Abstract
ObjectiveThis analysis examines governorate-level disease incidence as well as the relationship between incidence and the number of persons of concern for three vaccine-preventable diseases—measles, mumps, and rubella—between 2001 and 2016.MethodsUsing Iraqi Ministry of Health and United Nations High Commissioner for Refugees (UNHCR) data, we performed descriptive analyses of disease incidence and conducted a pooled statistical analysis with a linear mixed effects regression model to examine the role of vaccine coverage and migration of persons of concern on subnational disease incidence.ResultsWe found large variability in governorate-level incidence, particularly for measles (on the order of 100x). We identified decreases in incident measles cases per 100,000 persons for each additional percent vaccinated (0.82, 95% CI: [0.64, 1.00], p-value < 0.001) and for every additional 10,000 persons of concern when incorporating displacement into our model (0.26, 95% CI: [0.22, 0.30], p-value < 0.001). These relationships were insignificant for mumps and rubella.ConclusionsNational level summary statistics do not adequately capture the high geospatial disparity in disease incidence between 2001 and 2016. This variability is complicated by MMR vaccine coverage and the migration of “persons of concern” (refugees) during conflict. We found that even when vaccine coverage was constant, measles incidence was higher in locations with more displaced persons, suggesting conflict fueled the epidemic in ways that vaccine coverage could not control.
Highlights
Throughout the 1970s and 1980s, the health system in Iraq was well-regarded in the region and able to meet the health needs of Iraqis [1]
We examine a time series of subnational Iraq disease incidence for measles, mumps, and rubella, from 2001 to 2016
The primary dataset for this analysis comes from the Iraqi Ministry of Health (MoH)
Summary
Throughout the 1970s and 1980s, the health system in Iraq was well-regarded in the region and able to meet the health needs of Iraqis [1]. The United States-led invasion of Iraq began on March 20, 2003, peaked in 2006, and was followed by a formal occupation through the year 2011 [2]. In the years following the formal end of the U.S occupation, armed conflict continued. The extremist group, Islamic State (ISIS), carried out attacks beginning in 2011 but became a serious problem in 2014 when it launched larger attacks on Iraqi cities like Mosul and Tikrit, expanding territory under its control [3]. Throughout the three years, civil unrest ensued, ISIS lost control of 95% of its territory by the end of 2017 [3]
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