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Insulin crisis in Iraq

1860 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:
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
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
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
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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The health system in Iraq has undergone progressive decline since the embargo that followed the second gulf war in 1991. The aim of this study is to see barriers to glycemic control form the patient perspective, in a diabetic clinic in the south of Iraq. A cross sectional study from the diabetes out-patient clinic in Al-Faiha general hospital in Basrah, South Iraq for the period from January to December 2007. The study includes diabetic patients whether type 1 or 2 if they have at least one year of follow up in the same clinic. Those with A1C > or = 7% were interviewed by special questionnaire, that was filled in by the medical staff of the clinic. The subjects analyzed in this study were adults (> or = 18 years old) with previously diagnosed diabetes (n = 3522). The duration of diabetes range from 1 to 30 years. Mean A1C was 8.4 +/- 2 percent, with 835(23.7%) patients with A1C less than 7% and 2688(76.3%) equal to or more than 7%. Of 3522 studied patients, 46.6% were men and 51.5% were women, with mean age of 53.78 +/- 12.81 year and age range 18-97 years. Patient opinion for not achieving good glycemic control among 2688 patients with HbA1C > or = 7% included the following. No drug supply from primary health care center (PHC) or drug shortage is a cause in 50.8% of cases, while drugs and or laboratory expense were the cause in 50.2%. Thirty point seven percent of patients said that they were unaware of diabetics complications and 20.9% think that diabetes is an untreatable disease. Thirty percent think that non-control of their diabetes is due to migration after the war. No electricity or erratic electricity, self-monitoring of blood glucose (SMBG) is not available, or strips were not available or could not be used, and illiteracy as a cause was seen in 15%, 10.8% and 9.9% respectively. Our patients with diabetes mellitus declared that of the causes for poor glycemic control most of them related to the current health situation in Iraq.
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Issue number 2 Volume 4 August 2008 of the New Iraqi Journal of Medicine (ISSN: 1817-5562, 1998037X: 2005-2013) was published by Aamir Jalal Al-Mosawi as the Editor-in-Chief.
Background This study was designed to assess the achievement of a glycated hemoglobin (HbA1c) target in Iraqi type 2 diabetes mellitus (T2DM) patients via retrospective analysis of a tertiary care database over a 9-year period. Methods A total of 12,869 patients with T2DM with mean (SEM) age: 51.4(0.1) years, and 54.4% were females registered into Faiha Specialized Diabetes, Endocrine and Metabolism Center(FDEMC) database between August 2008 and July 2017 were included in this retrospective study. Data were recorded for each patient during routine follow-up visits performed at the center every 3–12 months. Results Patients were under oral antidiabetic drugs (OAD; 45.8%) or insulin + OAD (54.2%) therapy. Hypertension was evident in 42.0% of patients, while dyslipidemia was noted in 70.5%. Glycemic control (HbA1c <7%) was achieved by 13.8% of patients. Multivariate analysis revealed <55 years of age, female gender, >3 years duration of diabetes, presence of dyslipidemia, HbA1c >10% at the first visit and insulin treatment as significant determinants of an increased risk of poor glycemic control. BMI <25 kg/m² and presence of hypertension were associated with a decreased risk of poor glycemic control. Conclusion Using data from the largest cohort of T2DM patients from Iraq to date, this tertiary care database analysis over a 9-year period indicated poor glycemic control. Younger patient age, female gender, longer disease duration, initially high HbA1c levels, insulin treatment, comorbid dyslipidemia or obesity and lack of hypertension were associated with an increased risk of poor glycemic control in Iraqi T2DM patients.
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Background: Type 2 diabetic patients failing oral antidiabetes (OADs) medications need insulin. The aim of this study is to see if there was any difference in glycemic control if we started insulin naive patients with type 2 diabetes mellitus, on NPH or premixed insulin. Patients and Methods: This was an open-label, prospective study. Throughout July 2009, we enrolled insulin naïve patients with type 2 diabetes mellitus in the Al-Faiha Diabetes and Endocrine Center in Basrah. In the first month, we enrolled 1500 patients with suboptimal glycemic control (HbA1c > 7%) despite increasingly aggressive therapy with OADs in addition to lifestyle changes, but only 791 (52.7%) patients continued the study for 12 months. Both NPH or Premixed insulin was used for alternating patients, and started twice daily in a dose of 0.2 unit /kg/d. Secretagogues was stopped on commencing insulin, but metformin was continued. Results: Premixed insulin was used in 66.8 % and NPH in 33.2 %. Target HbA1c was achieved in 12.4 % of patients at the end of one year. The NPH group significantly had a higher age, 55.7±10.4 vs. 52.5±11.6 (OR, 2.805; 95% CI, 1.636-4.966; p <0.0001). HbA1c was slightly, but significantly statistically lower, in the premixed group 8.8± 1.5 vs. 8.5±1.4, (OR, 1.659; 95% CI, 0.106 -0.546; p =0.004). There was no statistically significant difference between the two groups regarding achieving the target HbA1c. Conclusion: This observational study suggests that in diabetic patients with failing OADs, starting with NPH or premixed human insulin makes no significant difference to the outcome for at least one year.
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Body mass index (BMI) is often used to reflect total body fat amount (general obesity), whereas waist circumference (WC), waist-to-hip ratio (WHpR) or waist-to height ratio (WHtR) is used as a surrogate of body fat centralization (central obesity). The purpose of the present study was to identify cut-offs for BMI and upper-body adiposity (WC, WHpR, and WHtR) that, associated with increased risk of type 2 DM and hypertension in Iraqi adults, would be consistent with overweight and central adiposity. This was a community-based cross-sectional survey for establishing cut-off values for BMI and upper-body adiposity (WC, WHpR or WHtR) associated with increased risk of type 2 DM and hypertension from one district in Southern Iraq, Basrah (Abu-Al-khasib). The total number of persons involved was 12,986 (6693 men and 6293 women), aged 45.6 +/- 15.7 years. The cut-off point in men associated with increased risk of type 2 DM and hypertension were BMI 25.4 and 24.9, WC 90 and 95 cm, WHpR 0.92 for both and WHtR 0.52 and 0.55, respectively. For women, the cut-off point associated with increased risk of type 2 DM and hypertension were BMI 26.1 and 26.5, WC 91 and 95 cm, WHpR 0.91 for both, and for WHtR 0.56 and 0.59, respectively. The best index for association with type 2 DM was WHpR with cut-off point of 0.92 for men and 0.91 for women. For hypertension, the best index is WHtR (with cut-off point of 0.55 for men and 0.59 for women), whereas the least reliable index was the BMI for both type 2 DM and hypertension. Our finding showed that, in Iraqi adults, WHpR has the strongest association with type 2 DM and WHtR for hypertension.