Improving infection prevention and control quality for Mpox response in Burundi: field-based WASH and infection control strategies

¹Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Walter Sisulu University, Mthatha, South Africa, ²University of Kinshasa, Faculty of Medicine and Health Sciences, Kinshasa, Lemba, Democratic Republic of Congo

^&Corresponding author
Jean Paul Muambangu Milambo, Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Walter Sisulu University, Mthatha, South Africa

Introduction    

Mpox, caused by the monkeypox virus, is endemic in parts of West and Central Africa and continues to pose a serious public health threat, particularly in regions with fragile healthcare systems. While zoonotic transmission remains the primary mode of spread, human-to-human transmission is increasingly reported, especially in densely populated areas lacking robust infection prevention and control (IPC) measures [1]. In such settings, poor IPC implementation significantly raises the risk of widespread transmission and complicates outbreak management [2]. The global spread of Mpox to non-endemic regions such as Europe and North America has underscored systemic vulnerabilities in IPC infrastructure. Many high-income countries faced challenges in rapid containment due to weak IPC frameworks, highlighting the urgent need for enhanced diagnostic capacity, trained personnel, and resilient outbreak response systems [3].

Across Africa, Mpox outbreaks remain frequent, particularly in countries like the Democratic Republic of Congo (DRC), Uganda, and Tanzania. These recurrent events reflect persistent deficiencies in healthcare systems, including limited access to personal protective equipment (PPE), underfunded public health infrastructure, and inadequate surveillance mechanisms [4]. Burundi faces similar constraints, which continue to hinder its capacity to respond to infectious disease outbreaks effectively [5]. In Burundi specifically, the Mpox outbreak response is hampered by under-resourced healthcare facilities, low diagnostic capacity, insufficient IPC training for health workers, and a lack of PPE. The absence of a formal IPC governance framework limits coordination, surveillance, and early warning capabilities [5]. Health workers, often without adequate training or support, face increased risks of cross-infection, which further escalates the public health threat.

Given this context, evaluating Burundi´s existing IPC and Water, Sanitation, and Hygiene (WASH) systems is crucial. Global evidence indicates that countries with well-established IPC and WASH systems are more successful in containing infectious disease outbreaks. Strong IPC frameworks in both healthcare settings and communities are associated with decreased transmission of diseases such as Ebola and Mpox [6-8]. Tools such as the IPC/WASH scorecard offer a structured, evidence-based method to identify gaps, inform interventions, and guide resource allocation. The integration of IPC Assessment Tools (IPCAT2) and the IPC Scorecard offers a robust framework for evaluating and enhancing IPC/WASH systems, particularly during outbreaks like Mpox. Infection prevention and control assessment tools (IPCAT2) are a qualitative tool developed by the World Health Organization (WHO) to assess implementation of IPC core components at national and facility levels, relying on stakeholder interviews, document reviews, and facility observations to identify systemic enablers and barriers, aligned with WHO´s eight core IPC components [9]. Conversely, the IPC Scorecard, adapted from tools developed by Africa CDC during Ebola and COVID-19 responses, is a quantitative instrument scoring 16 critical IPC/WASH components. It categorizes healthcare facilities into red (<50%), yellow (50-80%), or green (>80%) zones based on performance, guiding prioritization of support and follow-up [10].

These tools complement each other: IPCAT2 facilitates strategic planning and national gap identification, while the IPC scorecard operationalizes IPC performance monitoring at the facility level. Together, they support WHO´s IPC framework and align with the Ring Approach, a strategy that intensifies interventions around confirmed outbreak cases to limit transmission [1,2]. Infection prevention and control assessment tools (IPCAT2) ensure governance and protocols support rapid containment, while the scorecard pinpoints high-risk facilities within the ring for immediate action, such as PPE distribution, hygiene reinforcement, and staff mentoring. This integrated, data-driven approach enhances Burundi´s capacity to respond to Mpox outbreaks efficiently, address critical IPC/WASH weaknesses, and improve long-term health system resilience [9,10].

A comprehensive assessment of Burundi´s IPC/WASH performance during the Mpox outbreak can inform targeted improvements and strengthen national preparedness for future health emergencies. This study aims to evaluate the effectiveness of the country´s current IPC and WASH systems in managing Mpox outbreaks, identifying key weaknesses and offering evidence-based recommendations to enhance healthcare readiness and response capacity. Implementing structured tools such as the IPC/WASH scorecard, alongside the Ring Approach for context-specific interventions, represents a critical step toward addressing existing gaps, optimizing resource deployment, and reinforcing IPC practices at the healthcare facility level. By comparing the impact of the IPC/WASH scorecard to existing practices in Mpox-affected communities and healthcare settings, the study explores how these tools can improve outbreak preparedness, reduce transmission, ensure effective containment, and enhance resource allocation within a two-month timeframe.

Methods     

Study design: an Intra-Action Review (IAR) was conducted in Burundi in early 2025 as part of the national response to the Mpox outbreak. The review was designed to systematically assess IPC and WASH performance, identify operational challenges, and provide recommendations for improvement. The IAR followed a multi-phase approach, including planning, data collection, analysis, and intervention prioritization. An intra-action review (IAR) was conducted in Burundi to evaluate ongoing Infection Prevention and Control (IPC), Water, Sanitation and Hygiene (WASH), and Risk Communication and Community Engagement (RCCE) interventions in real time. This participatory evaluation involved key stakeholders, including Ministry of Health officials, healthcare workers, community representatives, and partner agencies, who participated in a five-day workshop structured around the adapted 10 pillars of the WHO/Africa CDC Mpox response framework. These pillars were reviewed in detail to guide IPC/WASH/RCCE interventions. Facilities were purposively selected based on patient load, capacity, and epidemiological risk across five high-risk districts, with baseline assessments using standardized IPC/WASH scorecards to evaluate infrastructure, resources, training, and compliance. Following this, a quality improvement plan was co-developed, incorporating targeted training, simulation exercises, and scenario drills to address identified gaps and strengthen IPC practices.

Data collected from qualitative discussions and quantitative scorecards were thematically analyzed to identify challenges and successes, enabling adaptive management of interventions. Key adjustments included refining training curricula, optimizing resource allocation, enhancing mentorship and supervision, and improving coordination among facilities, districts, and partners. This adaptive, stakeholder-driven approach increased ownership and responsiveness, ensuring alignment with national priorities and international best practices. The methodology emphasized multisectoral coordination, real-time monitoring, risk communication, and cross-sector collaboration, reflecting a comprehensive strategy to improve IPC/WASH/RCCE outcomes within Burundi´s evolving health system context.

Phase 1: preparation and planning

Stakeholder engagement: the process began with engaging key actors, including the Ministry of Health, local health departments, the WHO, and NGOs. These stakeholders helped define the scope, select evaluation criteria, and validate tools.

Team formation: multidisciplinary teams were established under dedicated pillars. The IPC/WASH pillar included specialists in IPC, epidemiology, public health logistics, healthcare infrastructure, and WASH.

Protocol development: a standardized protocol was created to ensure consistent data collection across health facilities and community-level responses.

Phase 2: data collection and analysis

The review focused on healthcare facilities and community settings, utilizing digital tools such as IPCAT2 and the IPC scorecard, adapted from tools previously used for Ebola and COVID-19. These tools enabled rapid assessments without collecting personal or identifiable information, in line with the Africa CDC and WHO guidelines. Data were collected through on-site assessments, audits of IPC protocols, structured interviews with healthcare workers, and document reviews. Indicators evaluated included PPE availability, hand hygiene, environmental sanitation, training, and post-exposure protocols. Data were aggregated and anonymized to ensure compliance with ethical standards. Literature from UNICEF and other partners in Burundi also informed the analysis.

Infection prevention and control scorecard use and facility classification: the IPC Scorecard helped classify healthcare facilities by performance red zone (<50%): critical need for daily follow-up; yellow zone (50-80%): moderate performance; supervision 2-3 times per week; green zone (>80%): adequate performance; weekly check-ins. This classification enabled real-time triage of facilities for support, resource allocation, and follow-up interventions. Facilities were reassessed two months later to evaluate improvements and adjust response efforts accordingly.

Ethical approval and consent to participate, and data use declaration: this study was conducted as part of the 2025 Mpox public health emergency response in Burundi. It involved a descriptive observational assessment of IPC/WASH practices using routine health system data. No human subjects research, clinical trials, or collection of identifiable personal information were involved. Formal ethical approval and participant consent were not required under national and international guidelines for emergency public health evaluations.

Results     

The IAR conducted in early 2025 assessed IPC and IAR(WASH) practices during the Mpox outbreak in Burundi. The review highlighted both strengths and weaknesses in the national response, along with key lessons learned and actionable recommendations. Table 1 provides the outcomes of the assessment. The review of 44 healthcare facilities in Burundi during the 2025 Mpox outbreak revealed an overall low baseline IPC/WASH performance, with an average score of 23.75% across 16 core indicators. Key deficiencies included healthcare worker training (17.91%), hand hygiene (36.36%), and equipment decontamination (29.55%). After two months of targeted interventions, only marginal improvements were observed, with the average score rising slightly to 24.31%. The highest gains were noted in case identification and post-exposure risk management, each improving by 5%, while other indicators such as PPE availability, IPC committee function, and hand hygiene showed minimal increases of 1-2%. Several critical areas, including injection safety, water supply, and body management, showed no improvement.

Strengths identified through the qualitative review included effective IPC/WASH coordination via regular sub-commission meetings, adequate PPE supply protecting healthcare workers, resource mobilization for training and supplies, community engagement promoting hygiene awareness, and timely distribution of IPC materials. Conversely, significant weaknesses persisted, such as weak collaboration between animal and human health sectors, the absence of a unified national IPC plan, delayed strategic planning, high staff turnover, and limited integration of IPC training within local health curricula. These findings highlight both the incremental progress made and the urgent need for systemic reforms to enhance Burundi´s outbreak response capacity. Table 2 provides a summary of the results at the initial and month 2 assessments.

Discussion     

The 2025 IAR assessing Burundi´s Mpox outbreak response revealed critical gaps alongside operational strengths in IPC and WASH systems. Initial findings showed an overall low IPC/WASH average score of 23.75%, indicating significant deficiencies, particularly in healthcare worker training (17.91%), hand hygiene (36.36%), and equipment decontamination (29.55%) [5,9,11]. These findings underscore systemic weaknesses in outbreak preparedness and IPC protocol implementation. After two months, a marginal improvement to 24.31% was observed, demonstrating persistent challenges despite targeted interventions.

Strengths included regular IPC/WASH sub-commission meetings that enhanced coordination among stakeholders, adequate PPE supply that prevented healthcare worker infections, resource mobilization for training and supplies, and community engagement that improved hygiene behaviors. However, major weaknesses persisted: limited collaboration between human and animal health sectors, absence of an integrated national IPC plan, high turnover of trained personnel, and insufficient integration of IPC training in local curricula [4,5,12]. These findings align with evidence from other African settings, where weak IPC infrastructures hinder outbreak containment, contrasting with more robust systems in high-income countries where IPC compliance often exceeds 80% [7,8,13]. Lessons learned emphasize the necessity of adopting a multisectoral “One Health” approach for zoonotic disease control, prioritizing the timely development of national IPC/WASH strategies, institutionalizing continuous training, and scaling up digital monitoring tools such as the WHO IPC scorecard for real-time oversight [9,10,14].

The complementary use of qualitative (IPCAT2) and quantitative (IPC scorecard) tools enabled a comprehensive assessment of IPC/WASH practices at both facility and national levels. Multi-stakeholder involvement ensured findings were contextually relevant and accepted, while community engagement and resource mobilization demonstrated a holistic, sustainable approach to outbreak preparedness and response [9,10,15]. Rapid follow-up after two months allowed timely evaluation of intervention impacts and early identification of persistent gaps. This adaptability is crucial in managing ongoing or emerging infectious disease threats. However, the short interval may have been insufficient to capture full intervention effects on entrenched IPC/WASH deficiencies. Incomplete documentation and high staff turnover may have compromised data accuracy and consistency. The lack of patient outcome data also limited direct correlation of IPC improvements with Mpox transmission reduction, highlighting the need for integrated health data systems in future efforts [16,17].

Sustained multisectoral efforts are essential to institutionalize a cohesive national IPC/WASH strategic plan, embed continuous healthcare worker training, strengthen One Health collaborations, and leverage digital monitoring tools to build a resilient IPC system [14,18]. These steps will enhance Burundi´s capacity to manage Mpox and other emerging infectious diseases, safeguarding public health [19,20].

Conclusion     

The 2025 Mpox outbreak in Burundi exposed major deficiencies in infection prevention and control (IPC) and Water, Sanitation, and Hygiene (WASH) systems, with healthcare facilities reporting a low baseline performance score of 23.75%. Despite implementing targeted interventions over two months-guided by the IPC/WASH scorecard-only marginal improvements were observed, with scores rising to 24.31%. These findings highlight deeply rooted challenges such as inadequate training, poor infrastructure, limited supplies, and weak intersectoral collaboration. Operational strengths included effective coordination through IPC/WASH sub-commissions, sufficient PPE availability, and proactive community involvement. The IPC/WASH Scorecard proved effective in identifying gaps and prioritizing actions, particularly when used in conjunction with the Ring Approach for targeted outbreak containment. To achieve sustainable progress, Burundi must institutionalize a national IPC/WASH strategy, integrate IPC into health training curricula, and adopt a One Health model that bridges human, animal, and environmental health. Long-term gains will require strong governance, enhanced digital monitoring, and sustained investment in health system resilience to prevent and control future infectious disease outbreaks.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Jean Paul Muambangu Milambo: conceptualization, project administration, methodology, writing - original draft, supervision, data curation, and formal analysis; Charles Businge: data collection, analysis, critical appraisal, supervision, and manuscript editing. All the authors read and approved the final version of this manuscript.

Acknowledgments     

We would like to acknowledge Ms Welile Dube, a scientist from the University of Stellenbosch, for her valuable support in critical appraisal, data collection, and analysis. We also extend our gratitude to the Burundi Department of Health and the HIV Program for their support in the outbreak investigation and data collection. Special thanks to Dr Valery Tshilombo from the University of Mbujimayi for his assistance with data collection and field advice. We are also deeply grateful to Prof. André Bulabula for his field supervision, scientific contributions, and critical insights throughout the investigation.

Tables     

Table 1: summary of infection prevention and control/water, sanitation, and hygiene intra-action review findings - Mpox Response, Burundi (2025)

Table 2: infection prevention and control/water, sanitation, and hygiene scorecard comparison (initial vs. after 2 months) (44 healthcare facilities, Burundi - Mpox response), infection prevention and control scorecard after 2 months

References