{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T18:10:03Z","timestamp":1790791803036,"version":"4.1.0"},"reference-count":29,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2022,1,20]],"date-time":"2022-01-20T00:00:00Z","timestamp":1642636800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec><jats:title>Objective<\/jats:title><jats:p>This 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\u2014measles, mumps, and rubella\u2014between 2001 and 2016.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Using 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.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>We 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], <jats:italic>p<\/jats:italic>-value &amp;lt; 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], <jats:italic>p<\/jats:italic>-value &amp;lt; 0.001). These relationships were insignificant for mumps and rubella.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>National 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 \u201cpersons of concern\u201d (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.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fpubh.2021.689458","type":"journal-article","created":{"date-parts":[[2022,1,20]],"date-time":"2022-01-20T04:46:15Z","timestamp":1642653975000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":7,"title":["Association Between Subnational Vaccine Coverage, Migration, and Incident Cases of Measles, Mumps, and Rubella in Iraq, 2001\u20132016"],"prefix":"10.3389","volume":"9","author":[{"given":"Haley","family":"Comfort","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Riyadh K.","family":"Lafta","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abraham D.","family":"Flaxman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amy","family":"Hagopian","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Herbert C.","family":"Duber","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2022,1,20]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"939","DOI":"10.1016\/S0140-6736(13)60320-7","article-title":"Health services in Iraq","volume":"381","author":"Al Hilfi","year":"2003","journal-title":"Lancet"},{"key":"B2","unstructured":"BeauchampZ\n            FisherM\n            MatthewsD\n          27 Maps That Explain the Crisis in Iraq2014"},{"key":"B3","unstructured":"Timeline: The Rise, Spread, and Fall of the Islamic State2019"},{"key":"B4","unstructured":"Immunization Supply Chain and Logistics"},{"key":"B5","unstructured":"Routine Immunization of Children Re-Established Across Iraq2003"},{"key":"B6","doi-asserted-by":"publisher","first-page":"1454","DOI":"10.1080\/21645515.2019.1688043","article-title":"Armed conflict, a neglected determinant of childhood vaccination: some children are left behind","volume":"16","author":"Ngo","year":"2020","journal-title":"Hum Vacc Immunother"},{"key":"B7","unstructured":"Substantial Decline in Global Measles Death, But Disease Still Kills 90,000 Per Year2017"},{"key":"B8","unstructured":"Two Thirds of Unimmunized Children Live in Conflict-Affected Countries2016"},{"key":"B9","doi-asserted-by":"publisher","first-page":"9","DOI":"10.1186\/s13031-018-0152-2","article-title":"Review of attacks on health care facilities in six conflicts of the past three decades","volume":"12","author":"Briody","year":"2018","journal-title":"Conflict Health."},{"key":"B10","unstructured":"Vaccination Services in Postwar Iraq, May 20032003"},{"key":"B11","unstructured":"IRC Launches Immunization Campaign in Iraq2003"},{"key":"B12","unstructured":"Iraq's Children 2007"},{"key":"B13","unstructured":"National Immunization Plan of Iraq for 20152014"},{"key":"B14","doi-asserted-by":"publisher","first-page":"102","DOI":"10.1016\/j.ijid.2019.09.018","article-title":"The epidemiology of 32 selected communicable diseases in Iraq, 2004-2006","volume":"89","author":"Zhao","year":"2019","journal-title":"Int J Infect Dis."},{"key":"B15","doi-asserted-by":"publisher","first-page":"130","DOI":"10.11604\/pamj.2018.31.130.16394","article-title":"and Hussain A. 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