Insulin crisis in Iraq

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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
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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
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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
fl uid, vesicles, and some tissues.
Besides these bene fi 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