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Received date: 01/03/2024 Published date: 20/03/2024 Case Study

Clinical Predictors and Determinants of Mpox Complications in Hospitalized Patients: A Prospective Cohort Study from Burundi

Liliane Nkengurutse^1,; John Otshudiema^2,3,; Godefroid Kamwenubusa^1,*; Issa Diallo²; Odette Nsavyimana⁴; Jean Claude Mbonicura⁴; Jean Claude Nkurunziza⁴; Fidèle Cishahayo⁵; Dieudonné Niyongere⁵; Bonite Havyarimana⁵; Déo Simbarariye⁶; Marc Nimburanira⁶; Bosco Ntiranyibagira⁶; Senya Diane Nzeyimana²; Brigitte Ndelema²; Denise Nkezimana²; Parfait Shingiro¹; Aimable Sibomana¹; Stany Nduwimana²; Freddy Nyabenda¹; Alexis Niyomwungere²; Mamadou Zongo^1,2; Abdoulaye Bousso^1,2; Samuel Boland²; Jeanine Ndayisenga⁷; Dionis Nizigiyimana⁷; Joseph Nyandwi^7,; Alimuddin Zumla^8,; Rosamund Lewis^9,; Stanislas Harakandi^4

* First Authors ** Senior Authors

¹Centre des Opérations d’Urgence de Santé Publique (COUSP/PHEOC Burundi), Bujumbura, Burundi.
²World Health Organization, WHO Burundi, Bujumbura, Burundi.
³African Region Mpox Response, World Health Organization, WHO African Regional Office, Brazzaville, Congo.
⁴Mpox Treatment Center, Centre Hospitalo-Universitaire de Kamenge (CHUK), Bujumbura, Burundi.
⁵Mpox Treatment Center, Clinique Prince Louis Rwagasore (CPLR), Bujumbura, Burundi.
⁶Mpox Treatment Center, Hôpital Militaire de Kamenge (HMK), Bujumbura, Burundi.
⁷Institut National de Santé Publique (INSP), Bujumbura, Burundi.
⁸Global Mpox Response, WHO Health Emergencies Programme, World Health Organization, WHO Headquarters, Geneva, Switzerland.
⁹Division of Infection and Immunity, Centre for Clinical Microbiology, University College London, London, and UK National Institutes of Healthcare Research (NIHR), Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, United Kingdom.

*Corresponding author

*Dr. Liliane Nkengurutse. Centre des Opérations d’Urgence de Santé Publique (COUSP/PHEOC Burundi), Bujumbura, Burundi.
*Dr. John Otshudiema. African Region Mpox Response, World Health Organization – WHO African Regional Office, OMS, Cité du Djoué, BP 06, Brazzaville, Republic of Congo.

DOI: 10.55920/JCRMHS.2025.09.001406

Abstract

Objectives: To identify predictors and determinants of mpox complications among hospitalized patients in Bujumbura, Burundi, amidst the ongoing mpox outbreak.

Methods: This prospective cohort study analyzed 850 laboratory-confirmed cases of mpox from three treatment centers between July and October 2024. We assessed clinical characteristics and outcomes using data from medical and laboratory records, along with structured interviews with health professionals. We estimated risk factors for complications using multivariate Firth penalized logistic regression stratified by age and HIV status.

Results: Among the 850 participants, 54.4% were male, and the median age was 20.3 years. Complications developed in 3.1% of cases, with conjunctivitis (OR 27.30, 95% CI: 7.67–122.23) and sore throat (OR 12.63, 95% CI: 5.78–30.21) as significant predictors of severe disease. In contrast, generalized rash (OR 0.10, 95% CI: 0.04–0.24) and lymphadenopathy (OR 0.24, 95% CI: 0.08–0.62) were associated with lower severity. Sexual contacts were the predominant route of infection.

Conclusions: Our findings identified key predictors of mpox complications with non-cutaneous symptoms like conjunctivitis and sore throat indicating severity. These insights support targeted interventions in resource-limited settings, although further research on underlying immunological mechanisms is required.

Keywords: Mpox; Clinical features; Predictors; Complications; Risk factors; Burundi; Management outcomes

Introduction

The terms life satisfaction and 'happiness' are often identical (1). Happiness here is defined as the degree to which an individual judges the overall quality of her/his life as a whole favorably (2). The experience of high levels of “happiness” is considered by some researchers. Thus, we perceive that an individual has a high degree of happiness when s/he is satisfied with life in a positive way. On the other hand, when someone experiences negative feelings such as worry and/or distress, s/he feels a low degree of happiness and is dissatisfied with her/his life (3).

Reversely, a low level of happiness is identified to be an early signal of maternal death, health problems (4). For this reason, in recent years, the health care system has more focused on preliminary health and happiness for all population (5). Life satisfaction is a phrase that is linked to communities from a variety of population groups and is related to factors such as age, culture, gender, qualification, class status, and social surroundings. Among the factors mentioned, the gender issue plays a key role in determining the life quality (6, 7). In accordance with the World Health Organization, women are considered one of the high-risk groups of the community because of their many roles in the family and society, spending different physiological periods such as puberty, menstruation, pregnancy, labor, and menopause and also a greater risk of suffering from poverty and gender discrimination illness (8, 9). In addition, Mussida and Patimo claim that the evaluation of women's health is important since they are the ones who care for children, parents, and husbands and are also responsible for many important social duties (10).

Women’s life satisfaction is among the studies conducted quantitatively to a large extent by numerous researchers during the recent decades in different communities (11). However, information from combined quantitative and qualitative studies on factors related to happiness and life satisfaction from the perspective of women in Iran is still not available. Feeling happy and satisfied with life is a subjective perception of well-being, and it has been argued that individual perceptions may be culturally influenced and should be recognized across societies (12). This could provide important information for local healthcare policymakers and other researchers to implement mental health interventions for women. Therefore, this study aimed to assess life satisfaction and identify predictors of happiness in women's lives.

Research in Context

Background of the Evidence : A comprehensive analysis of the World Health Organization (WHO), PubMed, and Scopus databases from 2018 to 2024 was conducted to identify knowledge gaps concerning mpox severity predictors. The search terms used included “risk factors”, “disease severity”, “mpox”, and “monkeypox”. Studies published in English and French were considered. As of 2023, known clinical and demographic predictors included age, sex, and HIV status, as reported by Charniga et al. (2023) and Ogoina et al. (2023). However, these results were weakened by small sample sizes and a lack of statistical power, particularly in sub-Saharan Africa.

Table 1: Summary of occupation data.

Table 2: Distribution of complications.

Table 3: Demographic, clinical characteristics and comorbidities of study participants.

Moreover, few studies have been conducted on countries with sustained transmission such as Burundi. Additionally, non-cutaneous symptoms such as conjunctivitis and sore throat, which may indicate severity, often go unnoticed in literature favoring cutaneous manifestations. Addressing these gaps in research and knowledge could facilitate the development of risk-stratification tools suited to the context of an outbreak and improving patient care in resource-limited settings.

Added Value of This Study: This is the most extensive cohort analysis of laboratory-confirmed mpox cases in Burundi to date (N = 850), providing robust proof through Firth penalized regression analysis. This study identifies non-cutaneous symptoms, especially conjunctivitis (OR 27.30) and sore throat (OR 12.63), as significant predictors of complications, and challenges the conventional focus on cutaneous symptoms. The research also uncovers protective associations of local lymphadenopathy and some types of lesions, potentially reflecting effective immune responses. The innovative application of age-stratified analyses, coupled with the inclusion of data on HIV status, offers entirely new insights into the demographic and clinical risk factors in African populations. These findings could directly influence clinical risk stratification and resource allocation strategies, particularly in low-resource settings. The present study addresses important knowledge gaps by using contemporary statistical modeling, which could contribute significantly to recommendations on best practices to mitigate adverse outcomes and thus inform public health interventions.

Table 4: Firth penalized multivariate logistic regression analysis of disease risk factors

*Statistically significant after Benjamini-Hochberg correction (FDR = 0.05)

Only variables with significant associations in at least one dataset are shown Model fit: Hosmer-Lemeshow test p = 0.82; AUC = 0.83

Table 5: Analysis of factors associated with mpox severity score, Chi-squared , and Fisher’s exact tests for association test between the clinical outcomes.

*p < 0.05; -, not applicable

Implications for available evidence: Contrary to previous studies concentrating on cutaneous manifestations, our results underscore the prognostic significance of non-cutaneous symptoms in the early detection of severe cases, including conjunctivitis and sore throat. The findings also emphasize the need for enhanced surveillance among older adults and HIV-positive patients, who are at a higher risk of severe disease. Practical applications include incorporating non-cutaneous manifestations into clinical scoring systems for improved early triaging and monitoring. Policy recommendations focus on age-based risk stratification with custom interventions for at-risk groups. Future studies should aim at validating these predictors across major geographic regions and figuring out the immunologic basis for protective factors such as local lymphadenopathy. Streamlined and simplified evidence-based tools are crucial for better global mpox management in resourcelimited settings.

Funding: This work was supported by the WHO through the USAID-funded Mpox Award. The funders played no role in the study design, data collection, analysis, or interpretation. The authors maintained complete academic independence throughout the research process.

Declaration of Competing Interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments: We extend our appreciation to the Burundi Ministry of Health, particularly to Dr. Lydwine

Baradahana and to Dr. Xavier Crespin, the World Health Organization (WHO) Representative to

Burundi, for their support. We extend our gratitude to Dr. Olivier Nijimbere, the Burundi mpox Incident Manager, and Dr. Canésius Nkundwanayo, the mpox Deputy Incident Manager, for their outstanding direction in addressing mpox. We extend our appreciation to Dr. Fiona Braka, WHO Emergency Response Manager, and Dr. Abdou Salam Gueye, WHO Regional Emergency Director for the African Region, for their support and guidance. We extend our gratitude to Dr. John Masina and Dr. Jerry-Jonas Mbasha for their significant contributions to the analysis and discussion, and to Professor Joseph Adekunle for his proficient statistical assistance. We express our gratitude to the health directors of the three designated mpox treatment sites, all stakeholders, study participants, and the supervisors and data managers at the Burundi Public Health Emergency Operations Center for their contributions to this study.

Journal of Clinical Case Reports, Medical Images and Health Sciences (ISSN 2832-1286) is a peer-reviewed journal dedicated to publishing clinical images from all sectors of medicine. The goal of this magazine is to disseminate information about new discoveries and treatments in science and medicine.

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