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Vaccination Services in Postwar Iraq, May 2003

In the aftermath of the war in Iraq, widespread looting and intentional damage to government facilities resulted in the interruption of public services and utilities. Basic communications were disrupted nationally. Public health headquarters, clinics, and laboratories were damaged, records were ruined, and equipment was stolen. Because travel often was difficult and dangerous, Coalition forces received numerous requests from hospital directors for armed security, and many health-care workers reportedly feared either to commute to their worksites or to remain after dark (D. Simpson, M.D., Coalition Provisional Authority [CPA]'s Ministry of Health Team, personal correspondence, 2003). Public health employees who were able to continue their work went unpaid for several weeks. As a result, throughout Iraq, core public health services (e.g., vaccination services, vectorborne disease control, and the Tuberculosis Directly Observed Therapy program) were disrupted. In addition, severe health hazards caused by damaged water and sanitation systems were added to an already compromised and deteriorating health-care system (1,2). This report assesses the cumulative impact of these conditions on vaccination services in postwar Iraq, including the subsequent loss of staff, facilities, and equipment. Because vaccinations in Iraq are available only through the national system of primary health-care centers (PHCCs), this assessment can help address comparable problems experienced by other programs offered through Iraq's PHCCs, guide subsequent emergency responses to vaccine shortages, and provide a preliminary gauge of the status of preventive health-care infrastructure and services to children in Iraq.

By late March 2003, public health officials thought that routine childhood vaccinations were unavailable at the majority of public health clinics. In mid-May, with assistance from CPA and the United Nations Children's Fund (UNICEF), the Iraqi Ministry of Health (IMoH) sent teams to assess the damage that hampered the efforts of the Expanded Program on Immunization (EPI). During May 17--22, six teams traveled to all of Iraq's 18 governorates and visited major vaccine-storage sites and some primary health-care centers. Each team visited three to four governorates and used a standard form to collect information on clinic staff availability, remaining vaccine supplies at the major storage sites, and the status of cold-chain equipment. Karkh and Rusafa, the two districts comprising the governorate of Baghdad, were assessed separately because of the size of their populations and the number of public health facilities (Table).

At the time of the survey, 893 (61%) PHCCs in Iraq had equipment and staff sufficient to provide vaccinations daily. On the basis of the amount of equipment known to have existed immediately before the war, the assessment found that 532 (33%) of the 1,628 refrigerators, 18 (46%) of the 39 cold rooms, and 81 (13%) of the 642 generators needed to provide electricity to some equipment were damaged. Four of the 18 governorates maintained >80% of their prewar cold-chain equipment. The overall loss for the entire Baghdad governorate was 24%, with the Karkh district losing substantially less equipment (12%) than Rusafa (40%). Total vaccine stocks* were assessed at the major storage sites but not at the clinic level. Only Sulaimaniyah had BCG vaccine, and stocks of HBV were low in all governorates except Najaf. However, tens of thousands of doses of both OPV and DTP vaccine were counted in all but five governorates. Although rabies is endemic in Iraq, stocks of rabies immunoglobulin were reported in only three governorates. Nine (50%) of the governorates had stocks of hepatitis B immunoglobulin. The presence of working cold-chain equipment was recorded, but levels of vaccine maintained constantly under proper environmental conditions at the surveyed sites were not determined.

Reported by: SA Ni'ma, MB CHB-MSC, AAK Imad, MB CHB-MSC, AAM Faiza, DTMH, Iraqi Ministry of Health; DM Simpson, MD, RL Mott, MD, B Kirkup, BM BCh, Ministry of Health Team, Coalition Provisional Authority, Baghdad, Iraq.

Editorial Note:

This assessment found that the Iraqi vaccination program had lost necessary cold-chain equipment throughout the country and that the supply of properly maintained vaccine and immunoglobulin had been disrupted. Despite the brief duration of the war in Iraq and the intent to spare hospitals and clinics from direct attack, resulting disruptions in civil order and public services affected public health programs severely. Of urgent concern to public health officials were the temporary disruption of routine childhood vaccination activities and the lack of potable water. Vaccination services were especially susceptible to disruption because the effectiveness of the vaccination program depended on continuous provision of services in all parts of the country, easy accessibility by vulnerable women and children, and working cold-chain equipment. Before the war, EPI typically provided approximately 750,000 doses of routine vaccines monthly to children aged <12 months and 123,000 doses monthly to children aged >12 months (IMoH, unpublished data, 2003).

Results of this survey are being used to revise distribution methods until damaged or looted cold-chain equipment can be replaced. Vaccines at central sites are being packaged into cold boxes and transported to clinics without refrigerators so vaccines will be available at least a few times each week in each PHCC. However, the provision of vaccines, medicines, supplies, and equipment is not alone sufficient to restore public health services interrupted in the aftermath of the war. A safe and secure work environment, a fair and reliable salary for public health staff, and accessible transportation also should be re-established.

CPA and IMoH, with the assistance of the Coalition forces, UNICEF, the World Health Organization, and many nongovernment organizations, are working to ensure security, rehabilitate clinics and laboratories, and restore public health programs. Early results of these combined efforts include 1) an increasing number of adequately chlorinated public water supplies, 2) a rapid assessment of the nutritional status of young children in Baghdad, and 3) the distribution of routine childhood vaccines throughout Iraq by the third week of June.

Despite these gains and the re-establishment of many services, substantial work remains for the Iraqi public health system to prevent resurgence of endemic diseases (e.g., visceral leishmaniasis, typhoid fever, and cholera) and the emergence of drug-resistant TB and malaria. The efforts of public health workers and the continued support of partner organizations will be critical to meeting these concerns in the coming months.


  1. Frankish H. Health of the Iraqi people hangs in the balance. Lancet 2003;361:623--5.
  2. Ali MM, Shah IH. Sanctions and childhood mortality in Iraq. Lancet 2000;355:1851--7.

* Vaccine stocks assessed included Bacillus Calmette-Guérin (BCG) (tuberculosis [TB] vaccine); diphtheria and tetanus toxoids and pertussis (DTP) vaccine; oral polio vaccine (OPV); hepatitis B (HepB) vaccine (pediatric and adult); measles-containing vaccine; measles, mumps, and rubella (MMR) vaccine; diphtheria and tetanus toxoid vaccine; tetanus toxoid vaccine; and rabies vaccine. Antisera stocks also were assessed.

Routine vaccination schedules in Iraq include BCG (TB vaccine) at birth; DTP vaccine at age 2, 4, 6, and 18 months, and 4--6 years; OPV at birth, age 2, 4, 6, and 18 months, and 4--6 years; HepB vaccine at birth and age 2 and 6 months; measles-containing vaccine at age 9 months; and MMR vaccine at age 15 months and at school entry.


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