Overview of Outbreak
- Surge in International Cases: Since November 2023, the Democratic Republic of Congo (DRC) has seen a significant increase in mpox Clade 1 This outbreak is distinct from the global Clade 2 outbreak that began in 2022.
- Transmission: Historically a zoonotic disease, Clade 1 has now shown increased person-to-person transmission, including within households and via sexual contact. This has led to the identification of a new lineage, Clade 1b.
- Geographic Spread: Clade 1a has spread beyond the DRC to neighboring Clade 1b has spread more widely to several other African countries. Clade 1b cases have also been seen in travelers to Sweden and Thailand.
- No spread to the US: No Clade 1a or Clade 1b cases have been reported in the US as of early September 2024.
- Clinical Concerns: Between January 2023 and August 2024, more than 25,000 cases and more than 1000 deaths have been confirmed in Africa; the case fatality rate of this current outbreak is nearly 3%. Although Clade 1a is associated with more severe disease, clade 1b does not have this association.
- Impact on Children: The Clade 1a and 1b outbreak have had a more significant impact on children, compared with Clade 2 outbreak. Currently, children account for over half of the mpox cases in Africa, with hundreds of pediatric deaths reported in the DRC this year. Clade 1a is largely responsible for severe outcomes in this population.
- Infection Control: See CDC guidance for general and pediatric-specific.
Transmission
Common routes of transmission to children
- Zoonotic Transmission: Traditional route via infected animals, which would only be expected to occur in areas outside of the US where mpox is commonly seen.
- Direct Contact: Skin-to-skin exposure to lesions or body fluids, which is more likely to occur among household contacts. Adolescents are at risk from direct contact occurring during sexual activity with someone with mpox.
Uncommon routes of transmission to children
- Fomites: Contact with contaminated objects or surfaces.
- Respiratory Droplets: Possible transmission through close, prolonged exposure.
- Nosocomial Transmission: Rare but reported in healthcare workers. Personal protective equipment is effective.
- Vertical Transmission: Documented but limited data.
- Breastfeeding: Unconfirmed, but caution is advised due to risk of close contact.
Symptoms and Complications
CDC: Symptoms and Complications
- Incubation period: 3-17 Illness lasts 2-4 weeks.
- Classic Symptoms: Characteristic rash often preceded by fever, chills, myalgias, malaise, headaches, lymphadenopathy.
- Atypical Presentations (Clade 2): Limited rash spread with more mild or absence of systemic symptoms.
- Complications: Potential for abscess formation, secondary bacterial infections, airway disease (e.g., pneumonia, epiglottitis), encephalitis, corneal infection, and gastrointestinal issues.
Diagnosis
- Testing: PCR testing is recommended, with samples taken from at least two
Contact state/local health departments before specimen collection. Commercial laboratory testing is available. Results are typically available within a few days.
- Differential Diagnosis: Consider chickenpox, molluscum contagiosum, measles, rickettsial infections, HSV, bacterial skin infections (e.g., impetigo), cutaneous anthrax, scabies, syphilis, or cutaneous drug reactions.
Treatment
CDC: Treatment
- Supportive Care: Includes hydration, complication management, and pain relief.
- Tecovirimat: Available under Expanded Access Investigational New Drug Protocol. Approved for smallpox and effective against mpox. Oral or IV form given for 14 days.
- Pediatric Considerations: Suspension not available but capsules can be mixed with liquids. IV form in children <2 years old requires monitoring of renal function.
- Ongoing Trials: Clinical trials for pediatric antiviral therapy are ongoing.
Vaccination
CDC: Vaccination
- JYNNEOS Vaccine: Administered to high-risk individuals in two subcutaneous doses, 28 days Intradermal administration is not recommended for those under 18.
- Post-Exposure Prophylaxis: Ideally given within 4-14 days post-exposure. Available under EUA for children and adolescents younger than 18 Vaccinia immune globulin intravenous should be considered for children younger than 6 months.
- Pre-Exposure Prophylaxis: Recommended for at-risk adolescents, including those younger than 18 years with the risk factors described by the CDC.
Active Items for Providers
- Stay up-to-date with current situation to know risk of mpox in travelers and in the community in the US.
- Work with your hospital to understand steps to obtain tecovirimat by EA-IND if needed for a pediatric patient.
- Promote vaccine use in high-risk adolescents age 18 years and
Additional Resources/References
- World Health Organization (WHO). “Mpox (Monkeypox) Outbreak – Democratic Republic of ” Available at: WHO Mpox Updates
- Centers for Disease Control and Prevention (CDC). “Clinical Guidance for Mpox Treatment and ” Available at: CDC Mpox Guidelines
- European Centre for Disease Prevention and Control (ECDC). “Mpox (Monkeypox): Epidemiological ” Available at: ECDC Mpox Report
- National Emerging Special Pathogens Training and Education Center (NETEC).“Mpox (Monkeypox) Laboratory Resources.” Available at: NETEC Laboratory Resources for Mpox
- Food and Drug Administration (FDA). “Emergency Use Authorization (EUA) for JYNNEOS Vaccine.” Available at: FDA JYNNEOS Vaccine
- Tecovirimat “Tecovirimat (TPOXX): Usage and Guidelines.” Available at: CDC Tecovirimat Information