Exploring key contextual, statistical and operational potential of the Early Warning and Response System (EWARS-csd) for Dengue outbreaks in Saudi Arabia

Sammanfattning

Background: Dengue fever is a rapidly expanding mosquito-borne viral disease and a growing public health concern, particularly in tropical and subtropical regions. Saudi Arabia has the highest dengue burden in the Middle East, where rapid urbanization, climate variability, and large population movements associated with Hajj and Umrah contribute to transmission. Traditional surveillance systems mainly rely on reactive case detection, often delaying outbreak response. This study evaluated the predictive performance, practical utility, and implementation potential of the Early Warning and Response System (EWARS-csd) for dengue fever in Saudi Arabia.Methods: A mixed-methods study with an abductive approach was conducted, combining quantitative analysis of dengue surveillance and meteorological data with qualitative stakeholder interviews. EWARS-csd performance was assessed using confirmed and suspected dengue cases across districts with varying endemicity levels, while interviews explored stakeholder perceptions and operational readiness for implementation.Results: Suspected dengue cases improved early outbreak prediction, while confirmed cases enhanced specificity; combining both strengthened overall predictive performance. Negative predictive value (NPV) was consistently high, indicating reliable identification of non-outbreak periods. However, positive predictive value (PPV) remained low, suggesting a risk of false alarms and inefficient resource allocation. Predictive performance was strongest in the moderate-endemic district. Qualitative findings identified implementation barriers but also highlighted strong operational structures, intersectoral communication, positive stakeholder attitudes, and a perceived need for predictive surveillance systems.Conclusion: EWARS-csd shows potential to support timely dengue outbreak prediction and response in Saudi Arabia. Integrating the system into national surveillance programs could strengthen dengue prevention and control, improve preparedness, and support more efficient allocation of public health resources.