PostScript
Letter
Epidemiology of varicella in
Iraq, 2012–2016
Although varicella is a vaccine-preventable
disease, vaccination policy varies widely
between countries and, sometimes, in the
same country based on the epidemiology
of varicella.1 2 The WHO’s advice is that
varicella vaccination should be started in
countries where varicella is a relatively
important public health and socioeco-
nomic problem; the vaccine is affordable;
and high (85%–90%) and sustained
vaccine coverage can be achieved.3
When developed countries introduced
varicella vaccine in their immunisation
programmes, the annual incidence of vari-
cella was already less than 16/100 000 popu-
lation.4 In addition, the vaccine strategy
Figure 1  Comparison of the median and
interquartile range of incidence of varicella in
Iraq in 2016 with incidence of varicella in years
2012–2015.
Figure 2  Incidence of varicella in Iraq,
2012–2016.
composed of a gradual increase in vaccine
coverage rate from <30% to >80% over a
9-year period, resulted in a significant reduc-
tion in varicella incidence, hospitalisations
and mortality without shifting in the age
at infection.1 4 In the Middle East, varicella
vaccine is included in school immunisation
programmes in Saudi Arabia, Lebanon,
Qatar and UAE. Not enough studies of the
long-term and short-term effect of varicella
vaccine in the aforementioned countries are
yet available.
A prior analysis of surveillance data in
2012 showed that Iraq was an endemic
country for varicella; 88% of varicella cases
were younger than 15 years old, the disease
is usually mild and almost all of the immu-
nocompetent patients recover with no
complications.3
The aim of the current study is to build
on the prior study of varicella epidemiology
in Iraq to determine whether the epidemi-
ology has changed so that varicella vaccine
can be introduced into the immunisation
programme. We used the same data source as
before3 to analyse varicella data from 2012
to 2016. Results from the current analysis
show that varicella is still an endemic disease
in Iraq. The median and the 25th percen-
tile of varicella incidence during 2012–
2016 are higher than their values reported
throughout 2007–2012, which may be due
to using new electronic surveillance forms
for data collection (figure 1). The new elec-
tronic surveillance made data entry easier
for surveillance focal points given that they
are responsible for data collection for other
health programmes as well. Moreover, the
peak rise in varicella incidence that occurred
in 2014 coincided with the internal displace-
ment of people from conflict areas to camps
where living conditions were not optimum
to ensure control of disease transmission. No
changes in the age, gender and geographic
distribution (figure 2) of varicella were
detected, indicating that the majority of chil-
dren will be immune due to natural infection
by the time they reach adulthood.3
In Iraq, the current surveillance for
varicella is lacking information regarding
complications, hospitalisations and deaths.
Arch Dis Child Month 2018 Vol 0 No 0
Moreover, mortality data may not be accu-
Arch Dis Child: first published as 10.1136/archdischild-2018-315048 on 21 June 2018. Downloaded from http://adc.bmj.com/ on 21 June 2018 by guest. Protected by copyright.
rate, that is, deaths due to varicella may be
reported as deaths due to any of the compli-
cations of varicella, such as pneumonia or
viral encephalitis. Therefore, there is a need
to strengthen the surveillance programme of
varicella in Iraq, which can be achieved by
upgrading the reporting system of hospitals
and primary healthcare centres to electronic
database.
Hanan Abdulghafoor Khaleel,
Adnan Nawar Khistawi
Surveillance Section, Communicable Diseases Control
Center, Ministry of Health, Baghdad, Iraq
Correspondence to Dr Hanan Abdulghafoor Khaleel,
Surveillance Section, Communicable Diseases Control
Center, Ministry of Health, Baghdad 55555, Iraq;
​hanan_​azawy2000@​yahoo.​com
Acknowledgements  We would like thank all those
who work in the counterpart surveillance units for their
cooperation.
Contributors  HAK performed the data analysis and
writing of the manuscript. ANK performed the data
collection and review of the manuscript.
Competing interests  None declared.
Patient consent  Not required.
Provenance and peer review  Not commissioned;
externally peer reviewed.
© Article author(s) (or their employer(s) unless
otherwise stated in the text of the article) 2018. All
rights reserved. No commercial use is permitted unless
otherwise expressly granted.
To cite Khaleel HA, Khistawi AN. Arch Dis Child Epub
ahead of print: [please include Day Month Year].
doi:10.1136/archdischild-2018-315048
Accepted 29 May 2018
Arch Dis Child 2018;0:1.
doi:10.1136/archdischild-2018-315048
References
1 European Centre for Disease Prevention and Control. ECDC
Guidance - Varicella Vaccination in the European Union,
2015.
2. Wu PY, Wu HD, Chou TC, et al. Varicella vaccination
alters the chronological trends of herpes zoster and
varicella. PLoS One 2013;8:e77709.
3 Khaleel HA, Abdelhussein HM. Clinical epidemiology of
chickenpox in Iraq from 2007-2011. Glob J Health Sci
2012;5:180-6.
4 Papaloukas O, Giannouli G, Papaevangelou V. Successes
and challenges in varicella vaccine. Ther Adv Vaccines
2014;2:39–55.
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