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ORS and Zinc : Treatment of diarrhoea is now more effective
Prevent deaths from diarrhoea and decrease child
susceptibility to diarrhoea after episodes by educating all health-care
providers and mothers about zinc supplementation. Through focused and
integrated campaigns, and through partnerships with local manufacturers,
we will increase availability of zinc supplements.
|Name: Zinc Supplementation
|Theme: Health Education to Mothers
||Region and Country: Maharashtra, India
Pediatric Zinc as Treatment for Diarrhea
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Every year approximately 1.7 million children die as a result of diarrhea and
dehydration. In the majority of cases, this is preventable through exclusive
breastfeeding, improved hygiene and sanitation and access to clean water, yet
diarrhea is still one of the leading causes of death among children under
In May 2004, WHO/UNICEF issued a joint statement recommending the use of
zinc, an essential micronutrient for human growth, development and
maintenance of the immune system, and a new formulation oral rehydration
solution (ORS), with reduced levels of glucose and salt, as a two-pronged
approach to improved case management of acute diarrhea in children.
Dispersible zinc tablets, which dissolve easily in a tablespoon of clean
water or breastmilk, can be used for zinc supplementation for children aged
one to 59 months. WHO and UNICEF recommend 20 mg of zinc per day for ten -14
days for infants and children, ten mg for infants under six months of age.
For more than 20 years researchers have been assessing the benefit of zinc
supplementation during diarrhea episodes. Studies have shown that zinc
supplementation results in a 25% reduction in duration of acute diarrhea and
40% reduction in treatment failure or death in persistent diarrhea. These
studies also revealed that children receiving zinc experience a decrease in
the severity of their diarrhea episodes. A ten day course has proven to
provide a prophylactic protection against future bouts of diarrhea for two to
three months after the episode.
The combined recommendation of zinc and ORS is a safe, effective and
inexpensive diarrhea treatment for children in the developing world. The only
known side effect of zinc use is vomiting, which is rarely reported and is
typically attributed to a metallic taste in the zinc. Use of high-quality
zinc products easily avert this side effect.
Zinc manufacture requires only simple technology and no expensive
ingredients. Zinc can be produced in both syrup and tablet form. Efforts are
already underway to transfer the technology from French developer and patent
holder, Nutriset/Rodael, to local manufacturers in the developing world, who
will be able to take over production, thus keeping costs affordable for the
poorest of the poor.
Pilot programs have begun in several countries, testing various approaches to
training both health facility staff and community health workers, developing
and delivering behavior change communication messages and consumer
educational materials, and monitoring program progress. Private sector zinc
programs are testing the feasibility of marketing zinc tablets and ORS as
stand alone products or packaging them together as a Diarrhea Treatment Kit (DTK).
For more information visit the POUZN (Social Marketing for Diarrheal Disease
Prevention and Treatment) website:
In the majority of cases, diarrhoea is preventable through exclusive
breastfeeding, improved hygiene and sanitation, and access to clean water,
yet it is still one of the leading causes of death among children under five
in India. A new Oral Rehydration Solution (ORS) formula and the introduction
of zinc supplementation offer much improved outcomes for the treatment of
childhood diarrhoea. The introduction of zinc supplementation in diarrhoea
treatment provides for a high impact child survival intervention.
This programme looks to prevent deaths from diarrhoea and decrease child
susceptibility to diarrhoea after episodes by educating all health-care
providers and mothers about zinc supplementation. The programme will be
two-fold. First, we will develop guidelines and training materials to educate
health care providers, mothers, and the general public about zinc treatment
in conjunction with ORS. The second focus of the programme will be to ensure
and monitor the availability of zinc supplements, create standards for
quality control of zinc tablets, and develop local delivery mechanisms for
distribution of the treatment.
In the early 1980s, the introduction of ORS led to significant and continuing
decreases in the rate of diarrhoea mortality that lasted for more than 20
years. Until recently, ORS, increased fluids, and continued feeding have been
the only recommended treatments for episodes of non-complicated diarrhoea.
Even though the accepted ORS formula was proven effective, researchers
continued to work on developing an improved formula that would allow for more
hydration while decreasing the amount of stool output. As a result, an ORS
formula with lower glucose and sodium concentrations was developed, and it
has proven to be more effective by decreasing the need for intravenous
therapy, decreasing stool output, and decreasing the rate of vomiting. This
new formula is recommended as one part of an improved diarrhoea therapy and
treatment. Zinc is another part.
Zinc is an essential micronutrient for human growth, development, and
maintenance of the immune system. The first cases of zinc deficiency were
recognized in the 1960s in adolescent boys in Egypt who suffered from growth
retardation. A recent assessment by the International Zinc Consultative Group
estimated that 20% of the world’s population is at risk of inadequate zinc
intake. In addition, high levels of zinc are lost in the stools during
diarrhoea episodes. For more than 20 years, researchers have assessed the
benefit of zinc supplementation during diarrhoea episodes. A meta-analysis of
eight trials of acute and persistent diarrhoea found a 15% reduction in the
duration of acute diarrhoea and a 24% reduction in the duration of persistent
diarrhoea among children receiving zinc supplementation when compared to
children who received a placebo. These studies also revealed that children
receiving zinc supplementation experienced a decrease in the severity of
their diarrhoea episodes. Children who received 10–14 days of zinc
supplementation also showed greater resistance to episodes of diarrhoea and
other infectious diseases for the 2–3 month period following treatment.6
Eleven additional trials have confirmed these results, supporting the
inclusion of 10–14 days of 10-20 mg of zinc supplementation as another
element in the recommended diarrhoea therapy.
Promotion and education of zinc supplementation with ORS in diarrhoea
treatment will make it the responsibility of the state of Maharashtra to
ensure that zinc is used to treat every diarrhoea episode in children under
5. There are several challenges that must be overcome to make this possible.
- International and national level product availability
- National and local level product coverage
- Health worker/physician training and endorsement
- Home-based treatment compliance
Zinc supplements are the new addition to diarrhoea treatment. Recommendations
for zinc treatment are always given in conjunction with ORS and continued
feeding. Introducing a new treatment, such as zinc, creates an opportunity to
energize current diarrhoea training programs and provides an excellent
opportunity to design enhanced or new programs where needed. This new
treatment will increase ORS use rates and improve continued feeding
Programme Management and Implementation:
Management and Implementation of this programme will occur after a careful
assessment of the quality and consistency of currently available zinc
products in Maharashtra. After this is assessed, programmatic endorsement and
promotion will occur. Zinc is an essential micronutrient and may be available
in local formulations. A careful assessment of the quality and consistency of
currently available zinc products, which may include varieties of local
tablets and syrups, should be complete before programmatic endorsement and
promotion occur. Continuous monitoring of product quality may be needed to
ensure children are receiving safe and effective zinc supplementation for the
treatment of diarrhoea. Ensuring zinc supplements reach local level health
clinics and health care providers will require the endorsement and commitment
of national and local level governments by either providing financial backing
or accepting and endorsing USAID missions and other aid agencies to procure
and distribute zinc products.
Health care providers and mothers will be taught about the importance of zinc
supplementation for diarrhoea treatment. This will take place in various
training courses and printed materials.
Programme Monitoring and Evaluation:
Continuous monitoring of product quality may be needed to ensure children are
receiving safe and effective zinc supplementation for the treatment of
diarrhoea. Ensuring zinc supplements reach local level health clinics and
health care providers will require the endorsement and commitment of national
and local level governments by either providing financial backing or
accepting and endorsing USAID missions and other aid agencies to procure and
distribute zinc products. Evaluation of partnerships with local aid agencies
will be monitored to achieve the highest product coverage rates in all areas
of the country. There are many country-level decisions regarding the sale
and/or dispersal of zinc supplements in addition to ORS. Programme monitoring
will ensure that zinc and ORS are to be recommended together, zinc should
never be promoted as a substitute of ORS. Ideally, zinc and ORS supplies
would always be given or sold in the same location. The price of zinc
supplements will be monitored and regulated if necessary. The programme will
be revised and accommodated as necessary.
Learning and Dissemination:
For an upto date list of Zinc Related Resources, kindly go to
ZINC Publications and Reference Materials
In May 2004, a WHO/UNICEF Joint Statement on the Clinical Management of Acute
Diarrhea was issued. This statement called for the adoption of new
recommendations for zinc supplementation together with a new ORS formula for
the clinical management of diarrhea. On behalf of USAID, MOST is supporting
the rapid scale-up of this high impact, child survival intervention. A
component of this support is to increase the accessibility of information
about the use of zinc supplementation as an adjuvant treatment for diarrhea.
The first eight documents provide key evidence in support of USAID's decision
to encourage the rapid global rollout of this new, high-impact child survival
The WHO/UNICEF Joint Statement May 2004 on the Clinical Management of Acute Diarrhoea
These new recommendations, formulated by UNICEF and WHO in collaboration with the
United States Agency for International Development (USAID) and experts
worldwide, take into account new research findings while building on past
Bhutta et al. Am J Clin Nutr 2000. Presents the meta-analyses of
efficacy studies demonstrating that 10-14 days of zinc supplementation reduce
the duration and severity of diarrhea episodes.
Zinc Investigators' Collaborative Group. The Journal of
Pediatrics 1999 (abstract only). Presents the evidence of reduction in
incidence in diarrhea and pneumonia for 2-3 months following treatment of
diarrhea with 10-14 days of zinc supplementation.
Baqui et al. BMJ 2002. Presents evidence from a community-based
trial confirming the shorter duration of diarrhea with zinc supplementation,
and other benefits of zinc including reduced incidence of both diarrhea and
acute lower respiratory tract infections, and fewer admissions to hospital in
children with diarrhea.
Robberstad et al. Bull WHO 2004. Presents a cost-effectiveness
analysis in terms of DALYs and child deaths averted using a simulation
technique with cost data from health facilities in Tanzania. The authors
concluded that zinc for diarrhea treatment is highly cost-effective.
Application for the inclusion of zinc sulphate in the WHO Model List of
Essential Medicines. Approved March 2005. It presents an update to March
2003 of further efficacy studies published and presents more detail on
Low Risk of Adverse Effects from Zinc Supplementation. This brief
reviews the available evidence on the safety of zinc supplementation in
children, summarizes reports of adverse effects from both long-term and
short-term studies, and concludes that zinc supplementation is a safe and
effective treatment for diarrhea.
US Pharmacopeia. The definition of the zinc tablet is developed to
enable quality assurance.
|The dispersible 20 mg zinc
tablets now recommended by WHO and UNICEF for use with ORT in treating
all forms of diarrhea may be obtained from Nutriset at
www.nutriset.fr or by e-mail at
firstname.lastname@example.org. USAID grantees and cooperative
agreements are able to use USAID funds to purchase the tablets from
NUTRISET under a waiver available for that purpose. For information on
the waiver write to Jill Boezwinkle at email@example.com.
Manuals, Guidelines, Statements Concerning Diarrhea Treatment
Guidelines for Clinic-Based Health Workers - Not yet field tested.
Guidance on how to implement the new WHO/UNICEF recommendations for the use
of ORS and zinc supplementation in the clinical management of diarrhea. The
guidelines presented in this document are generic; that is, they will be most
effective when modified to support the particular strategy being used to
introduce the new recommendations in each country. (no. 135) (PDF
file in English),
file in Spanish)
Introducing Zinc in a Diarrheal Control Program: A Manual for
Conducting Formative Research. Describes the methods used for formative
assessment in a multi-country clinical trial coordinated by INCLEN. The
purpose of the trial was to assess acceptance by the global community of zinc
supplementation as an adjuvant treatment to ORS prior to its introduction as
a policy. The manual was developed to provide a standardized approach to
developing appropriate and effective messages to use both ORS and zinc
together. This clinical trial was conducted in seven sites: 1) Lucknow and 2)
Nagpur in India, 3) Manila, Philippines, 4) Pretoria, South Africa, 5) Cairo,
Egypt, 6) Addis Ababa, Ethiopia, and 7) Fortazena, Brazil. (Available at
Look under What's New.)
of Diarrhoea – A manual for physicians and other senior health workers
has been updated to include
these changes and should serve as the reference for the management of diarrhoea. This guide is distributed by WHO
UNICEF/WHO Joint statement on ORS, March 2002. This document was
prepared to inform national authorities on the position of the United Nations
Children’s Fund (UNICEF) and of the World Health Organization (WHO) with
respect to issues such as flavoring, coloring, and rice-based ORS. It is
based on a document first published in July 1996 that was revised to take
into account results of studies on ORS formulation and zinc supplementation.
Other Zinc Links and Documents
Lessons learned in a pilot introduction of zinc treatment for childhood
diarrhea in Bougouni District in Mali. This April 2005 report is written
for program managers and planners interested in the lessons learned about
operational issues in the pilot introduction of zinc supplementation as an
adjunct treatment for childhood diarrhea in Mali.
Zinc Supplementation for the Treatment of Diarrhea: Moving from
Research to Practice. A five-page document
describing the history of ORS and the inclusion of zinc supplementation, case
studies proving the benefits of zinc, using zinc for diarrhea treatment, and
programmatic challenge points.
MOST summary article 2005. Cost-effectiveness of zinc supplementation
as an adjunct treatment for childhood diarrhea
New diarrhea treatment guidelines could save more lives,
article on pages 3-4 of
the 2004/4 Nutriview Newsletter
Effect of Zinc Supplementation on Clinical Course of Acute Diarrhoea.
Report of a Meeting, New Delhi, 7-8 May 2001
Scaling Up Zinc Treatment for Young Children with Diarrhoea in Bangladesh.
A large national program to introduce new guidelines for the management of diarrhea in Bangladesh.
Technical Document – The first IZiNCG Technical
Document has been compiled by the Steering Committee, and published as a
supplement to the United Nations University Food and Nutrition Bulletin
(March, volume 25, supplement 2:S94-S204; 2004).
Effectiveness and cost of facility-based Integrated Management of Childhood
Illness (IMCI) in Tanzania. Lancet. 2004 Oct 30;364(9445):1583-94.
Integrated Management of Childhood Illness (IMCI) in Bangladesh:
Early findings from a cluster-randomized study. Lancet. 2004 Oct
Summary Document from June 2004 Zinc Implementation Meeting in
Baltimore, the purpose of which was to bring together experts in zinc
research and program design/implementation to review recent research on zinc
in treatment of diarrhea; learn about WHO/UNICEF/USAID plans for rolling-out
zinc for treatment of diarrhea; and strategize next steps for the scaling up
of zinc supplementation through NGOs, public and private sectors
In preparation for promotion of zinc treatment for
childhood diarrhea: Cross-country comparison of diarrhea treatment practices
and implications for programs.
Summary document developed for the June 2004 Zinc Implementation Meeting in
PowerPoint presentation given at USAID in September 2004
regarding zinc and ORS. Document is in the form of a handout, six slides to a
Therapeutic effects of oral zinc in acute and persistent diarrhea in children in
developing countries: pooled analysis of randomized controlled trials. Am J Clin Nutr. 2000
Weekly zinc supplements can reduce deaths in young children
Giving young children in developing countries a weekly dose of zinc can substantially reduce their risk of illness and death, according to a study
published online today (Tuesday August 23, 2005) by THE LANCET...
A series of questions, to date, that has arisen in the field
regarding the promotion of ORS/zinc treatment.
Frequently asked questions concerning the "NEW ORS" - i.e. low
osmolarity ORS. Developed by WHO, May 2004.
PDF file (in English),
PDF file (in French)
following publications were distributed at the 2004 meetings of the
International Vitamin A Consultative Group (IVACG), the International
Nutritional Anemia Consultative Group (INACG), and the International Zinc
Nutrition Consultative Group (IZiNCG), held in Lima, Peru, November 15-19, 2004.
A Strategic Approach to Anemia Control.
Describes the MOST Project’s
experiences together with the options now available for addressing anemia in
developing countries. (no. 133)
Improving the Performance of Maternal Anemia Interventions in Africa.
Describes the process used to develop a comprehensive
program to control anemia in pregnant women in four districts of Uganda in 2002.
Overcoming Barriers to Effective Anemia Interventions
during Antenatal Services in Uganda . [Reprinted] Describes the process and results
of a study undertaken to identify barriers to implementation of effective
interventions aimed at addressing anemia in pregnancy.
Elements of a National Food-Fortification Program / Bangladesh. This
study’s primary objective is to identify major elements of a food-fortification
strategy in Bangladesh, including micronutrient formulation for the food
vehicles as suitable for fortification. (no. 138)
Micronutrients Lead the Way: Making Gains in Nutrition and Health.
Discusses options and strategies for improving micronutrient health in deficient
populations. Provides details on USAID's efforts to reduce micronutrient
deficiency through supplementation, fortification, and food-based programs.
Updated in 2004 to include zinc as a significant public health issue.
Cost Study Synthesis - Ghana, Zambia and Nepal. Although a variety of vitamin A supplementation programs
have been implemented in developing countries, little is known to date about
their costs. The major objective of this study is to provide researchers and
policymakers with that cost information. (no. 136)
Ghana Cost Study. [Reprinted] The
overall objective of this study is to provide the Ministry of Health in Ghana
with cost information on the vitamin A supplementation program. The MOH intends
to use this information to integrate the vitamin A supplementation program into
routine primary health care services over the next five years.
Zambia Cost Study. This study provides
policymakers in Zambia with cost information on vitamin A supplementation —
information that may help answer questions concerning the efficiency and
sustainability of the campaign approach vis-�-vis other modes of delivering
vitamin A supplementation. Specific objectives are to document the Child Health
Week and National Immunization Days programs as they presently operate, and to
analyze the two programs’ cost structures. (no. 137)
Modules for the Induction Training of Anganwadi Workers in Uttaranchal.
These are training modules aimed at developing
capacity in community day care centers, which are an important source for
extending nutrition and health-related service in the remotest areas of India’s
Uttaranchal state among children up to six years of age, adolescent girls, and
pregnant/lactating women. (no. 141)
Zambia Five Year Strategy. This five-year
strategic plan to prevent and control vitamin A deficiency in Zambia serves as a
model of a comprehensive strategic plan for any country wishing to develop a
micronutrient deficiency prevention and control program. (no. 143)
National Micronutrient Survey 2000 Summary Report – Nicaragua. The
Government of Nicaragua has paid special attention to micronutrient
deficiencies, particularly those of vitamin A, iron, and iodine, since the 1993
National Micronutrient Survey. This summary report of the subsequent 2000 survey
provides information about the evolution of these deficiencies, which are
considered to be significant public health problems in Nicaragua. (no. 139)
Prototipo de Sistema de Gesti�n Log�stica de Suplementos de Micronutrientes / El
El objetivo del presente
documento, preparado por el proyecto USAID/MOST como resultado de la experiencia
reciente en El Salvador, es presentar y divulgar un prototipo de sistema de
gesti�n log�stica de suplementos de micronutrientes que se ha implantado
exitosamente por el Ministerio de Salud y Asistencia Social (MSPAS), con
asistencia t�cnica de USAID/MOST, y que podr�a ser �til como modelo para ser
adaptado en otros pa�ses. (no. 140)
la carence en vitamine A / Madagascar.
L’objectif de l’enqu�te est de fournir: (a) Des
donn�es de r�f�rence repr�sentatives au niveau national pour la carence en
vitamine A chez les enfants de 6 � 59 mois, (b) Des donn�es de r�f�rence
repr�sentatives au niveau national pour la carence en vitamine A chez les femmes
de 15 � 49 mois, (c) Donn�es de r�f�rence sur l’an�mie chez les �coliers de 6 �
14 ans par rapport auxquelles le projet SEECALINE peut �valuer l’impact de ses
activit�s de nutrition scolaire. (no. 142)