Mpox Severity and Mortality in the Most Endemic Focus in Africa: A Systematic Review and Meta-Analysis (1970-2024)

BackgroundMpox, caused by the Mpox virus, is a zoonotic disease historically endemic in Central and West Africa. The Democratic Republic of Congo (DRC) bears the highest burden, with evolving epidemiology and significant public health challenges. Understanding severity and mortality trends is critical for global control efforts. MethodsThis systematic review and meta-analysis followed PRISMA guidelines to synthesize evidence on Mpox severity and mortality in the DRC from 1970 to 2024. We searched PubMed, ScienceDirect, Scopus, Web of Science identifying 19 eligible studies after screening 5443 records. Data on severity and death among suspected and confirmed cases were extracted. Random-effects models addressed high heterogeneity, and subgroup analyses examined temporal trends, regional differences, and healthcare settings. Meta-regression explored sources of heterogeneity, adjusting for study year, region, and setting. ResultsWe included a total of 19 study reports. The pooled severity rate among 3,280 confirmed cases was 39.47% (95% confidence interval [CI]: 29.11-50.86), declining from 46.34% (95% CI: 37.07-55.87) pre-2022 to 25.83% (95% CI: 11.16-49.11) in 2022-2024. Northern (43.82%; 95% CI: 37.81-50.03) and Central (63.89%; 95% CI: 57.10-70.30) regions had higher severity than Eastern regions (26.04%; 95% CI: 8.77-56.31). Case fatality rates (CFRs) were 1.70% (95% CI: 0.72-3.95) for suspected cases and 2.46% (95% CI: 0.65-8.85) for confirmed cases, with Western DRC disproportionately affected (22.03%; 95% CI: 13.25-34.34). Community settings showed higher CFRs (3.69%; 95% CI: 0.78-15.81) than hospitals (0.77%; 95% CI: 0.32-1.84), underscoring healthcare access disparities. Meta-regression confirmed study year (p = 0.044) as significant predictors of outcomes case severity heterogeneity and study year (p = 0.016), region (p = 0.003) and setting (p = 0.041), with mortality declining over time but remaining elevated in resource-limited areas. ConclusionMpox continues to impose a substantial burden in the DRC, with high severity and mortality rates, particularly in Western/Central regions and community settings. The observed temporal decline in severity and CFRs suggests the impact of strengthened surveillance and healthcare capacity. However, regional disparities persist might be due to inequitable healthcare access and potential differences in viral clades. Targeted interventions, including vaccination in high-risk areas, community education, and healthcare system strengthening are urgently needed.