Association Between Subnational Vaccine Coverage, Migration, and Incident Cases of Measles, Mumps, and Rubella in Iraq, 2001-2016

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.

Automated summary

This analysis explores the incidence of measles, mumps, and rubella at the governorate-level in Iraq between 2001 and 2016, and investigates the relationship between incidence and the number of persons of concern. The study reveals significant variability in disease incidence among different governorates, with vaccination coverage and migration of persons of concern playing a role in measles incidence. However, these factors do not show a significant influence on mumps and rubella incidence.