Mpox clinical and epidemiological patterns in the Central African Republic: a systematic review and meta-analysis

Background: Mpox remains a critical public health challenge in Central Africa, where endemic circulation of the virulent Clade I virus persists through zoonotic and human-to-human transmission. This systematic review and meta-analysis synthesize 40 years of evidence (1984-2024) to characterize Mpox epidemiology, vaccination gaps and clinical pattern in the Central African Republic (CAR), informing targeted control strategies for this re-emerging threat. Methods: Following PRISMA guidelines, we conducted a comprehensive search of PubMed, ScienceDirect, Cochrane Library, and Scopus for studies reporting laboratory-confirmed Mpox cases in CAR. Pooled estimates were calculated using random/fixed-effects models with R Statistics version 4.4.2 with subgroup analysis conducted for period, region, participants and disease burden. Heterogeneity (I2) and publication bias (funnel plots, Egger's and Begg's tests) were rigorously assessed. The confidence intervals (CIs) were estimated at 95% level of confidence. Results: Among 15 included studies representing 1984-2024 surveillance data, the pooled severity rate was 60.9% (95%CI:47.5-72.8) - highest in Health Region 6 (77.3%, 95%CI: 55.6-90.2). The Case fatality rate (CFR) among confirmed cases was 10.9% (95% CI: 5.9-19.0). There was non-significant decrease in CFR from 11.5%; (95% CI: 6.1-20.7) before 2022 to 7.14% (95% CI: 0.7-1.9) from 2022 on. There was a persistent post-2022 CFR elevations in high-burden areas (13.5% for >10 cases). Higher mortality was observed in Eastern Health Regions (11.11%; 95% CI: 5.08-22.60) compared to Western Health Regions with no reported death. Among suspected cases, the CFR was 10.7% (95%CI: 6.6-17.0). Vaccination uptake was low (20.0%, 95%CI: 10.3-35.2). The clinical profile included fever (91.1%, 42.9-99.3), rash (85.5%, 95%CI: 75.7-91.8), lymphadenopathy (57.0%, 95%CI: 34.3-77.1). Severe manifestations like hemorrhagic lesions (22.2%) and mucosal involvement (oral:59.2%; genital:57.4%) were also reported. Conclusion: The CAR faces a disproportionate Mpox burden characterized by high severity, elevated mortality, and suboptimal vaccine coverage, particularly in eastern regions. These findings suggest the urgent need for: (1) enhanced surveillance systems with genomic sequencing capacity; (2) prevention of disease lethality through early case detection and appropriate care provision; (3) strengthening vaccine distribution prioritizing high-risk populations; and (4) context-specific interventions, including community education and healthcare worker training, to curb future outbreaks.