A qualitative evaluation of dengue surveillance system implementation in southern Iran following autochthonous transmission

Abstract

Dengue fever, a re-emerging mosquito-borne viral disease, poses an escalating global health threat exacerbated by climate change and globalization. While Iran has historically reported only imported dengue cases, autochthonous transmission has been documented in southern provinces, particularly Hormozgan, following the first confirmed local transmission in 2024. Understanding stakeholders’ perspectives on the implementation of the national dengue surveillance system is therefore critical for informing evidence-based preparedness and policy-making. This retrospective qualitative study was conducted in Hormozgan Province between February and March 2025. Data were collected through semi-structured interviews and analyzed using directed content analysis guided by the CDC surveillance evaluation framework. Key surveillance attributes—including simplicity, data quality, acceptability, sensitivity, representativeness, and timeliness—were used as analytical categories to interpret participants’ perceptions of system performance. Nineteen participants—including senior and mid-level managers, public health experts, and provincial officials—were recruited through purposive sampling with maximum variation until data saturation was achieved. Data were analyzed using MAXQDA 2020, and trustworthiness was ensured based on Lincoln and Guba’s criteria. Five major themes emerged: (1) Simplicity of processes and system adaptability, (2) Data quality, integration, and acceptability challenges, (3) Early detection, clinical recognition, and diagnostic workflow limitations, (4) Comprehensive population coverage and rapid response, and (5) System sustainability and data utilization challenges. Participants identified reference laboratories and successful local initiatives as important strengths, alongside challenges such as parallel reporting systems, limited private-sector engagement, perceived false-negative rapid diagnostic test results during early-stage illness, incomplete migrant population coverage, and unstable digital infrastructure. The findings suggest that dengue surveillance in Iran is transitioning from a focus on imported cases to the management of local transmission. Participants highlighted challenges related to data integration, intersectoral coordination, and the coverage of vulnerable populations despite existing surveillance capacities. Strengthening surveillance integration, digital reporting systems, early diagnostic capacity, and cross-sector collaboration may improve timeliness, coverage, and overall preparedness.