Epidemiological Trends and Clinical Characteristics of Measles in Iraq (2023-2024): A Retrospective Cross-Sectional Study

doi:10.21203/rs.3.rs-5234424/v1

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Epidemiological Trends and Clinical Characteristics of Measles in Iraq (2023-2024): A Retrospective Cross-Sectional Study

https://doi.org/10.21203/rs.3.rs-5234424/v1

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Background: Measles remains a major public health challenge globally, especially in regions with low vaccination coverage. Iraq has experienced recurrent outbreaks in recent years, primarily due to inconsistent vaccination rates and a weakened healthcare system. Analyzing the epidemiological patterns and clinical features of measles in Iraq is essential for developing effective public health interventions.

Methods: This retrospective cross-sectional study examined measles cases reported from January 2023 to August 2024, using data from the national surveillance system. The analysis emphasized demographic and clinical information, specifically vaccination status, age distribution, and clinical symptoms. Statistical analyses were performed using SPSS version 25, incorporating descriptive statistics, logistic regression, and Chi-square tests.

Results: The measles incidence in Iraq increased significantly from 22.1 to 69.3 cases per-100,000 population. Notable rises in cases were observed among infants under 9 months (12% to 16.7%) and individuals over 15 years (6.4% to 12.1%). The percentage of cases with unknown vaccination status rose to 50.2%. Symptoms such as fever and rash were prevalent, exhibiting significant variations by age and vaccination status.

Conclusion: The resurgence of measles in Iraq from January 2023 to August 2024 highlights significant public health challenges, driven by socio-economic instability. The increase in cases, especially among under-immunized populations and infants, necessitates urgent action. Strengthening vaccination programs, enhancing public awareness, and improving healthcare access are essential. Additionally, better surveillance and record-keeping are crucial for effective outbreak management. Tailored public health strategies are needed to address geographic disparities in incidence, and further research on vaccine hesitancy is critical for developing robust catch-up vaccination campaigns.

Measles

epidemiology

vaccination

Iraq

outbreak

public health

clinical features

Measles, a highly contagious viral infection caused by the measles virus, which belongs to the Paramyxoviridae family, remains a significant public health challenge worldwide, despite the availability of an effective vaccine. The disease is transmitted through respiratory droplets and manifests with symptoms such as high fever, cough, coryza, conjunctivitis, and a characteristic maculopapular rash that begins on the face and spreads across the body [1]. Although measles has been largely controlled in regions with strong immunization programs, it remains a major concern in areas with inadequate vaccination coverage and weakened healthcare systems [2, 3].

Historically, measles was one of the leading causes of morbidity and mortality, particularly among children in low- and middle-income countries. Since the introduction of the measles vaccine in the 1960s, the global incidence of the disease has significantly declined, demonstrating the vaccine’s efficacy in controlling outbreaks [4, 5]. However, recent years have witnessed a resurgence of measles outbreaks, especially in regions with declining immunization rates. This resurgence is largely attributed to vaccine hesitancy, challenges in healthcare delivery, and the accumulation of susceptible individuals within unvaccinated populations [6].

In Iraq, measles remains a critical public health issue, with repeated outbreaks exacerbated by fluctuating vaccination coverage and challenges within the healthcare infrastructure [7]. Understanding the epidemiological trends and clinical characteristics of measles in Iraq is essential for developing effective public health interventions and enhancing national vaccination efforts.

Clinically, measles progresses through a prodromal phase characterized by fever, cough, coryza, and conjunctivitis, followed by a distinctive rash. Complications such as diarrhea, otitis media, pneumonia, and encephalitis can occur, particularly in malnourished children and individuals with weakened immune systems [8]. These complications significantly contribute to the morbidity and mortality associated with measles, especially in resource-limited settings.

The measles vaccine, typically administered as part of the measles-mumps-rubella (MMR) vaccine series, remains the cornerstone of measles prevention. The World Health Organization recommends two doses of the MMR vaccine for comprehensive protection against measles [9, 10]. However, global vaccination efforts have faced significant setbacks due to logistical barriers, conflicts, and vaccine hesitancy, leading to declines in coverage in several regions [11].

In Iraq, vaccination coverage has been inconsistent, influenced by socio-political instability and ongoing conflicts that have disrupted healthcare services and routine immunization programs. Addressing these challenges is crucial for achieving measles control and reducing the disease burden in the country [12].

The present study aims to investigate the epidemiological patterns and clinical features of measles in Iraq, with a focus on vaccination status and demographic factors influencing disease incidence. By examining these parameters, the study seeks to identify vulnerable populations, improve clinical recognition of measles, and contribute to the development of more effective public health strategies for prevention and control.

Study Design:

This study employs a retrospective cross-sectional design to assess the epidemiological patterns and clinical characteristics of measles cases in Iraq. This design was selected to allow for a comprehensive analysis of historical data over a defined period, facilitating the identification of trends and associations related to disease incidence and outcomes.

Study Setting and Period:

The study utilized data from the national surveillance system managed by the Respiratory Diseases Section of the Communicable Diseases Control Centre, Ministry of Health, Iraq. Data from January 2023 to August 2024 were included to provide a comprehensive overview of measles cases during this timeframe.

Data Source:

Data were extracted from the National Center for Communicable Diseases database, which consolidates primary data collected from all healthcare facilities across Iraq. This database is part of the national routine monitoring system for communicable diseases and contains detailed records of measles cases reported by these facilities.

Inclusion and Exclusion Criteria:

The study included all reported measles cases in Iraq from January 2023 to August 2024, provided they had complete demographic and clinical data available. Cases with incomplete records or those not confirmed as measles based on clinical or laboratory criteria were excluded.

Data Collection:

Data collection focused on key demographic variables, including age, sex, travel history, and residential address, as well as clinical characteristics such as the presence of fever, maculopapular rash, cough, coryza, conjunctivitis, lymphadenopathy, and vaccination status.

Variable Definitions for Measles Case Analysis in Iraq:

Age was categorized into distinct groups (e.g., < 1 year, 1–4 years, 5–9 years). Regional variations in disease incidence were inferred from residential addresses. Clinical features were recorded based on medical documentation, and vaccination status was categorized as under-age for vaccination (< 9 months), 0 doses, 1 dose, ≥ 2 doses, and Unknown.

Data Analysis:

Data analysis was conducted using SPSS version 25 for statistical evaluations, QGIS version 3.28.3 for visualization, and Excel for data management. Descriptive statistics summarized demographic and clinical characteristics, with frequency distributions for categorical variables. Logistic regression was employed to identify associations between confirmed measles cases and various risk factors, calculating odds ratios (OR) and 95% confidence intervals (CI). Chi-square tests compared categorical variables, while Student’s t-test assessed differences between two independent means, and ANOVA evaluated differences among three or more means, all at a 0.05 significance level.

The incidence of measles in Iraq increased significantly, rising from 22.1 cases per 100,000 population in 2023 to 69.3 in 2024, In contrast, rubella incidence slightly decreased from 0.25 to 0.03 cases per 100,000 population, as shown in Table 1 and Figs. 1 & 2. Gender distribution remained stable, with males accounting for 52% of cases in both years (p = 0.320).

Table 1: Annual Incidence Rates and Characteristics of Measles and Rubella (per 100,000 Population) in Iraq for 2023 and 2024

Variables		Years		P. Value
Variables		2023	2024	P. Value
	Total sample (44090)	12040 (27.7)	32050 (72.3)
	Iraq's incidence rate of Measles	22.1	69.3
	Iraq's incidence rate of Rubella	0.25	0.03
Gender: n (%)
	Male	6291(52)	16576 (52)	0.320*
	Female	5749 (48)	15474 (48)	0.320*
Age groups: n (%)
	< 9 Months	1445 (12)	5353 (16.7)	< 0.001
	9–11 Months	971 (8.1)	2486 (7.8)
	1–4 Years	4887 (40.6)	10829 (33.8)
	5–9 Years	2931 (24.3)	6342 (19.8)
	10–15 Years	1036 (8.6)	3156 (9.8)
	> 15 Years	770 (6.4)	3884 (12.1)
Vaccination status: n (%)
	Unknown	5111 (42.5)	16083 (50.2)	< 0.001
	Under age for vaccination (< 9 months)	1445 (12)	5353 (16.7)
	0 dose	3905 (32.4)	7685 (24)
	1 dose	480 (4)	1113 (3.5)
	≥ 2 doses	1099 (9.1)	1816 (5.7)
Type of cases: n (%)
	Laboratory confirmed Measles	1862 (15.5)	1807 (5.7)	< 0.001
	Laboratory confirmed Rubella	35 (0.3)	3 (0.01)
	Double Lab. confirmed (Measles & Rubella)	61 (0.5)	12 (0.04)
	Clinically compatible Measles	7285 (60.5)	26209 (81.8)
	Clinically compatible rubella	12 (0.1)	0 (0)
	Epidemiologically confirmed Measles	371 (3.1)	2770 (8.64)
	Discarded (negative)	2414 (20)	1249 (3.9)
*Significant difference between proportions using Pearson Chi-square test at 0.05 level

A notable shift occurred in age distribution, with a significant rise in cases among infants under 9 months (from 12–16.7%, p < .001) and individuals over 15 years (from 6.4–12.1%, p < .001). Meanwhile, the proportion of cases among children aged 1–4 years decreased from 40.6–33.8%. There was also a concerning increase in cases with unknown vaccination status, which rose from 42.5% in 2023 to 50.2% in 2024 (p < 0.001), alongside a decline in the proportion of fully vaccinated individuals.

The percentage of laboratory-confirmed measles cases significantly decreased from 15.5–5.7% (p < .001), while clinically compatible cases increased from 60.5–81.8%, suggesting a shift toward clinical diagnosis. Additionally, the decline in discarded cases (from 20–3.9%) indicates improved diagnostic accuracy.

The clinical characteristics of measles cases reveal variations across age groups, vaccination statuses, and case types. Fever and maculopapular rash were nearly universal, occurring in 99.7% and 99.4% of cases, respectively. Cough was reported in 87% of cases, coryza in 72.3%, conjunctivitis in 45.1%, and lymphadenopathy in 22.1%.

Significant age-specific variations were observed. While fever and rash remained consistently high, other symptoms such as cough and conjunctivitis varied. Cough was most prevalent in children aged 1–4 years (88.7%) and least common in those aged 5–9 years (85.3%). Lymphadenopathy was more frequently reported in older age groups, particularly among individuals over 15 years (26.6%). Vaccination status also influenced the prevalence of symptoms. Fever and rash were consistently high across all vaccination statuses, but cough was less common in vaccinated individuals. Differences in case types were also significant. Laboratory-confirmed measles cases exhibited higher rates of lymphadenopathy (30%) compared to clinically compatible cases (20.8%). Epidemiologically confirmed cases had higher rates of cough (89.9%) and conjunctivitis (63.1%) than discarded cases (73.2% and 35.9%, respectively). Laboratory-confirmed rubella and double-confirmed cases (measles and rubella) showed lower rates of cough and conjunctivitis; however, double-confirmed cases had a higher rate of conjunctivitis (58.9%). These findings are presented in Table 2.

Table 2

Distribution of Clinical Symptoms in Measles Cases by Age Group, Vaccination Status, and Case Classification.
Variables			Clinical characteristics of measles cases
		Total	Fever	Maculopapular rash	Cough	Coryza	Conjunctivitis	Lymphadenopathy
		Total	Yes (%)	Yes (%)	Yes (%)	Yes (%)	Yes (%)	Yes (%)
	Total sample (%)	44090	43962 (99.7)	43836 (99.4)	38347 (87)	31875 (72.3)	19868 (45.1)	9728 (22.1)
Age groups:
	< 9 Months	6798	6762 (99.5)	6740 (99.1)	6013 (88.5)	4990 (73.4)	2929 (43.1)	1309 (19.3)
	9–11 Months	3457	3448 (99.7)	3441 (99.5)	3098 (89.6)	2631 (76.1)	1590 (46)	667 (19.3)
	1–4 Years	15716	15680 (99.8)	15624 (99.4)	13947 (88.7)	11505 (73.2)	7180 (45.7)	3367 (21.4)
	5–9 Years	9273	9242 (99.7)	9225 (99.5)	7913 (85.3)	6624 (71.4)	4122 (44.5)	2143 (23.1)
	10–15 Years	4192	4187 (99.9)	4173 (99.5)	3464 (82.6)	2918 (69.6)	1813 (43.2)	1006 (24)
	> 15 Years	4654	4643 (99.8)	4633 (99.5)	3912 (84.1)	3207 (68.9)	2234 (48)	1236 (26.6)
	P-Value		< 0.001*	0.025	< 0.001	< 0.001	< 0.001	< .001
Vaccination status:
	Unknown	21194	21136 (99.7)	21076 (99.4)	18350 (86.6)	14872 (70.2)	9397 (44.3)	4391 (20.37
	Under age of vaccination (< 9 m.)	6798	6762 (99.5)	6740 (99.1)	6013 (88.5)	4990 (73.4)	2929 (43.1)	1309 (19.3)
	0 dose	11590	11570 (99.8)	11544 (99.6)	10349 (89.3)	8828 (76.2)	5525 (47.7)	2919 (25.2)
	1 dose	1593	1587 (99.6)	1581 (99.2)	1319 (82.8)	1157 (72.6)	716 (44.9)	395 (24.8)
	≥ 2 doses	2915	2907 (99.7)	2895 (99.3)	2316 (79.5)	2028 (69.6)	1301 (44.6)	714 (24.5)
	P-Value		< 0.001	0002	< 0.001	< 0.001	< 0.001	< .001
Type of cases:
	Lab. confirmed Measles	3669	3663 (99.8)	3652 (99.5)	3213 (87.6)	2774 (75.6)	1892 (51.6)	1113 (30.0)
	Lab. confirmed Rubella	38	38 (100)	38 (100)	24 (63.2)	23 (60.5)	13 (34.2)	13 (34.2)
	Double Lab. Confirmed (M & R) **	73	73 (100)	73 (100)	65 (89)	52 (71.2)	43 (58.9)	28 (38,4)
	Clinically compatible Measles	33494	33400 (99.7)	33294 (99.4)	29534 (88.2)	24135 (72.1)	14620 (43.6)	6953 (20.8)
	Clinically compatible rubella	12	12 (100)	12 (100)	7 (58.3)	8 (66.7)	3 (25)	2 (16.7)
	Epi. confirmed Measles	3141	3131 (99.7)	3129 (99.6)	2824 (89.9)	2604 (82.9)	1983 (63.1)	898 (28.6)
	Discarded (negative)	3663	3645 (99.5)	3638 (99.3)	2680 (73.2)	2279 (62.2)	1314 (35.9)	721 (19.7)
	P-Value		0.260	0.599	< 0.001	< 0.001	< 0.001	< .001
Significant difference between two independent means using Students t-test at 0.05 level or ANOVA test for difference among three independent means at 0.05 level, * Double Laboratory Confirmed (Measles & Rubella)

Significant associations exist between age, vaccination status, and clinical symptoms about the likelihood of measles (measles and rubella) cases. Infants under 9 months (OR = 1.355, 95% CI: 1.171–1.569) and those aged 9–11 months (OR = 1.257, 95% CI: 1.058–1.495) have notably higher odds of contracting measles than adults over 15 years. Conversely, children aged 5–15 exhibit significantly lower measles odds (p < 0.001). Vaccination status is crucial, as individuals who have not received doses have substantially higher odds (OR = 5.264, 95% CI: 4.767–5.814). Those with only one dose also remain at increased risk compared to individuals with two or more doses (p < 0.001). Among clinical symptoms, fever (AOR = 1.553), cough (AOR = 2.522), conjunctivitis (AOR = 1.311), and lymphadenopathy (AOR = 1.170) are all strongly associated with confirmed measles cases (p < 0.001). See Table 3 for further details.

Table 3

Multivariate Logistic Regression Analysis of Factors Associated with Confirmed Measles Cases
			Measles	Discarded	OR (95% CI) ^*	AOR (95% CI) ^**	P-value
			no. (%)	no. (%)
	Total: 44090		40427 (91.7)	3663 (8.3)
Age groups:
	< 9 Months		6393 (94)	405 (6)	1.355 (1.171–1.569)		< 0.001^***
	9–11 Months		3236 (93.6)	221 (6.4)	1.257 (1.058–1.495)		0.009
	1–4 Years		14551 (92.6)	1165 (7.4)	1.072 (0.949–1.212)		0.262
	5–9 Years		8228 (88.7)	1045 (11.3)	0.676 (0.597–0.766)		< 0.001
	10–15 Years		3733 (89.1)	459 (10.9)	0.698 (0.605–0.806)		< 0.001
	> 15 Years (ref.) ^****		4286 (92.1)	368 (7.9)
Vaccination status:
	Unknown		19850 (93.7)	1344 (6.3)	5.627 (4.941–6.407)		< 0.001
	Under age of vaccination		6393 (94)	405 (6)	4.408 (3.959–4.910)		< 0.001
	0 dose		10723 (92.5)	867 (7.5)	5.264 (4.767–5.814)		< 0.001
	1 dose		1312 (82.4)	281 (17.6)	1.664 (1.428–1.939)		< 0.001
	≥ 2 doses (ref.)		2149 (73.7)	766 (26.3)
Clinical characteristics:
	Fever	No	110 (85.9)	18 (14.1)			0.020
	Fever	Yes	40317 (91.7)	3645 (8.3)	1.81 (1.098–2.983)	1.553 (0.906–2.662)	0.020
	Maculopapular rash	No	229 (90.2)	25 (9.8)			0.375
	Maculopapular rash	Yes	40198 (91.7)	3638 (8.3)	1.206 (0.797–1.825)	0.850 (0.548–1.329)	0.375
	Cough	No	4760 (82.9)	983 (17.1)			< 0.001
	Cough	Yes	35667 (93)	2680 (7)	2.748 (2.539–2.975)	2.522 (2.296–2.770)	< 0.001
	Coryza	No	10831 (88.7)	1384 (11.3)			< 0.001
	Coryza	Yes	29596 (92.9)	2279 (7.1)	1.659 (1.547–1.780)	1.038 (0.951–1.133)	< 0.001
	Conjunctivitis	No	21873 (90.3)	2349 (9.7)			< 0.001
	Conjunctivitis	Yes	18554 (93.4)	1314 (6.6)	1.516 (1.413–1.627)	1.311 (1.211–1.419)	< 0.001
	Lymphadenopathy	No	31420 (91.4)	2942 (8.6)			< 0.001
	Lymphadenopathy	Yes	9007 (92.6)	721 (7.4)	1.170 (1.075–1.273)	1.170 1.075–1273)	< 0.001
^Odd Ratio (Confidence Intervale), ^* Adjusted Odd Ratio (Confidence Intervale), ^*Statistically Significant, ^**Reference,

The data indicate that the measles epidemic began in early 2023, with significant increases in both laboratory-confirmed and clinically compatible cases observed from the start of the year. Initially, sporadic cases were reported, but by the end of the first quarter, the incidence had risen markedly, peaking in the following months. The epidemic continued throughout the year, characterized by fluctuating case numbers, until it began to wane by international week 32 (W32) of 2024. During this period, the number of reported cases decreased substantially. See Fig. 3

Figure 4 illustrates the distribution of measles cases by age group and gender. Males generally exhibited higher case counts than females in the younger age groups (from < 9 months to 1–4 years). In the 5–9 years age group, case counts were nearly equal for both genders. However, in older age groups (10–15 years and over 15 years), females had higher case counts than males. This pattern indicates a gender-based variation in measles incidence across different age groups.

Figures 1 & 5 illustrate the distribution of measles cases across Iraqi governorates for 2023 and 2024. Most regions experienced significant increases in case numbers from 2023 to 2024, particularly in Baghdad, Babylon, and Wasit. In contrast, Sulaymaniyah and Dahuk saw substantial decreases in cases. Other governorates, such as Ninewa, Basrah, and Najaf Al-Ashraf, also exhibited varied changes. These findings highlight geographic disparities in the outbreak, indicating both regional surges and declines in measles cases over the two years.

The current study elucidates the epidemiological trends and clinical features of measles in Iraq during a critical resurgence period (January 2023–August 2024). Our analysis reveals a significant increase in measles incidence, accompanied by demographic and clinical pattern shifts that reflect both local challenges and broader global public health trends.

Measles Resurgence Amid Global Disruptions

The substantial rise in measles incidence in Iraq, from 22.1 to 69.3 cases per 100,000 population, mirrors global patterns observed in regions with compromised health systems, especially during and after conflicts or periods of socio-economic instability [13, 14]. Similar increases have been reported in conflict-affected areas like Syria and Yemen, where healthcare infrastructures have been severely affected, limiting the ability to sustain routine immunization programs [15, 16].

The resurgence of measles in Iraq may be attributed to several interconnected factors, including a decline in vaccination coverage, disruptions in healthcare services, and population displacement due to ongoing political and security challenges [17]. The gap in vaccine coverage is critical, as measles outbreaks often cluster in under-immunized populations [18]. Iraq’s suboptimal vaccination rates, particularly the decline in second-dose coverage, significantly increase the risk of widespread transmission. This aligns with findings from other studies emphasizing the need to maintain high coverage of both doses of the measles-containing vaccine (MCV) to prevent outbreaks [19].

Demographic and Immunological Shifts in Measles Cases

A key finding of this study is the changing demographic profile of measles cases. The increase in cases among infants under 9 months, rising from 12–16.7%, is particularly concerning, as these individuals are not yet eligible for routine vaccination. Infants typically rely on maternal antibodies for protection in their early months; however, waning maternal immunity in populations with high vaccine-derived immunity may leave this age group vulnerable [20, 21, 22]. This trend mirrors observations in other regions experiencing measles resurgence, where infants bear the brunt of outbreaks due to lower passive immunity transfer [23].

The concurrent rise in cases among older individuals (> 15 years) further underscores gaps in population immunity. This finding is consistent with global evidence showing that older children and young adults, who may have missed routine vaccinations or have waning immunity, are increasingly affected during outbreaks [24]. The data suggest a need for targeted catch-up vaccination campaigns aimed at adolescents and adults who may not have received full vaccination during childhood or whose immunity may have diminished over time [25].

Decline in Laboratory Confirmation: Implications for Surveillance

The decline in laboratory-confirmed measles cases, from 15.5–5.7%, coincided with a rise in clinically diagnosed cases. This change occurred as a result of the epidemic and aligns with guidelines issued by the Center for Disease Control in Iraq. According to these guidelines, if more than three cases are diagnosed in the same area within a month, any patient presenting with fever and rash is considered clinically infected, even without laboratory analysis [5]. As mentioned earlier, the reduction in discarded cases pertains to areas that have not recorded any laboratory-confirmed cases. In such areas, all cases that meet the standard definition of fever and skin rash are tested in the laboratory. These cases ultimately result in negative [26].

The Role of Vaccination Status and Public Health Interventions

One of the most concerning findings of this study is the increasing proportion of cases with unknown vaccination status (rising from 42.5–50.2%) and the decline in fully vaccinated individuals. These trends highlight systemic issues in Iraq’s health system, including poor record-keeping and inconsistent access to vaccination services, particularly in rural and conflict-affected areas [27]. The rise in unvaccinated or under-vaccinated individuals underscores the urgent need for improved vaccination tracking and outreach to underserved populations.

The observed low vaccination rates in this study cohort are consistent with other reports from the region, where challenges such as vaccine hesitancy, misinformation, and logistical barriers hinder vaccination efforts [28]. Research has shown that sustained high coverage with two doses of MMR vaccine is necessary to achieve the 95% coverage target recommended by the WHO to maintain herd immunity and prevent outbreaks [29, 30].

Geographical Variations in Outbreak Severity

Significant regional differences in measles incidence were noted, with the highest case numbers reported in Baghdad, Babylon, and Wasit. These governorates, which contain densely populated urban areas, may have experienced more intense outbreaks due to lower vaccination coverage and increased population movement, facilitating the rapid spread of the virus [27]. Conversely, regions like Sulaymaniyah and Dahuk, which reported fewer cases, may benefit from stronger local immunization programs and better healthcare access [31].

These geographic disparities emphasize the importance of tailored public health interventions that address local variations in healthcare access and vaccine coverage. Strengthening surveillance and immunization efforts in high-risk areas is critical for controlling the spread of measles and preventing future outbreaks [32, 33].

Study Limitations

This study has several limitations. Its retrospective design may introduce recall bias, particularly concerning vaccination status and symptom reporting, potentially resulting in incomplete or inaccurate data. The high proportion of cases with unknown vaccination status (50.2%) in Table 1 constrains the evaluation of vaccination's impact on disease incidence. Additionally, geographic variability in healthcare access affects the generalizability of the findings. The absence of longitudinal data also limits trend analysis and the assessment of public health interventions. Moreover, factors such as socioeconomic status and healthcare access were not thoroughly examined, which could influence measles incidence and its characteristics. These limitations underscore the need for further research to enhance our understanding of measles epidemiology in Iraq.

The resurgence of measles in Iraq from January 2023 to August 2024 highlights critical public health challenges exacerbated by conflict, socio-economic instability, and declining vaccination coverage. The significant increase in case incidence, particularly among under-immunized populations and vulnerable infants, underscores the urgent need for targeted interventions. Strengthening routine vaccination programs, enhancing public awareness, and improving healthcare access are essential to reversing these trends.

Moreover, the rise in cases with unknown vaccination status calls for improved surveillance and record-keeping to inform effective outbreak management. Geographic disparities in incidence further emphasize the need for tailored public health strategies that address local healthcare access and vaccination rates. As we move forward, further research into the underlying factors contributing to vaccine hesitancy and the development of robust catch-up vaccination campaigns will be critical in combating this resurgence and safeguarding public health in Iraq.

Ethical considerations

As this study is part of the Epidemiology and Communicable Diseases Control Sections of the Public Health Department and utilizes pre-existing data, it was not classified as primary data research, and ethical approval was therefore not required. However, approvals were obtained from the Iraq Research Committee at the National Center for Training and Human Development, Ministry of Health (MOH).

The human data:

The data received from Iraq's Ministry of Health (MOH) does not include the patient's name, pictures, or any other information that would violate the patient's rights.

requirement for informed consent was waived by the Ethics Committee of (the Research Committee in the National Center for Training and Human Development Iraq Ministry of Health (MOH)) because of the retrospective nature of the study.

Consent for Publication:

Not Applicable

Conflicts of interest

The authors declare that there are no conflicts of interest.

Funding

This research received no internal or external funding from any individual, organization, or academic institution.

Author Contribution

Mohammed A. Jalal: Writing – original draft, Methodology, Conceptualization, Data curation, formal analysis, and Project administration. Kamil M. Halboot: Writing –the original draft, Methodology, and Conceptualization. Sondos A. Lami: Writing – review & editing, Visualization, Supervision. Entidhar A. Gumar: Writing – review & editing. Mortada H. Kreeb al-Delphi: Writing – review & editing. Faris Lami: review & editing, Validation, Supervision, Methodology. Taqi Mohammed Jwad Taher: review & editing, Validation, Supervision, Methodology.

Acknowledgement

The authors wish to express their sincere gratitude to the Acute Respiratory Diseases officers at all sites for their dedication and efforts on the front lines of the Public Health Department in Iraq in providing this data

Data Availability

Declarations:1. Ethical considerationsAs this study is part of the Epidemiology and Communicable Diseases Control Sections of the Public Health Department and utilizes pre-existing data, it was not classified as primary data research, and ethical approval was therefore not required. However, approvals were obtained from the Iraq Research Committee at the National Center for Training and Human Development, Ministry of Health (MOH).2. The human data:The data received from Iraq's Ministry of Health (MOH) does not include the patient's name, pictures, or any other information that would violate the patient's rights.requirement for informed consent was waived by the Ethics Committee of (the Research Committee in the National Center for Training and Human Development Iraq Ministry of Health (MOH)) because of the retrospective nature of the study.3. Consent for Publication:Not Applicable4. Availability of data and materials: The raw data are not stored in a publicly accessible repository and are treated as confidential. However, they can be obtained from the corresponding author upon reasonable request.5. Funding This research received no internal or external funding from any individual, organization, or academic institution

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Figure 1. Annual Incidence Rates of Measles (per 100,000 Population) in Iraq (2023–2024).
Figure 2. Geographic Distribution of Incidence rate of Measles Outbreaks in Iraq's Governorates (2023–2024).
Figure 3. Epidemiological Trends in Measles Cases: Laboratory-confirmed, Clinically Compatible, and Epidemiologically Confirmed Cases from 2023 to 2024.
Figure 4. Distribution of Measles Cases by Age Group and Gender.
Figure 5. Percentage of the measles outbreak by governorates in Iraq in 2023 and 2024.
Table 1. Annual Incidence Rates and Characteristics of Measles and Rubella (per 100,000 Population) in Iraq for 2023 and 2024.

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Epidemiological Trends and Clinical Characteristics of Measles in Iraq (2023-2024): A Retrospective Cross-Sectional Study

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