Validation of the Early Warning and Response System (EWARS) for dengue outbreaks: Evidence from the national vector control program in Mexico

Background: During 2017, twenty health districts (locations) implemented a dengue outbreak Early Warning and Response System (EWARS) in Mexico, which processes epidemiological, meteorological and entomological alarm indicators to predict dengue outbreaks and triggers early response activities. Methods: Five indicators of dengue outbreak response (larval control, entomological studies with water container interventions, focal spraying and indoor residual spraying) were quantitatively analyzed across two groups (”outbreak districts” and “non-outbreak districts”). However, for quality control purposes, only qualitative concluding remarks were derived from the fifth response indicator (fogging). Results: The average coverage of vector control responses was significantly higher in non-outbreak districts and across all four indicators. In the “outbreak districts” the response activities started late and were of much lower intensity compared to “non-outbreak districts”. Vector control teams at districts-level demonstrated diverse levels of compliance with local guidelines for ‘initial’, ‘early’ and ‘late’ responses to outbreak alarms, which could potentially explain the different outcomes observed following the outbreak alarms. Conclusion: Failing timely and adequate response of alarm signals generated by EWARS showed to negatively impact the disease outbreak control process. On the other hand, districts with adequate and timely response guided by alarm signals demonstrated successful records of outbreak prevention. This study presents important operational scenarios when failing or successding EWARS but warrants investigating the effectiveness and cost-effectiveness of EWARS using a more robust designs. Author summary: While the Early Warning and Response System (EWARS) for dengue and other vector-borne diseases has significantly advanced in methodologies and applications in more recent time, evidence from the field on the implications of EWARS in the context of vector control and response is still rare. Assessing the effectiveness (and cost) of EWARS in reducing or mitigating disease outbreaks entails complex study designs, including randomized controlled trials. This study employs a pragmatic validation design; comparing groups of outbreak and non-outbreak districts from the Mexican national vector control and response program for dengue, all districts with implemented EWARS and generated alerts. The study authors have illustrated and discussed important operational implications when failing or succeeding timely and adequate response to EWARS alerts, revealing that responding to EWARS alerts in time and space, during or beyond the routine vector control and response process can significantly reduce unnecessary outbreaks and hospitalizations.