SWOT analysis of Mpox surveillance in high-burden districts in Uganda, February–March 2025

Abstract

Background

From July 2024–February 2025, three-quarters of the districts in Uganda experienced mpox outbreaks, with sustained transmission in urban cities and towns. Following the rise in cases and severe outcomes, there was an urgent need to assess sub-national surveillance capacities to inform improvements in mpox response. This study aimed to assess the strengths, weaknesses, opportunities, and threats to mpox surveillance in Uganda’s high-burden districts and document lessons learned for responding to future outbreaks.

Methods

We conducted a cross-sectional qualitative study during February–March 2025 in 30 purposively selected districts across five high-burden regions of Uganda. Participants were drawn from regional, district, facility, and community levels, including surveillance officers, clinicians, laboratory personnel, and community health leaders. Data were collected through focus group discussions using semi-structured interview guides. Notes were manually coded by two researchers and analyzed thematically using a SWOT (Strengths, Weaknesses, Opportunities, and Threats) framework. Sub-themes were developed inductively, and written informed consent was obtained from all participants.

Results

A total of twenty focus group discussions were conducted across five high-burden regions. Participants identified key strengths in mpox surveillance, including functional regional emergency coordination centers, onsite capacity building in digital tools like Go.Data, dedicated surveillance personnel, prior outbreak response experience, and the presence of trusted community health structures. However, notable weaknesses included inaccurate contact information, delayed laboratory test results, workforce shortages, misdiagnosis at lower health facilities, limited digital capacity, inadequate isolation facilities, and stockouts of essential supplies, food, and personal protective equipment. Key opportunities included scaling capacity-building efforts and enhancing surveillance infrastructure, such as call centers and toll-free lines, while surveillance threats included community fear of isolation and strain of concurrent outbreaks such as Ebola.

Conclusion

Uganda’s mpox surveillance revealed key strengths, including functional regional coordination hubs, trusted community health structures, and dedicated surveillance personnel that supported early detection. However, gaps such as limited human resources, delayed laboratory results, stockouts, and fear of isolation hindered effective response. Addressing these challenges through investments in decentralized coordination, digital tools, surge staffing, and supply chain systems could enhance future surveillance efforts.

Introduction

On August 14, 2024, the Director General of the World Health Organization (WHO) declared the rising number of mpox cases in the Democratic Republic of the Congo (DRC) and other African countries, a Public Health Emergency of International Concern (PHEIC) [1]. As of 31 July 2024, the WHO had received reports of over 100,000 laboratory-confirmed mpox cases and 223 associated deaths from 121 member states across all six WHO regions [2]. The increase and expanded distribution of mpox in 2024, particularly of the more pathogenic clade 1, in regions beyond the endemic DRC, including Rwanda, Uganda, Kenya, Côte d’Ivoire and Sudan, and non-endemic countries, suggested a complex interplay in the transmission dynamics of mpox [3]. This spread occurred mainly through human-to-human transmission, primarily in sexual and social networks that were previously unexposed [4, 5].

In comparison to non-endemic regions where mpox vaccination and treatment strategies have been more accessible, African countries face persistent challenges. These include limited vaccine access, constrained health infrastructure, underdeveloped surveillance and laboratory systems, and low levels of public awareness and community engagement [6–9]. The threat of mpox continues to be exacerbated by rapid urbanization, hence sustaining mpox as an ongoing risk in countries such as Uganda. This underscores the need for improved surveillance and public health interventions to monitor and contain mpox outbreaks across countries. Uganda’s Ministry of Health (MOH) emphasizes strengthening health systems at the sub-national level of both regional and district levels to improve preparedness and response to outbreaks at all levels [10].

According to the Uganda mpox surveillance data, there were increasing peaks of mpox incidences across the country; a total of 2,209 cases and 13 deaths were reported by January 28, 2025, with cities and fishing communities being most affected [11]. Case management also noted increased severity among patients admitted with mpox. Mpox can cause complications, such as necrotizing skin lesions with bacterial superinfection, pneumonia, and encephalitis, particularly in immunocompromised individuals, such as those with advanced HIV infection (CD4 count < 200 cells/µL) [12]. The ongoing mpox outbreaks could strain Uganda’s already resource-limited healthcare system. Severe cases, which necessitate hospitalization, could lead to bed shortages in referral hospitals, the redirection of critical resources, and increased outbreak response costs. Effective preparedness and response to such outbreaks require a robust, coordinated surveillance system, prompt case detection, and timely case management. These elements depend heavily on the capacity and preparedness of rapid response teams (RRTs) and healthcare workers across all levels of the health system.

Rapid response teams are recognized as key components of the Global Health Security Agenda (GHSA) under the International Health Regulations [13, 14]. At the sub-national level, RRTs and health workers are instrumental in early case detection, case management, contact tracing, infection prevention, risk communication, and overall coordination of response efforts at the sub-national level. They relate to four of the 2014 GHSA Action Packages: workforce development, emergency operations centers, linking public health with law and multisectoral rapid response, and medical countermeasures and personnel deployment [15]. Furthermore, Uganda’s MOH established the National Public Health Emergency Operations Center (PHEOC) in September 2013 as a central coordination unit for all public health emergencies in the country. Sub-national PHEOCs, i.e., Regional Public Health Emergency Operations Centers (RPHEOCs), are resourceful in mounting regional responses to public health emergencies, and these oversee RRTs at sub-national levels. With the existence of these structures, we aimed to assess the strengths, weaknesses, opportunities, and threats to mpox surveillance at subnational levels in high mpox-burden regions in Uganda, February–March 2025, to inform strategies for strengthening decentralized surveillance systems.

Methods

Study design

This was a cross-sectional study that employed qualitative methods of data collection from February–March 2025.

Study area

The study was implemented in five regions of Uganda: Ankole, South Buganda, North Buganda, Busoga, and Kampala, and in these regions, a total of thirty districts were selected (Fig. 1). The regions and districts were purposively selected based on the highest mpox burden at the time of conducting the study.

Fig. 1.

Selected districts by region, Uganda, February–March 2025

Study population

We enrolled participants by level of Uganda’s healthcare system, including regional, district, health facility, and community health workers. At the regional level, we selected five participants at each RPHEOC who were directly involved in mpox surveillance activities, including the head of the community health department, a data analyst, a surveillance focal person, an epidemiologist, a laboratory focal person, and a clinician. Participants at the district level included the district health officers (DHOs), assistant district health officers, district laboratory focal persons, biostatisticians, district surveillance focal persons (DSFPs), and district health educators (DHEs). At the health facility level, the participants included health facility in-charges, surveillance focal persons, and data or records personnel supporting mpox surveillance. At the community health level, the participants were the members of the Village Health Teams (VHTs).

Sampling methods

We used purposive sampling to select information-rich participants based on their level within the healthcare delivery system. Stakeholders within the health sector were identified through discussions with the national PHEOC, RPHEOC, district health offices, and in-charges of health facilities. Individuals who had significant involvement and influence in mpox surveillance, as well as those who had firsthand experience with the challenges and successes of the mpox response, were selected. Efforts were made to include a diverse range of participants from different regions, levels of the health system (region, district, and community), and various roles within the mpox response to ensure a comprehensive understanding of the issues.

Data collection procedures and tools

Data were collected through focus group discussions (FGDs), using a semi-structured interview guide with open-ended questions. Each FGD was conducted using manual note-taking following participants’ preferences to ensure their comfort. Most participants held administrative roles and were uncomfortable being audio-recorded due to concerns about disclosing weaknesses in the surveillance system. Each FGD was attended by three trained notetakers who documented the discussions independently. We held immediate debriefing sessions where the FGD facilitators and notetakers met to review, compare, and consolidate notes after each session. The consolidated notes were subsequently shared with two participants from each FGD to validate what was documented by the notetakers. Additionally, an independent qualitative expert reviewed a sample of the consolidated notes to assess their completeness and accuracy. Final notes were stored in password-protected computers.

All FGDs were conducted by a team of experienced qualitative researchers who held a half-day refresher session to harmonize their approach and ensure consistency across all study sites. Each FGD was composed of 6–8 participants and lasted for 30–45 min. The sessions were held in reserved boardrooms at the RPHEOC or district health offices. Data collection continued until similar thematic saturation was achieved, defined as a point at which no new discussion ideas emerged in successive FGDs. This was assessed by the facilitation team through the debrief sessions held after each FGD.

Data management and analysis

We reviewed each interview several times to familiarize ourselves with the data and identify words, phrases, sentences, and paragraphs that described particular phenomena. These were summarized using a deductive framework based on the SWOT (Strengths, Weaknesses, Opportunities, and Threats) structure. Two researchers independently reviewed, summarized the findings, and manually coded the consolidated FGD notes. Within each main theme, subthemes were developed inductively to capture specific insights that emerged from participants’ responses. They refined the initial codes, merging similar ones to generate subthemes using an inductive thematic analysis approach. We presented the findings along the sub-themes and quoted representative statements by respondents verbatim.

Piloting

We piloted the data collection tools, including the consent form, in the Bunyoro sub-region. The sub-region was not among the study sites in this study, and all eight districts in this region had recorded at least one mpox case. The Bunyoro sub-region also hosts refugees and has a dynamic population. This enabled the study team to pilot the tools among people in different settings to ensure appropriateness of questions, consistency, and ease of use. We held a feedback meeting following the pilot and made necessary adjustments in the tools to address the gaps identified.

Data quality

We used experienced research supervisors and assistants to conduct this study. The supervisors were drawn from the Uganda Public Health Fellowship Program (PHFP) at the Uganda National Institute of Public Health (UNIPH), the National Public Health Emergency Operations Center (NPHEOC), and the Ministry of Health. The research assistants were PHFP fellows, with a minimum of a master’s degree and experience in conducting similar qualitative interviews. The supervisors and research assistants were trained on the protocol and all study tools for two days, and all participated in the piloting. They were also oriented in research ethics and the conduct of quality research and evaluations. During the survey, we held daily evening virtual meetings with all study teams to track progress towards the set targets and assess the data quality.

Results

We conducted twenty focused group discussions. The mean age of the participants was 39 years, with a range of 34 to 43 years, and the majority were male (71%; 114/160). The educational attainment of the participants ranged from a certificate to post-master’s, with most of the participants having attained a bachelor’s degree (33%; 53/160). We generated four themes based on the SWOT framework: strengths, weaknesses, opportunities, and threats to mpox surveillance at the sub-national levels. From these, five sub-themes emerged under strengths, nine under the weaknesses, and two sub-themes each under opportunities and threats (Fig. 2).

Fig. 2.

Summary of sub-themes that emerged under the themes of strengths, weaknesses, opportunities, and threats to mpox surveillance in Uganda, January─March, 2025

Theme I. Strengths in Mpox surveillance

Functional regional public health emergency operation centers

District teams reported that Regional Public Health Emergency Operations Centers (RPHEOCs) remained operational during the outbreak and played a critical role in coordinating surveillance, case management, logistics, and risk communication.

“Even with limited funding and staff, the RPHEOC has kept things moving. They are our go-to hub as districts, guiding field teams, ensuring samples are picked and transported through the hub system. Without their involvement, the mpox surveillance activities would have stalled.” — FGD 1, Participant 2 (P2).

“When we reported a shortage of personal protective equipment (PPEs) and had challenges with getting results for the samples we had sent, the RPHEOC quickly stepped in and redistributed to us from their stores. They also followed up on results with the national testing laboratory, and we were able to receive these results shortly.” — FGD 4, P8.

On-site capacity Building

All RPHEOCs and some districts reported they had received on-site capacity building on the use of digital surveillance tools, specifically Go.Data from the Ministry of Health and other partners. Go.Data is an outbreak investigation tool that provides information on cases confirmed, ensuring contacts are linked to confirmed cases, followed up, and visualized with transmission chains. Many respondents reported conducting contact tracing and follow-up using Go.Data that eased their work compared to manual contact follow-up. Some highlighted their ability to clear the backlog of contacts that were previously not entered into Go.Data.

“Using Go.Data made contract tracing much easier for us. Before, we were following up contacts manually, which was time-consuming but also subject to forgetting some contacts and missing information. With the system, everything is recorded and tracked in real-time, so we can follow up easily.” — FGD 2, P3.

“I had only heard of Go.Data but never used it. After the training, we practically entered all our backlog contacts, and I am now confident moving forward, I will be able to enter all contacts.” — FGD 12, P1.

Dedicated surveillance personnel

Healthcare managers and district leaders reported that the presence of dedicated surveillance focal persons at both district, health sub-district (HSD), and health facility levels contributed to early case detection, improved community reporting, and coordination of response efforts even in hard-to-reach areas.

“Whenever a suspected mpox case is identified at the facility, the team notifies the facility surveillance focal person, who then alerts the district surveillance focal person. From there, arrangements are made for the patient to be evacuated to the isolation unit at the regional referral hospital.” — FGD 6, P8.

“Our surveillance focal person has been like the engine of mpox response, always coordinating, following up cases, and guiding our teams on how to trace contacts.” — FGD 2, P5.

Previous experience in responding to outbreaks

Some participants at the community level reported that their experience in responding to previous outbreaks, such as ebola and COVID-19, bolstered their community engagement and laid a strong foundation for case identification and contact tracing during the mpox outbreak.

“From the previous outbreaks where we have responded, the already existing ties with the community have helped us maneuver and respond to this new disease easily. We have been able to mobilize and educate community members who have cooperated in giving alerts in case of a suspect.” — FGD 3, P5.

Established community structures

Several participants reported that the presence of established community structures, particularly Village Health Teams (VHTs), played a vital role in the mpox surveillance. The VHTs enabled early identification and reporting of suspected cases at the community level. Their trusted presence helped facilitate effective risk communication, community mobilization, and acceptance of control measures such as isolation.

“The VHTs are the first to identify and report suspected cases in villages and their presence has made it easier to trace cases, their contacts, and also talk to families about isolation. People trust them and because of this, the community is willing to cooperate with the health teams.” — FGD 9, P3.

Theme II. Weakness in the Mpox surveillance

Inaccurate case-contact information

Some district teams reported challenges in tracing contacts due to incorrect contact information provided by confirmed cases. They noted that individuals either gave false names, wrong physical addresses, or unreachable phone numbers that made it difficult for surveillance teams to conduct timely contact tracing and follow-up. This was attributed to the fear of other community members getting to know their disease status.

“Sometimes the cases provide us incorrect addresses or phone numbers, and by the time we realize it, we have already lost time. This has affected our ability to trace contacts. We think some people are afraid or don’t want other community members to know.” — FGD 11, P3.

Long laboratory turnaround time for results

Several district laboratory teams reported a long laboratory turnaround time (TAT) for results. They reported that at times it would take more than a week without receiving test results, causing a slowdown in decision-making, which affected the response efforts.

“In some cases, it took more than a week to get confirmation. By the time the results were out, the patient had either improved, worsened, or infected other people. These delays have limited our ability to implement timely interventions such as contact tracing. It would have been better if we had regional laboratories, which we believe would produce results faster.” — FGD 20, P7.

Work overload

Health workers reported a heavy workload, attributing it to inadequate staffing at the isolation units. Some noted that during peak periods, the isolation units admitted many patients, as it was a requirement by the Ministry of Health to isolate every case in a designated health facility. As a result, critical care for severe cases was sometimes compromised, including basic hygiene support. Similarly, some district teams reported being overburdened, explaining that in addition to their routine responsibilities, they were tasked with mpox surveillance, which was an additional demand.

“We have few human resources at the isolation unit and sometimes get overwhelmed with patient numbers. Ideally, some of the critical patients would need supervision by one nurse the entire day, but this is not possible. Even the hygienists are very few and overwhelmed.” — FGD 19, P2.

“I am only one surveillance person for the entire district, and I have to look for cases and all their contacts amidst my other routine workload. Sometimes I get overwhelmed because I am expected to follow up every alert, compile reports, attend coordination meetings, and still manage other diseases.” — FGD 1, P4.

Misidentification of Mpox cases by health workers

Regional health teams reported limited knowledge about mpox among health workers, especially at lower-level facilities, where they misdiagnosed it. They stated that there was a low index of suspicion among health workers, and most time they failed to recognize its signs in the communities. They reported that in most instances, the disease was confused with chickenpox, urinary tract infections, or measles, which delayed diagnosis and response.

“Our health workers struggle to differentiate mpox from other skin conditions, because mpox is a new disease to most of them. Most of them haven’t received adequate training and exposure to mpox cases, yet the clinical presentations can easily be confused with common illnesses like chicken pox, urinary tract infections. This has contributed to missed or delayed diagnosis, especially at lower levels of health care.” — FGD 18, P3.

Limited capacity in digital surveillance tools

Several district surveillance focal persons reported that they were not well-versed in the use of digital reporting systems such as the electronic Integrated Disease Surveillance and Response Strategy (eIDSR) and Go.Data. They stated a lack of training on these reporting tools and the absence of login access to these platforms, which affected their capacity to do efficient contact tracing and follow-up.

“In our district, we haven’t been trained on the use of GO.Data, and we also don’t have login access to the system. This has affected contact tracing because we have been using a paper-based system. You cannot easily track who has been followed up or identify missed contacts on time.” — FGD 7, P3.

Inadequate isolation facilities

Regional and district health teams reported a lack of adequate isolation facilities—many had limited space, while others had none at all. For example, some isolation units which were located in areas affected by concurrent outbreaks such ebola. As a result, space initially designated for mpox cases was reallocated to accommodate ebola contacts, leading to overcrowding.

“When Ebola broke out alongside mpox, our isolation capacity was stretched. Priority had to be given to ebola contacts, and mpox cases were left in a limited space. We have had to make tough decisions about who should stay and who had to go home. Managing two high-risk diseases in the same facility is overwhelming with no clear protocol on how to safely separate them, but also it has created fear among staff and communities.” — FGD 17, P8.

“We are hosting a large refugee population, but we only have one health facility that can serve as an isolation center. The infrastructure is completely inadequate for the level of demand we face, both from the refugee and host communities.” — FGD 5, P2.

Stock out of essential medicines and supplies

Several health facility in-charges at isolation units, along with regional health teams, reported frequent stock-outs of essential medications and supportive treatment supplies across most regions. They stated that many health facilities lacked basic items such as antibiotics, analgesics, and wound care supplies. They highlighted that these stock-outs not only compromised the quality of care provided to admitted patients but also hindered case detection and reporting. Community members, aware that treatment was unavailable at health centers, became reluctant to report symptoms or seek care, further weakening surveillance and response efforts.

“You can’t expect people to come forward when they know there’s nothing to help them at the health center. We are admitting patients, but sometimes we don’t even have basic drugs to manage pain or infection. Over time, this discourages communities from reporting symptoms or seeking care.” — FGD 8, P1.

Lack of food in isolation units

Health workers at isolation units reported a challenge of no food for isolated cases. They highlighted that the absence of food discouraged suspected cases from reporting early or accepting admission, fearing not only isolation but also hunger. They reported that this undermined surveillance efforts, as people chose to hide their symptoms or manage the illness at home rather than risk being admitted without basic needs being met.

“Some patients refuse to be isolated because they ask, ‘If I’m locked away, who will feed me?’ We even had some cases where patients have escaped due to a lack of food. It’s hard to enforce isolation when people are worried about basic survival.” — FGD 4, P5.

Insufficient personal protective equipment for frontline health workers

Laboratory teams and other frontline health workers reported a challenge of inadequate personal protective equipment (PPE). They reported that during case investigations and contact tracing, they were often required to interact with potentially infectious individuals with limited supplies, such as gloves and gowns that fell short of both national and WHO guidelines for mpox response. They raised safety concerns and indicated that this delayed response activities due to fear of exposure.

“We are asked to collect samples, but sometimes we have to do it without proper PPE. You start to wonder if I get infected, who will take care of me? Some staff hesitate to go into the field, and honestly, you can’t blame them.” — FGD 3, P6.

Theme III: opportunities for Mpox surveillance in Uganda

Scaling capacity-building to other diseases

Most participants who had received onsite capacity-building on mpox reporting highlighted that this had improved their ability to conduct timely case investigations and contact tracing. Regional and district health teams indicated that this was an opportunity to cascade similar training to districts and lower sub-national levels that hadn’t received similar training.

“The training we received on mpox reporting has not only helped with mpox surveillance but also other diseases since the principle is the same. I feel more prepared to detect and act even for diseases that we haven’t dealt with before. We would recommend that these same benefits be extended to our colleagues who haven’t received this training.” — FGD 10, P7.

Strengthening disease surveillance infrastructure

Regional health teams reported that during the outbreak response, RPHEOCs were equipped with call centers and toll-free hotlines. They highlighted that community members and health care workers were able to report suspected cases in real time. This innovation was reported as an opportunity to improve the speed and accuracy of case detection and overall surveillance.

“With these hotlines in place, we no longer wait for cases to trickle through the system but rather get alerts directly from the field, sometimes even before a patient reaches a health facility.” — FGD 9, P7.

Theme IV: threats to Mpox surveillance in Uganda

Community fear of isolation

A number of community health workers reported that there was a threat of stigma around isolation for mpox, where the communities referred to the previous COVID isolation experience. They highlighted that the community feared being isolated and separated from their families and communities, further discouraging patients from seeking treatment.

“Ever since COVID, the word ‘isolation’ brings fear in our communities. People think they’ll be taken far away, cut off from their families, and left without support. So, when mpox came, many chose to keep quiet rather than report symptoms.” — FGD 14, P4.

Concurrent outbreaks

Regional and district health teams reported that the concurrent burden of mpox and other outbreaks, such as ebola, Crimean-Congo hemorrhagic fever (CCHF), led to competition for the limited resources for surveillance. In January 2025, the ebola outbreak re-emerged in Uganda. Health teams reported delays in mpox detection due to priority being given to the ebola response, including human resources for mpox surveillance that were diverted to ebola.

“When ebola hit, everything shifted. Surveillance, contact tracing, and even lab testing for mpox slowed down. We had to choose which one to give our attention, and ebola took focus.” — FGD 7, P8.

Discussion

The response to the mpox outbreak in Uganda, as described by participants, reflected a mix of preparedness and operational challenges at sub-national levels. Reported strengths included the functionality of RPHEOCs, existing community health structures, capacity building of regional and district teams, committed surveillance personnel, and previous experience in responding to disease outbreaks. However, participants reported several barriers to effective mpox surveillance. These included: incorrect or incomplete contact information, long laboratory turnaround time, limited familiarity with digital reporting tools, limited human resources, insufficient isolation facilities, and stockouts of essential medicines and supplies. In addition, there was a lack of food for cases in isolation units and inadequate personal protective equipment for health workers. These were compounded by threats such as community mistrust, stigma, and the burden of concurrent outbreaks such as ebola.

Participants in high-burden mpox regions reported delays in receiving laboratory test results for mpox, which they perceived as a barrier to a timely response. This challenge has previously been cited in other mpox outbreak responses in low-resource settings, where limited designated testing laboratories and logistical constraints in specimen transport have been identified as key barriers [16, 17]. While our study did not assess diagnostic systems directly, participants’ suggestions emphasized the value of decentralizing mpox testing and improving specimen transport systems. Point-of-care (POC) testing has demonstrated significant benefits in resource-limited settings, enabling rapid and accurate results that enhance patient care by facilitating prompt treatment decisions [18].

Participants across districts and regions described being overwhelmed by competing responsibilities during the mpox response, particularly in surveillance and mpox isolation units. The work overload led to delays in case investigation and compromised patient care, undermining the effectiveness of the response. Similar concerns have been documented in other African countries such as Liberia and Guinea-Bissau [19, 20]. Addressing these challenges requires establishing surge staffing mechanisms such as task-shifting to trained community health workers and investing in appropriate staffing norms for isolation units to sustain frontline capacity during outbreaks.

Misdiagnosis of mpox by frontline health workers was highlighted as a barrier for mpox surveillance and overall response. These findings align with reports from other outbreaks where mpox was frequently misclassified for other dermatologic or febrile illnesses, such as chicken pox, measles, scabies, and urinary tract infections due to non-specific symptoms and often limited clinical experience [21–24]. In a systematic review by Bunge et al. (2022), it was reported that mpox was frequently underdiagnosed or misdiagnosed due to insufficient clinical suspicion and inadequate differential diagnosis protocols [21]. Misdiagnosis of mpox leads to inappropriate clinical management, increased risk of transmission, and failure to implement timely infection prevention and control measures. Integrating mpox case definitions into routine integrated disease surveillance and response training and refresher programs could enhance frontline detection.

Inadequate isolation facilities were another commonly reported concern. Participants described scenarios where mpox cases lacked a dedicated space, and some had to be discharged for home management, raising concerns about infection prevention. Similar challenges have been noted in previous outbreaks, including in Nigeria, where designated isolation units for mpox were either insufficient or unavailable [16]. Inadequate isolation facilities put healthcare workers, caregivers, and other patients at elevated risk of infection. Integrating mpox case management into existing infectious disease preparedness platforms, e.g., ebola, COVID-19, could improve the surge capacity without requiring parallel infrastructure.

Stock-outs of essential medicines and supplies, such as antibiotics and wound care items, were also described as a barrier to providing adequate clinical care. Such shortages could compromise clinical outcomes and increase the risk of complications such as bacterial infections [25]. Stockouts also reportedly diminished community trust in the health system. Although this study did not assess the supply chain, the accounts highlight the importance of strengthening logistics and readiness systems during outbreaks.

Participants also noted that fear of isolation discouraged individuals from seeking care or disclosing symptoms. When fear of isolation deters individuals from seeking care, outbreak control measures such as surveillance, case finding, and contact tracing become less effective. Similar findings have been documented in other contexts where community mistrust undermined surveillance and response efforts. A qualitative study in the DRC found that communities often associated isolation with death, especially during outbreaks of infectious diseases such as ebola and COVID-19 [26, 27]. Integrating community-led risk communication and psychosocial support would reduce fear and stigma associated with isolation and improve early care seeking and disclosure during outbreaks.

Despite these challenges, the role of RPHEOCs was cited by participants as facilitating coordination and logistics. Many stakeholders perceived the RPHEOC structures as helpful in organizing specimen transport and streamlining communication across districts. The presence and functionality of RPHEOCs in previous outbreaks have also demonstrated that decentralized coordination structures can significantly enhance outbreak response [28, 29]. Sustained investment in RPHEOCs could improve resilience to future public health emergencies.

Furthermore, the existence of community health structures, especially village health teams, was reported as a key facilitator for early detection and follow-up, given their trusted role in communities. In previous outbreaks in Uganda, community health workers have enhanced outbreak control through community-based surveillance [30, 31]. Our findings affirm that community health structures are a core component of national outbreak preparedness and response strategies.

Participant perspectives suggest that Uganda’s mpox surveillance response benefited from strategic investment in decentralized emergency coordination structures. These perceived strengths from Uganda’s mpox surveillance mirror experiences documented in other African contexts, such as Cameroon’s integrated disease surveillance during mpox outbreaks and Liberia’s district-level response capacity building after the ebola outbreak [32, 33]. These insights highlight the potential value of decentralizing coordination hubs and strengthening local surveillance networks to improve surveillance and response in resource-limited settings.

Study limitations

We relied on self-reports from health workers for data on strengths, challenges, opportunities, and threats for mpox surveillance, which might have led to social desirability bias. Nevertheless, it was minimized during the consenting process, during which health workers were assured of confidentiality and no risks arising from their participation. We also endeavored to create enough rapport with the participants and conducted all interviews in privacy to encourage disclosure.

Conclusion

Uganda’s mpox surveillance response highlighted both strengths and challenges within the sub-national health system. Functional regional coordination hubs (RPHEOCs), existing community structures such as village health teams, and dedicated surveillance personnel were viewed as key enablers for early detection and contact follow-up. However, the response was challenged by inadequate human resources, delays in laboratory results, limited digital reporting capacity, stock-outs of essential medicines and supplies, and fear of isolation. Strengthening decentralized coordination, community engagement, investing in outbreak-specific surge staffing and expanding access and capacity in digital tools, and improving supply chain and laboratory systems could strengthen mpox surveillance.

Abbreviations

DHT

District Health Team

DRC

Democratic Republic of Congo

GHSA

Global Health Security Agenda

IDSR

Integrated Disease Surveillance and Response

IPC

Infection Prevention and Control

KOFIH

Korea Foundation for International Healthcare

PPE

Personal Protective Equipment

RPHEOC

Regional Public Health Emergency Operations Center

TAT

Turnaround Time

UNIPH

Uganda National Institute of Public Health

VHTs

Village Health Teams

Author contributions

CM, RM, IL, BK, SG, LB, IL, and DA: participated in the conception, design, analysis, and interpretation of the study and wrote the draft manuscript; CM, RM, IL, BK, SG, LB, IL, and DA: participated in the implementation of the study and data collection; RM reviewed the report, reviewed the drafts of the manuscript for intellectual content and made multiple edits to the draft manuscript; RM, LB, DK, IL, DA and ARA reviewed the manuscript to ensure intellectual content and scientific integrity. All authors read and approved the final manuscript.

Funding

The project was supported by the Korea Foundation for International Healthcare (KOFIH) under the project titled “Strengthening Health Systems to Prevent, Detect and Respond to Infectious Diseases in Uganda” implemented in collaboration with the Uganda National Institute of Public Health (UNIPH) and the Ministry of Health. Additional support was provided by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the US Centers for Disease Control and Prevention (CDC) Cooperative Agreement number GH001353–01, through Makerere University School of Public Health to the Uganda Public Health Fellowship Program, Ministry of Health.

Data availability

The datasets on which our findings are based belong to the Uganda Public Health Fellowship Program. For confidentiality reasons, the datasets are not publicly available. However, the datasets are available upon reasonable request from the corresponding author with permission from the Uganda Public Health Fellowship Program.

Declarations

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

The Ministry of Health, Uganda, provided administrative clearance to conduct this study as part of the routine national public health surveillance efforts to identify existing gaps and strengths, guiding targeted interventions in mpox outbreak detection and response. The US Centers for Disease Control and Prevention (CDC) provided the non-research determination (NRD) for non-human subjects. In agreement with the International Guidelines for Ethical Review of Epidemiological Studies by the Council for International Organizations of Medical Sciences (1991) and the Office of the Associate Director for Science, US CDC/Uganda, it was determined that this activity was not human subject research and that its primary intent was to improve public health practice or disease control. This activity was reviewed by the US CDC and was conducted consistent with applicable federal law and CDC policy. §§See, e.g., 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. § 241(d); 5 U.S.C. § 552a; 44 U.S.C. § 3501 et seq. The protocol was approved by the US CDC human subjects review board (The National Institute for Occupational Safety and Health Institutional Review Board) and the Uganda Ministry of Health, and the study was performed by the Declaration of Helsinki. Furthermore, written informed consent was obtained from all the participants. We conducted the interviews in private to ensure confidentiality, and the data was kept under password protection by the study team.

Disclaimer

The funders had no role in the study design, data collection, analysis, decision to publish, or manuscript preparation. The findings and conclusions presented in this report are those of the authors and do not necessarily reflect the official positions of KOFIH, the U.S. Centers for Disease Control and Prevention, the Department of Health and Human Services, Makerere University School of Public Health, or the Uganda Ministry of Health.

Disclosure

The funders had no role in the study design, data collection, data analysis, and decision to publish or preparation of the manuscript.

Consent for publication

Not applicable.

Competing interests

The authors declare that they had no conflict of interest.