Overview of ORS & Zinc Therapy for the Management of Diarrhea

Diarrhoea and Child Mortality • 10.5 million child deaths each year, 2/3 of which are preventable with low-cost interventions • Nearly 2 million child deaths from diarrhea • 88% of diarrhoea deaths are preventable with widespread prevention and treatment interventions, including: – Breastfeeding – Vitamin A supplementation – Treatment of pneumonia – Treatment of diarrhoea with ORS, zinc supplementation, home fluids, and continued feeding Zinc: The basics Burden attributable to zinc deficiency includes 779,000 child deaths and 27 million DALYs annually, about 2% of global DALYs Preventive or therapeutic use of zinc supplements has the potential to reduce infectious disease illness and death if effective delivery systems can be deployed Either a preventive or therapeutic approach could avert at least 4% of child deaths in developing countries Zinc deficiency is common in developing country children Breast milk not sufficient source >6 mo Intake of complementary foods low, particularly animal foods Low content of soil, of foods Limited bioavailability;­ phytates from cereals High fecal losses during diarrheal illness Effects of mild zinc deficiency ¯ T-dependent lymphocyte antibody responses ¯ SlgA ¯ Thymulin, ¯ IL-2 ¯ NK activity ¯ CD4 cells ¯ CTL precursors TH1 to TH2 shift Zinc deficiency has direct effects on mucosal functions Disrupts intestinal mucosa Reduces brush border enzymes Increases mucosal permeability Increases intestinal secretion Plasma Zinc Concentration as a Predictor of Infectious Diseases • Indian 12-59 mo old children with initial plasma zinc 8.4μmol/L had 1.5 times more diarrhea and 3.5 times more ALRI1 • Malawian pregnant women with low hair zinc had higher malaria prevalence2 If sick, more likely that you have low levels of zinc Zinc sources are needed • Zinc deficiencies are common in developing countries – Inadequate zinc in the diet – Breast milk not sufficient source – Intake of complementary foods low, particularly animal foods • Lower zinc concentrations is associated with higher rates of illness • And zinc is lost during diarrhea illness Zinc is in a vicious cycle, low dietary, contributes to illness and illness further depletes zinc, Community-based Trial Demonstrates Zinc Effectiveness in Treating Diarrhoea A study of 30 health worker areas in rural Bangladesh randomized to ORS alone or ORS + zinc (20mg/d for 14 days) for diarrhoea treatment. 11,880 child-years of observation during the 2 year study In zinc treatment clusters compared to control – 23% decrease in duration of all diarrhea episodes (RH 0.77, 95% CI 0.69-0.86) – 19% decrease in diarrhea related hospitalization : RR 0.81 (0.65, 1.00) – Reduced mortality: RR 0.49 (0.25, 0.94) – Reduction in use of antibiotics by 62% and other drugs by 67% •Baqui, Black, Arifeen. BMJ 2003 In Sum, Zinc (with ORS) Works • ORS + Zinc supplementation reduces diarrhea episode morbidity – the duration of acute and persistent diarrhea – the severity of diarrhea (reduced frequency and output) – proportion of episodes that become persistent (>14 d) – decrease the need for hospitalisation • ORS + Zinc supplementation reduces subsequent morbidity (2-3 months) – reduction in prevalence of diarrhea – reduction in incidence of pneumonia • Zinc saves lives (reduces mortality) (Evidence of the impact of zinc supplementation in the absence of diarrhea is mixed.) Zinc is safe and cost-effective Safe • Zinc is well tolerated by children with diarrhea • Use of zinc in acute diarrhea has no side effects – Vomiting is the only reported adverse effect Cost-effective • Low cost dispersible and stable tablets of zinc are available • Reduces the use of antibiotics Global Diarrhoea Management Policy • In May 2004, WHO and UNICEF signed a joint policy for the treatment of diarrhoea in children Based on this recommendation, health-workers should: – Counsel mothers to begin administering suitable available home fluids immediately upon onset of diarrhea in a child – Treat dehydration with ORS solution (or with an intravenous electrolyte solution in cases of severe dehydration) – Emphasize continued feeding or increased breastfeeding during, and increased feeding after the diarrheal episode – Use antibiotics only when appropriate, i.e. in the presence of bloody diarrhea or shigellosis, and abstain from administering antidiarrhoeal drugs – Provide children with 20 mg per day of zinc supplementation for 10–14 days (10 mg per day for infants under six months old) – Advise mothers of the need to increase fluids and continue feeding during future episodes