Low Disease Burden in One Saudi Region Reveals Gaps in National Premarital Screening Data

A retrospective analysis of mandatory premarital screening records from Dawadmi General Hospital in Saudi Arabia has found strikingly low prevalence of the conditions the national program targets: hemoglobinopathies such as sickle cell disease and thalassemia, along with hepatitis B and hepatitis C. Among 2,370 individuals screened between January 2022 and December 2023, the prevalence of any hemoglobinopathy was 0.18% in 2022 and 0.33% in 2023, while hepatitis B virus infection remained below 1% in both years and hepatitis C was detected in just one person across the entire period. The study, published in Discover Public Health, argues that such regional figures reveal subnational epidemiological heterogeneity that aggregated national statistics can obscure.

Saudi Arabia launched its mandatory premarital screening program nearly two decades ago, making certification a legal prerequisite for marriage registration. The program screens for sickle cell disease, thalassemia, hepatitis B virus, and hepatitis C virus, and offers genetic counseling to carriers or affected individuals. Because screening is compulsory and the Genetic Center at Dawadmi General Hospital is the sole public facility providing these services in the region, the study population captures virtually all individuals seeking to marry in Dawadmi during the two-year window, providing what the researchers describe as a near-complete regional denominator.

The analysis included all individuals aged 18 to 40 who underwent screening at the center between 1 January 2022 and 31 December 2023, excluding anyone tested for other reasons. Screening volume rose slightly from 1,140 individuals in 2022 to 1,230 in 2023. More females were screened in both years, though the male proportion increased slightly in 2023. Males were generally older, a pattern the authors attribute to gender differences in age at marriage. Ages ranged from 18 to 40, with a mean of 27.2 years and a standard deviation of 4.8.

Hemoglobinopathy screening followed a two-stage protocol consistent with national Saudi Arabian guidelines. Initial testing used a complete blood count measuring hemoglobin concentration, mean corpuscular volume, and mean corpuscular hemoglobin. Individuals with abnormal indices suggestive of a hemoglobinopathy, or with a documented relevant family history, underwent confirmatory testing by high-performance liquid chromatography or capillary electrophoresis. Diagnoses were classified as sickle cell disease, thalassemia, or no detected abnormality according to established national criteria. Most detected cases were sickle cell disease, while thalassemia was rare, with only one case identified over the two years.

Infectious disease screening identified hepatitis B infection through detection of hepatitis B surface antigen and assessed hepatitis C exposure through anti-HCV antibody testing, with all assays performed using validated immunoassay techniques in the hospital’s accredited central laboratory. Hepatitis B prevalence was 0.53% in 2022, with a 95% confidence interval of 0.19% to 1.15%, and 0.57% in 2023, with a confidence interval of 0.23% to 1.17%. Hepatitis C infection was found in a single individual in 2022 and in none in 2023. Over the two years, hepatitis B prevalence was slightly higher in males than in females, but the authors caution that the small number of positive cases produced wide confidence intervals that prevent definitive sex-based conclusions.

The confidence intervals around these estimates are notably wide, a direct consequence of the very small number of detected cases. The 95% confidence interval for any hemoglobinopathy spanned 0.02% to 0.65% in 2022 and 0.09% to 0.85% in 2023. The authors emphasize that this imprecision limits the interpretation of differences between the two study years and between demographic groups. Comparisons between the 2022 and 2023 cohorts did not demonstrate clear differences in the prevalence of any screened condition, and the researchers explicitly warn that the apparent similarity between years should not be read as evidence of epidemiological stability over time.

Placed alongside estimates from other Saudi regions, the Dawadmi figures sit at the lower end of the reported epidemiological range. National surveillance data and regional studies, particularly from the Eastern and Southern provinces where hemoglobinopathy burdens have historically been higher, indicate changing epidemiological patterns that are often interpreted as signs of program success. The authors argue instead that prevalence data from mandatory screening should be treated as epidemiological outputs rather than direct measures of prevention success. Previous Saudi research has documented a persistent gap between screening results and reproductive actions, with many high-risk couples marrying despite counseling, an effectiveness gap that cautions against equating low prevalence or high screening coverage with real population impact.

The study is careful about what its data cannot show. Consanguinity status was not systematically recorded in the registry and therefore could not be examined as an explanatory variable, even though previous Saudi studies have documented substantial regional variation in consanguinity that may contribute to differences in the distribution of inherited disorders. Direct measures of genetic ancestry, migration history, and subsequent marital decision-making were also unavailable. The authors state that the findings should be regarded as hypothesis-generating rather than as evidence that any specific demographic or social factor accounts for the lower prevalence observed in Dawadmi, and they note that comparisons with other regions are further complicated by differences in study populations, periods, sampling characteristics, and outcome definitions.

The retrospective, single-centre design limits generalisability beyond the Dawadmi region, and the two-year window precludes assessment of long-term trends. Reliance on routinely collected registry data may introduce incomplete recording or misclassification, although the use of established screening protocols and accredited laboratory procedures supports the validity of the reported outcomes. Family history, counseling outcomes, and subsequent marital decisions were not systematically available, which the authors identify as a major limitation that precludes direct evaluation of the program’s effectiveness. A low prevalence of screened conditions among people attending mandatory screening does not, by itself, demonstrate that screening has reduced risky marriages, altered reproductive decision-making, or prevented transmission of genetic or infectious disease.

The researchers propose that premarital screening surveillance be strengthened beyond reporting prevalence alone, by linking routine screening results with information on consanguinity, family history, counseling processes, and subsequent reproductive or marital decisions. Such integrated surveillance, they argue, would help determine whether observed subnational differences are associated with demographic, genetic, social, or healthcare-related factors that were not directly measured here, and would be particularly valuable in low-prevalence settings where small case numbers make prevalence estimates imprecise and apparent regional differences sensitive to variation in underlying population composition. Longer-term, multi-regional surveillance incorporating relevant demographic and social variables, the study concludes, is needed to distinguish persistent subnational heterogeneity from short-term variation and to evaluate the downstream public health impact of the screening program.

Subject of Research: Regional variation in mandatory premarital screening outcomes for hemoglobinopathies and viral hepatitis in Saudi Arabia

Article Title: Subnational epidemiological variation in mandatory premarital screening outcomes in Saudi Arabia

Article References: Mohamed, N., Mustafa, W., Alotaibi, M., Alotaibi, A., Alotaibi, B., Alhusayni, Y., Al-Ayfan, N., Alruwais, F., Alotaibi, A. N., Alotaibi, A., Ali, A., Alotaibi, N., Alotaibi, A. A., Hakmi, I., Albaiz, A., Alzahrani, S., Salamah, M., Mohammed, M., Elbadawi, F., & Ibrahim, E. (2026). Subnational epidemiological variation in mandatory premarital screening outcomes in Saudi Arabia. Discover Public Health, 23(1), Article 1730. https://doi.org/10.1186/s12982-026-03101-8

Image Credits: AI Generated

DOI: 10.1186/s12982-026-03101-8

Keywords: premarital screening, Saudi Arabia, sickle cell disease, thalassemia, hepatitis B, hepatitis C, hemoglobinopathies, epidemiology, public health surveillance, consanguinity, Dawadmi, registry data