreak and need for better reporting

The recent Comment by Cohen and colleagues provided a timely guidance on management of monkeypox cases in children during the current global outbreak.¹ Based on scant reports from endemic countries and individual case reports in non-endemic countries over several decades, young children are considered high risk for severe monkeypox disease, yet in the current global outbreak due to a less severe West African monkeypox clade, we know very little about their risks, clinical presentation, course of illness, treatment or outcomes. Here, we provide an update on the current Monkeypox outbreak in children and call for a need for better reporting.

As of September 6, 2022, there have been 59 childhood cases reported in the European Union (EU) and European Economic Area (EEA) countries, 5 cases among 0–17-year-olds in Canada, only one case in the UK, and 31 child cases in the US. In Spain, 3 of 4 cases in <4 year-olds were household-acquired, while 13–17 year-olds acquired the infection in a tattoo parlour (n=9) or through sexual contact (n=3).² One infant in the US reportedly presented with a rash, was hospitalized for several days and treated with tecovirimat.³ The UK case was reported by a national newspaper to be hospitalised in a London Intensive Care Unit, but this was neither confirmed nor denied by public health authorities.⁴

In Brazil, high community infection rates have so far resulted in 141 confirmed/probable infections in 0–17 year-olds. Probable cases relied on clinical signs and epidemiological links but there is no further information on their source of infection, severity of illness or outcomes. These cases included 38 children aged <4 years including two infants,⁵ a 2-month-old in Bahia, and a 10-month-old in São Paulo. Notably, PCR-positivity between male and female children was ∼50%, which differs greatly to the very high male-to-female ratio in adults, where cases are primarily reported among men who have sex with men (MSM).

Reports are also emerging on neonates following pregnancy and perinatal exposures. In Brazil, one of nine infected pregnant women has given birth and there was no vertical transmission to the infant. Vertical transmission also did not occur in the first US case of a monkeypox-infected pregnant woman; the neonate received prophylactic vaccinia immune globulin and did not develop monkeypox disease.⁶

As schools reopen after summer holidays, despite no transmissions reported in educational settings so far, increased vigilance and timely reporting will be critical in communities with on-going transmissions.

Taken together, global reports of monkeypox disease in young children are reassuring, but we need more robust and systematic data beyond media reports to both reassure parents and provide evidence-based care for children.

Contributors

All authors contributed equally to the manuscript.

Declaration of interests

Professor Khalil is the obstetric lead of the national maternity perinatal audit at the Royal College of Obstetrics and Gynaecology. Professor O'Brien is the Vice President of the Royal College of Obstetrics and Gynaecology. All other authors declare no conflict of interest.