Factors associated with delayed care seeking among mpox cases in Mbarara City, Uganda, October 2024–May 2025

Summary

 In April 2025, Mbarara City reported Uganda’s highest mpox attack rate of 142/100,000 population. There were reported high infection rates and delayed healthcare seeking, which contribute to prolonged transmission, increased severity, and deaths. We assessed the magnitude and factors associated with delayed care-seeking and explored facilitators and barriers to delayed care-seeking among mpox cases in Mbarara City, October 2024–May 2025.

Methods: We conducted a cross-sectional study among suspected, probable, and confirmed mpox case-patients identified through active case finding in Nyamityobora Ward during October 2024–May 2025. Delayed care seeking was defined as seeking formal healthcare >2 days after symptom onset. We administered a standardized questionnaire and used modified Poisson regression with robust standard errors to estimate prevalence ratios and 95% confidence intervals for factors associated with delayed care seeking.

Results: Among 106 mpox cases (confirmed=53, probable=5, and suspected=48), 66 (62%) delayed care-seeking; the mean interval from symptom onset to care seeking was 4 days. Delayed care seeking was more common among case-patients whose rash began in the genital area than among those whose rash began elsewhere (adjusted prevalence ratio [aPR]=1.9; 95% confidence interval [CI]=1.39-2.59). Case-patients reporting severe pain were less likely to delay care than those reporting mild pain (aPR=0.6; 95% CI=0.46-0.78).

Conclusion: Delayed care seeking was common among mpox case-patients. Response efforts should promote early care-seeking for mild or genital symptoms, reduce stigma, strengthen confidentiality-sensitive services, and leverage trusted community networks to support timely referral and care.

Introduction

Mpox, formerly known as monkeypox, is a re-emerging viral disease caused by the monkeypox virus, which gained global public health importance following the 2022 multi-country outbreak (1, 2). Although mpox is usually self-limiting, delayed healthcare seeking after symptom onset increases the risk of transmission, severe disease, secondary infections, and death, particularly among immunocompromised individuals, such as people living with HIV (3-5). Early healthcare seeking is therefore essential for timely diagnosis, isolation, treatment, and contact tracing (6). Despite this critical role in outbreak control, studies have shown that many mpox patients delay seeking formal healthcare, undermining outbreak control efforts (7, 8). In African settings such as Uganda, delayed care seeking is driven by stigma, fear of isolation, misinformation, lesion location, and health system barriers, similar to challenges observed in Ebola, HIV, and tuberculosis control (6, 9). Mpox is transmitted through close contact with infected persons, animals, or contaminated materials. Symptoms, including fever, lymphadenopathy, malaise, and rash, often resemble other febrile illnesses and sexually transmitted infections, contributing to delayed recognition and care seeking (10). Despite continued mpox transmission in Uganda, evidence on the extent of delayed healthcare seeking and its associated factors remains limited.

Uganda Ministry of Health declared a national mpox outbreak on August 2, 2024, following confirmation of 2 cases in Kasese District (9). By June 2025, the outbreak had spread to more than 100 districts with about 5,600 confirmed cases, initially affecting urban centers and fishing communities, particularly among high-risk sexual networks (11). Mbarara City became a major hotspot and reported the country’s highest attack rate by April 2025. Investigations at Mbarara Regional Referral Hospital found that many patients presented several days after symptom onset with severe disease, suggesting delayed care seeking. We investigated the magnitude and factors associated with delayed care seeking among mpox patients in Mbarara City to inform outbreak response and strengthen epidemic preparedness.

Methods

Mbarara City is located in southwestern Uganda and had an estimated population of 325,075 in 2024. Mbarara City is a major commercial and transport hub in southwestern Uganda. During Uganda’s national mpox outbreak, the city reported its first confirmed mpox cases in November 2024. Nyamityobora Ward in Mbarara City was the most affected area, with 10 cells and a highly mobile urban population that may have facilitated rapid mpox transmission through frequent social and occupational interactions.

We defined mpox cases as suspected, probable, or confirmed. A suspected mpox case was defined as a resident of Nyamityobora ward with an acute onset of skin rash or genital lesions with ≥2 of the following symptoms: fever ≥38.5°C, headache, weakness, myalgia, back pain, genital discharge, lymphadenopathy, or mucosal lesions from October 2024–May 2025. A probable case as a suspected case with an epidemiological link to a confirmed mpox case in the 21 days before symptom onset. A confirmed case was a suspected case with RT-PCR-confirmed mpox infection. Delayed care seeking was defined as first seeking formal healthcare more than 2 days after symptom onset, based on previous Ebola studies in Uganda and World Health Organization mpox guidance recommending immediate care seeking after symptom onset (6, 9).

We conducted a cross-sectional study and conducted an active house-to-house case search in Nyamityobora Ward. Case-patients were interviewed using a standardized questionnaire to collect sociodemographic, clinical, health-seeking, and exposure information.  Modified Poisson regression with robust standard errors to estimate prevalence ratios and 95% confidence intervals was used to identify factors associated with delayed care seeking.

Permission to conduct the investigation was obtained from the City Health Office and the leadership of Nyamityobora Ward cells. The Ministry of Health, Uganda, granted administrative clearance for this activity as part of routine national public health surveillance conducted during a public health emergency. A non-research determination was obtained from the Associate Director for Science, US CDC/Uganda.  We obtained verbal informed consent from adult participants, while parental consent and minor assent were obtained for participants aged <18 years. Participation was voluntary, and all data were anonymized, password-protected, and accessible only to authorized study personnel.

Results

Descriptive epidemiology among mpox cases, Nyamityobora ward, Mbarara City, Uganda, October 2024–May 2025  

We identified 106 mpox case-patients, including 53 confirmed, 5 probable, and 48 suspected cases. The median age was 29 years, with an interquartile range of 24-34 years. Overall, 57 (54%) were female, and 91 (86%) were aged 15-44 years. Most case-patients had primary education (52%) or secondary education (33%). Twenty-seven (25%) were sex workers, and 25 (24%) were businesspeople. Sixty-four (60%) case-patients reported severe pain at symptom onset, 49 (46%) had rash that began in the genital area, and 23 (22%) were HIV-positive.

Delayed care seeking and associated factors among mpox cases, Nyamityobora ward, Mbarara City, Uganda, October 2024–May 2025.

Of the 106 case-patients, 66 (62%) delayed care. Case-patients whose rash began in the genital area were 1.9 times more likely to delay care seeking compared to those whose rash started elsewhere (aPR=1.9; 95% CI:1.39-2.59). Patients reporting severe pain were 0.6 times less likely to delay care seeking compared to those reporting mild pain (aPR=0.6; 95% CI:0.46-0.78) (Table 1).

Table 1: Factors associated with delayed care seeking among mpox cases, Nyamityobora ward, Mbarara City, Uganda, October 2024–May 2025 (n=106)

Characteristic	cPR	95% CI	p-value	aPR	95% CI	p-value
Pain severity at symptom onset
Mild pain	Ref			Ref
Severe pain	0.55	0.41–0.73	<0.001	0.60	0.46–0.78	<0.001
Rash began in genital area
No	Ref			Ref
Yes	2.04	1.47–2.82	<0.001	1.90	1.39–2.59	<0.001

aPR: Adjusted prevalence ratio; CI: Confidence interval; cPR: Crude prevalence ratio; Ref: reference category

Discussion

More than half of mpox case-patients delayed care seeking. Delays were more common among patients reporting mild pain and those whose rash began in the genital area.

Delayed care seeking increases risks at both individual and community levels, including severe disease, secondary bacterial infections, prolonged morbidity, and death, as well as sustained transmission and weakened outbreak control (12). At the community level, it may prolong opportunities for onward disease transmission (13). Consistent with patient narratives, delays were also linked to stigma, fear, and reliance on traditional/herbal remedies.

Patients with mild symptoms were more likely to delay care seeking, often adopting a “wait-and-see” approach or self-treatment, consistent with findings from other studies (14). Similarly, genital-onset rash was associated with delayed care seeking, likely due to stigma, concerns about confidentiality, and misclassification as sexually transmitted infections such as syphilis (14).

Study limitation: Recall bias from self-reported symptom onset and care-seeking dates may have led to misclassification of delays, although local event calendars and probing were used to improve accuracy. Stigma may also have resulted in underreporting of symptoms such as genital rash and delayed care seeking; to minimize this, interviews were conducted privately and confidentially. Additionally, qualitative findings reflect perspectives from Mbarara City and may not be generalizable to other mpox patients in Uganda.

Conclusion: Delayed care seeking was common. Delays in care seeking were high among patients with a rash appearing first on the genital areas and those experiencing mild pain. Stigma and fear of isolation also contributed to delays. Community sensitization, led by trusted community members, may reduce stigma and fear and foster trust in the health system. This may lead to reduced delays in care seeking during the outbreak response.

Public health action: The investigation team provided health education to the residents of Nyamityobora Ward during active case searches in the community on causes, transmission, and prevention of mpox.

 Acknowledgments: We thank the Uganda Public Health Fellowship Program for technical guidance, the Mbarara City local government and health authorities for facilitating field activities and community engagement and the administration of Mbarara Reginal Referral Hospital for providing access to patient records and clinical information, the Mbarara Regional Emergency Operations Centre team for coordination support, and Nyamityobora Ward Village Health Teams for community mobilization and case identification during the investigation..

Author contributions: ALA took the lead in conceptualizing the study idea, data collection, data analysis, bulletin writing, and editing. NA, KDA, MN, and NM were involved in the investigation, data collection, and bulletin writing. IK, BK, RM, PEO, PE were involved in supervision, validation, editing, and review of the bulletin. All authors read and approved the final bulletin.

Conflict of interest: The authors have no competing interests to declare.

Copyrighting and licensing: All materials in the Uganda Public Health Bulletin is in the public domain and may be used and printed without permission. However, citation as to source is appreciated. Any article can be reprinted or published. If cited as a reprint, it should be referenced in the original form.

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