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Insulin crisis in Iraq

Authors:
Correspondence
1860
www.thelancet.com Vol 369 June 2, 2007
1 Schrauder A, Henke-Gendo C, Seidemann K,
et al. Varicella vaccination in a child with acute
lymphoblastic leukaemia. Lancet 2007; 369:
1232.
2 Campsall PA, Au NHC, Prendiville JS, Speert DP,
Tang R, Thomas EE. Detection and genotyping
of varicella-zoster virus by Taq-Man allelic
discrimination Real-time PCR. J Clin Microbiol
2004; 42: 1409–13.
3 Parker SP, Quinlivan M, Taha Y, Breuer J.
Genotyping of varicella-zoster virus and the
discrimination of Oka vaccine strains by Taq-Man
real time PCR. J Clin Microbiol; 2006: 44: 3911–14.
4 Takayama M, Takayama N. New method of
diff erentiating wild-type varicella-zoster virus
(VZV) strains from Oka varicella vaccine strain
by VZV ORF 6-based PCR and restriction
fragment length polymorphism analysis.
J Clin Virol 2004; 29: 113–19.
5 Espy MJ, Uhl JR, Sloan LM, et al. Real-time PCR
in clinical microbiology: applications for
routine laboratory testing. Clin Microbiol Rev
2006; 19: 165–256.
available insulin last until the end
of the crisis; 149 (25%) were using
insulin that had expired in December,
2006; 58 (10%) had changed to
oral glucose-lowering drugs; and 91
(15%) were taking insulin imported
from neighbouring countries with no
quality controls.
This problem is going to get worse
in the next few months when the
environ mental temperature increases
to 50ºC and the storage and transport
of insulin becomes more diffi cult. In
fact, the situation in Basrah is quite
stable; we cannot image the situation
in Baghdad and in areas where
there has been extensive migration
between cities.
Diabetes care in Iraq needs the
help of local Middle Eastern and UN
agencies. The insulin might be in the
country, but the distribution of the
drug between cities needs safety,
which is far from being achieved.
We declare that we have no confl ict of interest.
*Abbas Ali Mansour,
Hameed Laftah Wanoose
aambaam@yahoo.com
Basrah College of Medicine, Basrah, Iraq
1 Khoshnaw AI. The diabetic foot in Iraq.
Lancet 2005; 366: 1718.
2 Mansour AA, Al-Jazairi MI. Cut-off values for
anthropometric variables that confer
increased risk of type 2 diabetes mellitus and
hypertension in Iraq. Arch Med Res 2007;
38: 253–58.
Insulin crisis in Iraq
Data on diabetes management in Iraq
have been anecdotal and limited.1,2 In
this letter we discuss one problem
that might have catastrophic conse-
quences if it is not solved urgently.
Before December, 2006, insulin in
Iraq was available as human neutral
protamine hagedorn (NPH) insulin
with short-acting insulin. Premixed
human insulin was available in limited
amounts. There was no real problem
for patients with diabetes, despite
the erratic electricity supply in Iraq.
The Iraqi mini stry of health imported
insulin from Novo Nordisk, stored it in
the capi tal Baghdad, and distributed
it via pri mary health-care centres
to the rest of the country. However,
since Dec 31, 2006, no insulin has
been available be cause, although it is
still being imported, it is not safe to
distribute it.
During Jan 1 to Apr 9, 2007, we
did a survey of 2859 patients with
diabetes attending a diabetic centre
in Basrah. 106 had type 1 diabetes.
589 (21%) were prescribed insulin
with or without oral glucose-lowering
drugs, according to the degree of
control. Since the end of the previous
year, 147 (25%) had stopped using
insulin altogether; 144 (24%) had
decreased the dose to make the
Department of Error
Olusanya BO, Newton V. Global burden of
childhood hearing impairment and disease control
priorities for developing countries. Lancet 2007;
369: 1314–17—The corresponding author of
this Viewpoint (April 14) failed to inform us
about a related article (Olusanya BO. Addressing
the global neglect of childhood hearing
impairment in developing countries. PLoS Med
2007; 4: e74), which should have been cited.
Strandberg TE, Pitkälä KH. Frailty in elderly
people. Lancet 2007; 369: 1328–29—In this
Comment (April 21), the fi gure should have
shown an arrow pointing from primary frailty
to disability.
Varicella vaccine and
fatal outcome in
leukaemia
In their unusual and dramatic Case
Report (April 7, p 1232),1 André
Schrauder and colleagues describe
a 4-year-old girl with acute lympho-
blastic leukaemia and varicella who
died of multiple-organ failure and
other complications. She had received
live attenuated varicella zoster virus
(VZV) vaccine 1 month before the
onset of symptoms. Understandably,
Schrauder and colleagues focus on the
clinical information and comment to
a lesser degree on the laboratory test
used to diff erentiate between wild-
type VZV and VZV vaccine strain.
This case illustrates the impor-
tance of doing this test for many
reasons. It has important impli ca-
tions from diagnostic, thera peutic,
epidemiological, and infection-
control points of view, both in
immuno com promised and immuno-
competent patients. Specifi c PCR
tests to diff erentiate wild-type from
vaccine-strain VZV are available in a
few laboratories around the world.2–5
With these tests, results can be
obtained quickly from specimens
obtained from blood, cerebrospinal
uid, vesicles, and some tissues.
Besides these bene ts, VZV viral load
can be measured by TaqMan PCR,
which helps in the monitoring of
disseminated disease progression
and response to antiviral treatment,
among other benefi ts.2
Also, early distinction of the two
diff erent VZV scenarios is crucial for
the correct management of exposed
individuals in hospital and community
settings, including neonates, pregnant
women, immunosuppressed patients,
and high-risk individuals.
I declare that I have no confl ict of interest.
Rolando Ulloa-Gutierrez
rolandoug@racsa.co.cr
Paediatric Infectious Diseases Division, National
Children’s Hospital of Costa Rica, PO Box
1654-1000, San José, Costa Rica
See Editorial page 1834
... The Iraqi health system has a lot of problems [1] probably made worse by the United Nations economic sanctions against Iraq in 1990 [2][3][4][5][6] . Self-medication and the use of nonprescription drugs are common in developing countries [7][8][9] . ...
... More than one type used by some and different routes of administration including oral tablets, syrup and injections.2 Allergy includes eyes, nose, cough, dyspnea and skin including urticaria and itching.3 Includes 4 cases of Behçet's disease, 1 ulcerative colitis, 2 peripheral neuropathy, 2 nephrotic syndrome, 3 immune thrombocytopenic purpura, 3 obstructive airway disease, and 1 hair fall. ...
... Patients may have more than one feature.2 Because most of those who stopped it did that suddenly.3 Repeated vomiting, severe hyperemesis gravidarum. ...
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To study the prevalence and attitude of using nonprescription corticosteroids (oral or parenteral formulation of glucocorticosteroids) in Basrah, Iraq. A face-to-face model structured interview was used to collect information from 682 patients between January 2006 and December 2008. The following information was obtained: age, gender, marital status, smoking, drinking of alcohol, occupation, educational level, social class and place of residence. Of the 682 (2.6%) subjects using nonprescription corticosteroids most were females: 471 (69%); married: 567 (83%); of low social class: 430 (63.1%); lived in the city center: 475 (69.6%). The majority (569, 83.5%) thought that corticosteroid use was safe and 463 (68.0%) did not feel guilty for using such medications. About half of them (377, 55.3%) were still using drugs at the time of presentation. Three hundred and fifty-seven (52.4%) reported that physicians advised them for the first time to use corticosteroids and the remaining 325 (42.2%) used it to become beautiful or marry. Three hundred and sixty-four (53.4%) patients obtained the drug from the pharmacy and 252 (36.9%) from street vendors. Weight gain was the main indication for use in 342 (50.1%) patients. Almost all had some features of corticosteroid side effects. This study showed high use of nonprescription corticosteroid in Basrah, Iraq. We therefore recommend educational programs to alert the population of the untoward side effects of corticosteroids.
... The health system in Iraq underwent progressive decline since the embargo that followed the second gulf war in 1991. The war in 2003, exacerbated that by causing further damage to the infrastructure, with lack of security that making even drug distribution unsafe, with further deterioration due to electricity problems123. This makes drug storage even more difficult. ...
... In United Kingdom Prospective Diabetes Study over 6 years, ~53% of patients will require addition of insulin therapy to achieve target HbA1C[18]. In Iraq, diabetic patients received their medications including insulin from the PHC that distributed all over, but after the war in 2003, there was catastrophic shortage of drug supply [1]. That's why most patients blame the PHC as a cause of uncontrolled of diabetes. ...
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