Monkeypox (MPOX) has emerged as a global health concern, with the 2024 outbreak originating from South Kivu, a province in the Democratic Republic of Congo (DRC). Interestingly, two neighbouring countries, Rwanda and Burundi, have shown significant differences in MPOX prevalence despite sharing borders with the DRC. While Burundi is one of the hardest-hit nations in the current outbreak, Rwanda has successfully managed to limit the spread of the virus. This narrative review study explores the factors behind this disparity by reviewing existing literature and data on health activities in both countries over the past decade, focusing on responses to MPOX, coronavirus disease (COVID-19), and human immunodeficiency virus infection or acquired immune deficiency syndrome (HIV/AIDS). Rwanda’s success is attributed to its centralized health intervention structure, efficient training of healthcare workers via partnership with the Clinton Health Initiative, rapid SMS health alerts for community workers, and a robust community-based health insurance (CBHI) scheme, the Mutuelles. Conversely, Burundi’s progress has been hampered by the independence of foreign organizations. Another key factor in the MPOX disparity between Rwanda and Burundi is Burundi’s proximity to South Kivu through Lake Tanganyika, with frequent uncontrolled immigration. Monitoring these checkpoints is crucial to curb the spread of the MPOX virus in Burundi. Rwanda’s health system and policies provide a credible model for controlling disease outbreaks.

Monkeypox (MPOX), Coronavirus disease (COVID-19), Outbreak, Mutuelles, Public health, Healthcare systems.

MPOX has emerged as one of the most concerning diseases globally in recent times, prompting the world health organization (WHO) to declare it a public health emergency of international concern twice within two years.[1] The 2024 outbreak began in the DRC, a country that shares borders with both Rwanda and Burundi.[2] As of 25th August, the DRC had recorded 3,235 confirmed MPOX cases out of 14,934 suspected cases, with 511 deaths.[3]

The MPOX virus was first isolated from captive monkeys travelling to Denmark in 1959.[4] It was later discovered in humans in the DRC in a child.[5] There are two major strains of the MPOX virus, Clade 1 and Clade 2. Clade 2 was responsible for the 2022 outbreak, which began in Europe, while Clade 1 is responsible for the more recent 2024 outbreak, which started in Africa. Transmission of both clades primarily occurs through contact with infected animals, particularly rodents, squirrels, African dormice, monkeys, pigs, and hedgehogs. Secondary transmission occurs from human-to-human contact, especially via sexual transmission, with a notable prevalence among men who have sex with men.[6,7]

The 2024 MPOX outbreak is not confined to Africa. More than 100 confirmed cases have been recorded in Spain, France, the United Kingdom, the United States, Canada, Brazil, China, and Australia.[8] Despite its proximity to the outbreak’s origin, Rwanda has recorded only 4 confirmed cases with no deaths, whereas Burundi has recorded 170 confirmed cases.[9] This disparity in MPOX prevalence between the two neighbouring countries warrants discussion to explore the possible factors behind the spread of MPOX, using Rwanda and Burundi as case studies to inform targeted interventions.

Comparative health and socioeconomic analysis of Rwanda and Burundi
DRC has played a significant role in the historical development of MPOX and is the epicentre of the 2024 outbreak. Rwanda, located to the east of the DRC, has been noted in several studies to bear a high burden of both communicable and non-communicable diseases, with HIV-tuberculosis (HIV-TB) co-infection being particularly noteworthy.[10,11] Similarly, Burundi, also east of the DRC, faces a high burden of infectious diseases.[12]

Both countries are situated in Central Africa, a region characterized by its dense forests and abundant rainfall.[13] The Congo Basin Rainforest, which spans most of Central Africa, is the second largest in the world. It is, therefore, unsurprising that Rwanda and Burundi share a similar climate primarily a tropical savanna climate (Koppen climate classification), with highland climates in regions such as Virunga and Ngozi.[14]

Both countries are landlocked and small, with population densities of 578/km² in Rwanda and 547/km² in Burundi.[15] Economically, both are classified as low-income nations; however, Rwanda has a much higher gross domestic product (GDP) per capita of $1,000.2 compared to Burundi’s $199.6 in 2023.[16] Additionally, Rwandans are slightly more likely to have better knowledge of healthcare practices than Burundians, as evidenced by an adult literacy rate of 79% in Rwanda compared to 76% in Burundi in 2022.[16]

This is perhaps a driving factor behind the significant increase in life expectancy in Rwanda, which has risen from 51.2 years in 2002 to 69.9 years in 2024.[17] In contrast, Burundi’s life expectancy, while lower, has also seen a notable rise, from 43.8 years in 2000 to 64 years in 2021.[18]

MPOX prevalence and mortality in both countries
MPOX disease in the DRC has been particularly menacing, with a total of 14,626 cases reported in 2023, making it the most affected country in the WHO Africa region.[19] The 2024 outbreak began in the South Kivu province, a region notorious for being a hotspot during the Congolese civil wars and notable for prostitution and transactional sex.[20] As of 2024, there have been 7,851 confirmed MPOX cases, with 384 deaths.[2] Children under the age of 5 have been disproportionately affected, accounting for 240 of these deaths, representing 62% of the total mortality from MPOX.[2]

Despite its proximity to the South Kivu province of the DRC, Rwanda has reported only 4 confirmed MPOX cases in 2024, with no recorded deaths.[21] In early May, 16 suspected cases were investigated in the Rusizi and Nyamasheke districts, but all tested negative after gene polymerase chain reaction (PCR) testing.[2]

In contrast, Burundi, also bordering South Kivu, has reported 474 confirmed MPOX cases out of 545 suspected cases between the beginning of 2024 and the 17th of August.[21] The first cases in Burundi were detected on the 25th of July, 13 days after the initial outbreak in South Kivu.[21] Bujumbura Nord, a region separated from Uvira in South Kivu by Lake Tanganyika, is the most affected area in Burundi. Like Rwanda, no MPOX-related deaths have been reported in Burundi.[21] However, similar to the DRC, children under the age of 5 represent the majority of the affected population, accounting for 28.9% of cases.[21]

Possible factors contributing to the disparity in MPOX prevalence in Rwanda and Burundi
Healthcare systems and indices: In 2021, Burundi’s health expenditure as a percentage of GDP was 9.10%, surpassing Rwanda’s 7.31%.[22] However, despite Burundi’s financial commitment to healthcare, the country lacks the necessary infrastructure to meet its growing health demands.[23] The effectiveness of these countries healthcare systems can be measured by their response to past public health interventions.

COVID-19, a pandemic that devastated even the United States despite its high healthcare spending, also impacted Rwanda and Burundi.[24] Rwanda recorded 133,194 confirmed cases, affecting over 0.9% of its population, with 1,468 deaths.[25] Burundi reported 53,631 confirmed cases, about 0.4% of its population, with 38 deaths.[26] Although Rwanda experienced higher morbidity and mortality, it implemented more proactive measures to mitigate COVID-19’s impact. For instance, 81.63% of Rwanda’s population was vaccinated against COVID-19, a remarkable figure compared to Burundi’s 0.28%.[25,26] This is one of the highest vaccine acceptance rates in Africa, surpassing Nigeria’s 38.44% and South Africa’s 40.42%.[27] Rwanda’s organized healthcare system was particularly evident in its vaccination efforts. Health workers received training a month before vaccinations began, and door-to-door campaigns targeted the elderly and vulnerable.[28] The Rwanda Biomedical Centre was recognized as a COVID-19 vaccination centre of excellence by the Africa centers for disease control and prevention (CDC).[29]

Rwanda has consistently been proactive in its vaccination initiatives. It was among the first African nations to introduce rotavirus and pneumococcal vaccines into its national immunization programme.[30,31] Notably, Rwanda was the first African country to implement a national human papillomavirus (HPV) vaccination programme, achieving a 98% vaccination rate among eligible girls under 15.[32] Burundi has also achieved commendable vaccination coverage for common vaccines such as pneumococcal, polio, and measles, ranging from 80% to 89%.[33] A study in Bujumbura showed a 64.81% vaccination uptake among children aged 24 to 48 months.[34]

Both Rwanda and Burundi were severely impacted by the HIV/AIDS epidemic in the 1990s, with 17% of Rwanda’s urban population and 15% of Burundi’s urban population diagnosed with AIDS by 1992.[35,36] This led to a significant reduction in life expectancy in both countries at the time. However, both nations have made significant progress in combating the disease, with HIV/AIDS prevalence rates at 2.2% and 0.9% in Rwanda and Burundi, respectively, by 2023.[37,38] The antiretroviral therapy coverage is also impressive, with 96% in Rwanda and 91% in Burundi.[39]

Health policies and strategies: While both the Rwandan and Burundian healthcare systems are hierarchically centralized, they differ significantly in their implementation strategies. In Rwanda, healthcare policies are designed at the Ministry of Health, with implementations delegated to local units, focusing on specific areas of need.[39] Non-governmental organizations (NGOs) and foreign entities are required to collaborate with the government by aligning with pre-established structures.[40] In contrast, Burundi’s healthcare system can be best described as authoritative, as seen in policies like the abolition of user fees for pregnant women and children under the age of five.[41] It is also less structurally organized compared to Rwanda at the implementation stage, allowing NGOs and foreign organizations greater freedom to develop and execute their ideas.[40]

Following the genocide of the 1990s, Rwanda invested heavily in a seven-year partnership with reputable medical institutions, particularly in the United States, through the Clinton Health Access Initiative.[42] This partnership deployed approximately 100 U.S. faculty members to Rwanda for a year-long academic and clinical mentorship.[42] However, Burundi focused more on ensuring the accuracy and integrity of its healthcare systems, leading to the creation of the Burundi Health Workforce Observatory.[40]

Both countries invested significantly in their health information systems. However, Rwanda introduced an additional innovation: a rapid mobile messaging system for community health workers to report vital events and monitor pregnancies.[43] This system allowed for faster reporting of healthcare developments in Rwanda.

Regarding health financing, Rwanda introduced a community-based health insurance scheme, the “Rwandan Mutuelles,” which is now legally mandated for all Rwandans. [44] Rwanda also incentivized primary healthcare providers with performance-based rewards, shifting attention to the quality of care provided by caregivers.[39] Burundi, on the other hand, implemented free healthcare policies such as abolishing user fees for pregnant women and children under five, reducing flat-fee payments to combat poverty, and increasing public health allocations.[41,45]

Burundi also created a separate Ministry of HIV/AIDS, distinct from the Ministry of Health, to focus more effectively on combating the epidemic.[46] However, this move had its drawbacks, leading to disorganization and ambiguity between the two ministries.[40]

Level of immigration: Immigration into Burundi has been substantial over the past decade, with more than 500,000 Burundian refugees returning to the country from neighbouring nations.[47] Burundi’s net migration rate in 2024 stands at -0.7 per 1,000 people, while Rwanda’s is 3.1 per 1,000 people.[47] This suggests that Rwanda attracts fewer immigrants relative to emigrants when compared to Burundi. It also implies that for every immigrant entering Rwanda, approximately 4.4 immigrants are entering Burundi, assuming the emigration rate is constant for both countries.

It is, however, important to note within the context of this article that Burundi has hosted thousands of refugees, primarily from the DRC, the source of the 2024 outbreak, and to a lesser extent, from Rwanda. In 2024, 87,157 refugees and asylum seekers from the DRC were reported in Burundi.[48]

Rwanda, while also receiving a considerable number of immigrants from the DRC, hosts relatively fewer, with a total of 79,720 refugees from the DRC.[49] Immigration has been studied as a contributing factor in the spread of infectious diseases, and with Burundi experiencing a higher immigration rate relative to Rwanda, this could help explain the higher prevalence of MPOX in Burundi.[50]

Closer Transactions with the DRC: Both Burundi and Rwanda are located to the east of the DRC, in proximity to the South Kivu region. Burundi shares a boundary with South Kivu via the expansive Lake Tanganyika. Lake Tanganyika plays an important economic role for both the DRC and Burundi, with approximately 10 million people residing in its basin. Various activities such as farming, fishing, and mining are prevalent around the lake, and trade exchanges across its waters significantly influence immigration into Burundi from the DRC through both controlled and uncontrolled entry points.[51]

Rumonge, Cibitoke, Bujumbura, and Kamenge are among the most vulnerable regions in Burundi, partly due to the trading activities around Lake Tanganyika.[52,53] It is therefore unsurprising that the first recorded MPOX cases in Burundi were reported at the Kamenge University Hospital Center and the Kamenge Military Hospital. Early cases were also reported in Israel and Kinama, both located in Bujumbura provinces.[54]

Rwanda shares a boundary with the DRC, adjacent to the North Kivu and South Kivu provinces, with Lake Kivu separating them. While Lake Kivu is smaller and of lesser economic importance than Lake Tanganyika, it is still significant, particularly for fishing, to those residing on both sides. However, the surrounding mountainous terrain makes it less easily accessible compared to Lake Tanganyika.[55,56]

Given that South Kivu was the source of the 2024 MPOX outbreak and the vibrant trade exchanges between South Kivu and Burundi at Lake Tanganyika, this could be a key factor driving the higher prevalence of MPOX in Burundi.

Recommendations
To effectively mitigate the spread of MPOX in Burundi, it is important to implement stringent measures along the borders surrounding Lake Tanganyika. The frequent, uncontrolled entry points from South Kivu via Lake Tanganyika necessitate rigorous surveillance and monitoring. We advocate for the establishment of a dedicated quarantine facility near the border to facilitate daily testing of immigrants and to isolate those who test positive for MPOX.

Additionally, we recommend that other African healthcare systems, both governmental and non-governmental, consider adopting Rwanda’s rapid mobile messaging system utilized by community healthcare workers. This system has demonstrated efficacy in the prompt identification and management of MPOX cases within communities, enabling timely interventions and containment.

Furthermore, African governments should consider adopting the Rwandan Mutuelles model, a community-based healthcare insurance scheme. This model, which involves collective contributions from families to cover future medical expenses, has proven effective in Rwanda and holds potential benefits in regions where familial bonds are strong.

Lastly, African countries should prioritize performance-based incentives for healthcare workers over universal free healthcare policies. Such incentives have been shown to enhance the capacity and effectiveness of healthcare professionals, as evidenced by successful implementations in Rwanda. This approach may lead to improved healthcare delivery and better outcomes in the region.

Limitations
The comparison between MPOX prevalence in Rwanda and Burundi may be limited by the availability and reliability of health data. Differences in reporting practices, data collection methods, and healthcare infrastructure could impact the accuracy of reported cases and outcomes.

The study highlights differences in healthcare systems and policies between Rwanda and Burundi, but it may not fully account for all variables affecting MPOX prevalence. The effectiveness of health interventions and policies may be influenced by factors beyond those discussed, such as political stability, healthcare workforce quality, and resource allocation.

While the comparison between Rwanda and Burundi provides valuable insights, the findings may not be directly applicable to other countries or regions with different health systems, socio-economic conditions, and disease dynamics. Generalizing recommendations may require further validation.

While Burundi and Rwanda have shown a serious commitment to improving healthcare in their respective countries, this article offers insights into the factors behind the striking difference in MPOX prevalence between them. Both nations are direct neighbours of the DRC, the source of the outbreak, and share similar climatic conditions, literacy rates, and dedication to healthcare.

Their differing approaches to healthcare management play a key role in the disparity. Rwanda has prioritized investments in medical training, integrated innovative ideas into a centralized healthcare structure, and established a well-planned community-based health insurance scheme. However, the neighboring Burundi’s government made healthcare more accessible by autocratically reducing healthcare costs and providing room for a variety of ideas to flourish. Furthermore, Burundi has experienced higher immigration rates compared to Rwanda, with most immigrants originating from the DRC.

One of the most obscure yet critical factors contributing to the relatively high prevalence of MPOX in Burundi is its connection to the DRC, particularly the South Kivu region, through Lake Tanganyika. This economically vibrant area, marked by both legal and illegal trade exchanges between the two countries, facilitates the transmission of the MPOX virus around the lake.

Burundi must enforce strict measures along the borders surrounding Lake Tanganyika to curb the spread of MPOX. Additionally, other countries should consider emulating Rwanda’s healthcare strategies, policies, and implementation methods to prevent or limit the transmission of the MPOX virus.

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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.

Corresponding Author:
Iyanuloluwa S. Ojo
Department of Medicine
General Physician, University College Hospital Ibadan, Nigeria
Email: iyanuloluwaojo7@gmail.com

Co-Authors:
Faridat Ibidun
Department of Nursing
Registered Nurse, Nobles Hospital, The Isle of Man
Email: ibidunfaridat479@gmail.com

Samuelii O. Alawode
Department of General Physician
University College Hospital, Ibadan, Nigeria
Email: alawodesamuelii@gmail.com

Mujib O. Surakat
Department of General Physician
University College Hospital, Ibadan, Nigeria
Email: prince.opeoluwa@gmail.com

Vivian Ugwu
Department of Medicine
Enugu State University College of Medicine, Enugu State, Nigeria
Email: ugwuvivian200@gmail.com

All authors contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles. They were collectively involved in the writing – original draft preparation, and writing – review & editing to refine the manuscript. Additionally, all authors participated in the supervision of the work, ensuring accuracy and completeness. The final manuscript was approved by all named authors for submission to the journal.

Not reported

Not reported

Not reported

https://doi.org/10.63096/medtigo30622475

Iyanuloluwa SO, Faridat I, Samuelii OA, Mujib OS, Vivian U. Paradoxical Disparities in the 2024 MPOX Outbreak Between Two Neighboring Countries: Rwanda and Burundi. medtigo J Med. 2024;2(4):e30622475. doi:10.63096/medtigo30622475 Crossref