Annual cost savings of US$70 million with similar outcomes: vaccine procurement experience from Iraq

Introduction Iraq is classified as an upper-middle-income country with 2019 gross national income per capita of US$5740.1 The poverty rate increased from 19% to 23% between 2012 and 2014 and exceeds 70% in some Southern districts.2 Iraq has had a dramatic population increase in the past decades; the population totalled seven million in 1960 and was 41 million in 2021.3 The Expanded Programme on Immunisation was launched in Iraq in 1985, aiming to protect children against tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus and measles, and their mothers against tetanus for prevention of neonatal tetanus.4 Measles-mumps-rubella combined (MMR) vaccine was introduced in 1988, hepatitis B vaccine in 1994, Haemophilus influenzae type b (Hib) and rotavirus vaccines in 2012, inactivated polio vaccine (IPV) in 2016 and 13-valent Pneumococcal Conjugate vaccine (PCV13) in 2017.4 In early 2019, the Ministry of Health convened a series of meetings to review the National Immunisation Programme in collaboration with WHO and Unicef.5 The objective was to strengthen the efficiency of the programme and improve immunisation coverage. IPV introduction In October 2015, the WHO Strategic Advisory Group of Experts on Immunisation recommended that all countries should introduce at least one dose of IPV into their routine immunisation schedule.6 This was part of the Polio Eradication and Endgame Strategic Plan 2013–2018, which included global withdrawal of the type 2 component of oral polio vaccine (OPV).7 The primary purpose of the IPV dose is to induce an immunity base that can be rapidly boosted should there be an outbreak of poliovirus type 2 after the removal of type 2 virus from OPV.6 At that time, the Ministry of Health leadership in Iraq decided to revise the immunisation schedule to include five doses of IPV as part of combined vaccines, which all contained acellular pertussis (aP). The NITAG considered the WHO pertussis and polio position papers.6 11 The 2015 WHO pertussis position paper concluded that while the licensed aP and whole-cell pertussis (wP) vaccines have equivalent initial effectiveness in preventing disease in the first year of life, there is more rapid waning of immunity, and possibly a reduced impact on transmission, with aP relative to wP vaccines.11 Hence, the use of aP vaccines may result in a resurgence of pertussis after several years, which could lead to an increased risk of death in those too young to be vaccinated.11 For polio-endemic coun