It’s back-to-school season, which apparently means it’s time to do the last thing parents want to: Study up on yet another infectious disease. This time, it’s monkeypox.
Last week, an Illinois day care worker tested positive for the disease, raising the specter of outbreaks among young children as they gear up for the new school year. These fears are understandable: Monkeypox can be quite serious for young children, and although there’s treatment available, kids aren’t yet eligible for a vaccine, which is in limited supply anyway.
So far, there are only five known pediatric monkeypox cases in the U.S. out of a total of 10,700 cases as of Friday, June 12. But low numbers today may not feel reassuring. As we saw with COVID, infectious diseases can grow exponentially—a handful of cases this month might turn into hundreds next month and millions next year. A Centers for Disease Control health alert from late July warned that children younger than 8 years of age could be at increased risk for more severe disease. My 4-year-old son will be strapping on his tiny backpack for the first day of pre-K in a few weeks, and I’m wondering: how concerned should I be?
Over the past two years, we’ve developed a mental model of how COVID spreads, and it would be tempting to apply that hard-earned knowledge to monkeypox. But monkeypox, while also caused by a virus, behaves very differently than SARS-CoV-2. Experts believe that the monkeypox virus can be spread in three ways: direct contact with viral skin lesions, contact with saliva from someone with viral lesions in their mouth or throat, or touching a contaminated object. It almost certainly doesn’t spread like the coronavirus in puffs of viral smoke.
Of the three ways that monkeypox is capable of spreading, direct contact with viral skin lesions is what’s really driving the outbreak. And “direct contact” does not mean just a fleeting touch. “This virus is in the lesions, and it’s on the surface of lesions. You have to rub the lesion enough on somebody so that enough virus finds a break in their skin, or finds a mucous membrane to cross,” says Susan McLellan, an infectious disease specialist at the University of Texas Medical Branch at Galveston. The best way for the virus to do this, McLellan said, is sex. “Once the virus found its way to the genital area, it’s like ‘oh, wow, this is nice warm area with mucous membranes and people seem to like to rub their genital areas against each other. That’s a great way for me to spread.’” The epidemiological data reflects the virus’s biological proclivities: A recent WHO study found that 92 percent of transmission occurred during sex. For comparison, only 0.2 percent of people report catching the virus from a contaminated surface. Several other studies have come to the same conclusion.
The virus’s spread through sexual networks for men who have sex with men is also consistent with sexual activity as the main driver of the outbreak. Although the relatively higher rates seen in men who have sex with men could simply be due to increased testing in that population, researchers believe that if there were substantially more infected people outside the MSM community, the more severe cases would have shown up in the hospitalization statistics by now. “Monkeypox not the kind of thing that you get onto a bus, where lots of people are getting infected from someone’s breath, like COVID,” McLellan says. “Otherwise, we’d be seeing lots more people who got it from a bus.”
That doesn’t mean monkeypox can’t spread among children. The known infected kids probably caught the virus at home from a parent or caretaker—perhaps through some unlucky cuddles or kisses. Household transmission like this will surely happen again, and from there, a child could bring the virus into day care or school. If the infected child has hand lesions, and they go unnoticed by school staff, then theoretically other kids could pick up the virus from, say, contaminated toys, though it probably would be through somewhat involved play, not merely touching a toy that an infected kid also at some point touched. A toddler with undetected throat lesions might drool into another toddler’s mouth (gross, I know, but toddlers are kinda gross). And for the youngest children, who still need diapers changed or may need to be hand-fed, a day care worker with a hand lesion could transmit the virus to the child—or vice versa, a child with a lesion could transmit the virus to the day care worker, who could in turn transmit the virus to other babies in the center.
While these routes are all possible, McLellan says, a lot of things would have to fall into place. “At this point, if it was so easy to jump into the child population, it seems like it would have done so,” she says. “There might be isolated outbreaks, but I’m not super worried about elementary schools and day cares turning out to be hugely important.” (Sexually active high-school and college students could be more at risk.)
Yes, it’s possible the monkeypox epidemic could surprise us. But unlike COVID, monkeypox isn’t caused by a new virus. McLellan points to a 2003 U.S. outbreak, when a bunch of pet prairie dogs got infected with monkeypox. There were at least 40 confirmed cases, including children, but no human-to-human transmission—meaning the kids got it from contact with the pets—and no outbreaks in schools or day cares. In a media briefing, the WHO noted that a few infected children had no infected household members, meaning those children caught the virus elsewhere. This makes sense, because the 2022 outbreak is spreading on a very large scale: rare events will happen here and there.
Thankfully, so far no children in this outbreak have become seriously ill or died, and any particular kid who does catch the disease is unlikely to have a severe outcome. The viral strain causing this outbreak kills fewer than one percent of those it infects; there have only been a few deaths recorded in this outbreak overall. (With other viral strains, children seem to be harder hit by monkeypox than adults, and in pregnant people, the virus has causes stillbirths. But data for this strain is lacking.)
As a parent, this information made me rest easy, but I’ll still ask my son’s school what protocols they have in place. Simple measures they could take include sanitizing a little more than usual, keeping an extra eye out for lesions among staff and kids, and just being stricter with sick policies generally (monkeypox may begin with flu-like symptoms or rashes before lesions show up). Yes, monkeypox is yet another item on the concern list for parents. But in the scheme of things, it’s a pretty small one.
Update August 15th: This piece has been updated to clarify the date that the total monkeypox case count is from. It has gotten higher since.