Written by Knvul Sheikh and Catherine Pearson
As children around the country head back to school for the third time since the COVID pandemic began, a different infectious disease is now spreading globally: monkeypox.

Almost every single state and territory in the United States has reported cases of monkeypox, with more than 11,000 confirmed cases nationwide. And news of a day care worker in Illinois testing positive earlier this month prompted some infectious disease specialists to warn there is potential for spread in group settings like schools and day cares.

But more than 98% of those infected with monkeypox are adult men who acquired the virus through intimate contact with other men — and so far, less than a dozen pediatric cases have been recorded in the U.S.

Monkeypox is not spread as easily as COVID-19 or common childhood illnesses, said Dr. Ibukun Kalu, a pediatric infectious diseases specialist at the Duke University School of Medicine. It typically requires direct contact with an infected person’s rash. According to the Centers for Disease Control and Prevention, monkeypox can also spread by touching objects, fabrics and surfaces that have been used by someone with monkeypox and haven’t been cleaned, or by respiratory droplets expelled by an infected person during close face-to-face contact.

However, new data suggests that indirect contact and environmental contamination are not major sources of transmission. If someone with monkeypox comes to shared spaces like offices or schools, scientists have found that they do not leave behind enough live virus that can replicate and infect others.

Additionally, there is a vaccine and a treatment for monkeypox. The vaccine is not publicly available, but an emergency use authorization now allows children under 18 to receive the vaccine if they have been exposed or are at high risk of getting monkeypox.

Parents who are concerned about the virus may also be relieved to know that many pandemic precautions and behaviors can be repurposed to protect children against monkeypox: wearing masks in crowded indoor areas, avoiding sharing personal use items, increasing the frequency of hand washing and isolating at home when you’re sick.

It’s important to pay attention to new rashes and other symptoms, Kalu said. “Get your child assessed by a doctor if the rash starts spreading or is something you’ve not really seen on your child before.”

What to look out for

A monkeypox rash starts off as red lesions that can become raised and filled with pus. It can appear anywhere on the body, including the face, hands, feet and genitals, and sometimes resembles chickenpox (which is caused by an unrelated virus) or hand, foot and mouth disease, a common childhood rash that tends to circulate during back-to-school season.

Monkeypox cases in adults can also look like acne or sexually transmitted diseases such as herpes or syphilis, particularly if the rash is limited to just a few pustules. Other symptoms of monkeypox include a fever, headaches, muscle aches, swollen lymph nodes, and rectal pain or bleeding. Symptoms can appear up to three weeks after an exposure and last two to four weeks.

How to think about transmission risks

Though monkeypox is unlikely to spread widely in schools and day cares, parents should expect to hear of more cases spilling over to these and other settings if the disease continues to proliferate.

“There will absolutely be cases that will occur in women, in children and in people who are pregnant,” said Dr. Jay Varma, a physician and epidemiologist who specializes in infectious diseases at Weill Cornell Medical School in New York City.

However, for now, children are more likely to pick up monkeypox from people they come into contact with at home than at school, Varma said. Still, a child who lives with someone with monkeypox could potentially bring the virus to their day care or school.

The activities that may put children at risk and the signs of infection that parents should look out for also differ by age. Here’s what to know.

If your children are in day care (ages 0-4)

Because monkeypox spreads primarily through prolonged close contact, babies and toddlers could theoretically get monkeypox from caregivers who are sick — if they hug or kiss children, change dirty diapers with an exposed rash on their hands — or through contaminated toys, shared utensils and beds. However, most day cares already have policies to disinfect toys and surfaces, as well as avoid shared beds, linens or clothing. After the day care worker in Illinois tested positive for monkeypox, no cases were found in children or other staff members. All were offered the vaccine.

“I think the important thing to know is that monkeypox is extraordinarily rare in children, especially young children,” said Dr. Kristina Bryant, a pediatric infectious diseases specialist with Norton Children’s Hospital in Louisville, Kentucky, and a member of the American Academy of Pediatrics’ Committee on Infectious Diseases.

That said, parents should take any new rash seriously, particularly if it lasts for more than a few days or if it is accompanied by a fever, Bryant said. Though experts say it is far more likely to be the result of a common childhood illness such as hand, foot and mouth disease, monkeypox may be more severe in children younger than 8 years old, as well as in those who are immunocompromised or who have certain skin conditions like eczema.

Trust your “spidey sense,” said Dr. Joshua Schaffzin, director of infection prevention and control at Cincinnati Children’s Hospital Medical Center, and contact your child’s pediatrician if you are worried. They may be able to determine what is behind your child’s rash just by looking at a photo or scheduling a phone conversation.

Parents should keep children home if they have any kind of rash. “A child who has a fever and a rash should not be going to day care,” Schaffzin said. If there is an exposure, your child’s day care staff should manage it much like they would manage other viruses, like norovirus, that spread via surfaces and person-to-person contact, Schaffzin said. That entails a thorough cleaning and ensuring any staff or children with symptoms stay home until they are no longer contagious, while carefully monitoring for
symptoms in others.

If you have pre- or elementary schoolers (ages 4-10)

As with day care, it is important to keep children with a rash and fever at home and encourage them to frequently wash their hands. “I think the protocols schools have in place have only gotten better since COVID,” Bryant said. “That’s the good news.”

Children in this age group also have a pretty good understanding of concepts like keeping their hands and bodies to themselves, and not sharing personal items — strategies that can help prevent the spread of more common back-to-school concerns, like head lice, as well as rare cases of monkeypox, Bryant said.

According to Bryant, it will also be important for parents and adults at home to be aware of their own health and be open about discussing the disease in an age-appropriate way with their children. If anyone gets infected with monkeypox, they should isolate in a room away from others to the extent it is possible, wear a well-fitting medical mask and cover their rash with long sleeves, pants or gloves.

“The cases in children have been linked to household transmission,” Bryant said. “So the best way to protect your children from monkeypox is for parents to protect themselves.”

If you have tweens or teens (ages 11-18)

Older children who participate in close-contact sports like wrestling or activities that involve shared costumes or uniforms may be at higher risk for monkeypox compared to their peers.

But that does not mean students should discontinue these activities. As long as school administrators and parents are aware of which activities and areas have potential for virus transmission, and they communicate that clearly to students, monkeypox risks can be contained.

“Athletes are already encouraged to keep up on their personal hygiene and to check their skin for other infections like staph,” Kalu said. “I’m not really worried that playing sports is going to lead to lots of new monkeypox outbreaks in schools.”

Many schools use disinfectants to clean high-touch surfaces like workout equipment, separate uniforms into dirty or clean piles and handle potential contamination with gloves, all of which can help reduce virus transmission, Kalu said.

Parents may also start having sex talks with children around this age or earlier. For those who are having conversations about sex, you may want to bring up monkeypox proactively, since one of the main ways it is spreading right now is through intimate contact. Close physical contact during oral, anal or vaginal sex, as well as when kissing or cuddling, can spread the virus.

You can ask if your teen has heard about monkeypox and what they know. Make sure they understand what symptoms to look out for and how to engage in safe sex. (While condoms may reduce monkeypox transmission, they are unlikely to completely eliminate the risk. The CDC has some guidance on safe sex for monkeypox, although it is not specific to young adults.)

If your children are in college

A handful of colleges and universities have recently reported monkeypox cases and launched public health campaigns around the disease as students and faculty return to campus in the fall. Although the risk of monkeypox transmission is still fairly low in classrooms, college students are more likely to be sexually active or to come in close contact with others in dorms and at parties, so their risk is more similar to that of other adults, Kalu said.

Students who are over 18 may be eligible for the monkeypox vaccine before they go to school — if they meet their state’s criteria, such as having had multiple sex partners in the past two weeks or if they are men who have sex with men. If students develop a suspicious rash, they may be able to access monkeypox tests at their student health center. Concerned parents can also talk to campus officials about medical or emotional support available to students and find out whether there is an isolation protocol for
those who test positive.