Transcript The Impact of Zinc Supplementation during Diarrhoeal
Where are we now?
WHO’s Perspective Dr Olivier Fontaine World Health Organization Geneva
Recent developments in the clinical management of acute diarrhoea
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Demonstration of the increased efficacy of a new formulation for oral rehydration salts (ORS) containing lower concentrations of glucose and salt, and
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Success in using zinc supplementation in addition to rehydration therapy in the management of diarrhoeal disease
Meta-analysis of unscheduled intravenous infusion among children randomized to reduced osmolarity and standard WHO rehydration solution
Hahn S et al. BMJ 2001; 323:81-5
Meta-analysis of stool output among children randomized to reduced osmolarity and standard WHO rehydration solution
Hahn S et al. BMJ 2001; 323:81-5
Meta-analysis of vomiting among children randomized to reduced osmolarity and standard WHO rehydration solution
Hahn S et al. BMJ 2001; 323:81-5
CONCLUSION (1) The group of experts recommended that a single ORS solution be used and that this ORS solution contain 75 mEq/l of sodium and 75 mmol/l of glucose, and have a total osmolarity of 245 mOsmol/l.
Trials on the Therapeutic Effect of Zinc on Acute Diarrhea
Countries: Bangladesh (4), Brazil, India (6), Indonesia, Nepal
Age groups: 1-60 months
Dose of zinc: 5 to 40 mg/day (1 to 4 RDA)
Total number of children:
zinc control 4965 4351
Effect of Zinc Supplementation on Duration of Acute Diarrhoea/Time to Recovery * India, 1988 * Bangladesh, 1999 *India, 2000 *Brazil, 2000 *India, 2001 Indonesia, 1998 India, 1995 Bangladesh, 1997 India, 2001 India, 2001 Nepal, 2001 Bangladesh, 2001 Meta-analysis 1 *Difference in mean and 95% CI Relative Hazards and 95% CI
Effect of Zinc Supplementation on Duration of Episodes Lasting More than 7 Days Indonesia, 1998 India, 1995 Bangladesh, 1997 India, 2001 Nepal, 2001 Meta-analysis 1 Odds ratio and 95% CI
Therapeutic Effects of Zinc Supplementation on Acute Diarrheal Severity (1) Country India, 1988 Outcome Measure Stool Percent Reduction 18 India, 1995 Stool India, 2001 Stool 39* 28* Nepal, Brazil Stool Stool 9* 59* * p<0.05
Therapeutic Effects of Zinc Supplementation on Acute Diarrheal Severity (2) Country Banglades h, 1997 India, 2000 Outcome Measure Stool Output Stool Output Percent Reduction 28 38* India, 2001 Stool Output 28* * p<0.05
CONCLUSIONS (2)
Zinc supplementation given at a dose of about 2 RDAs per day (10-20 mg) for 10-14 days, is efficacious in reducing the severity of diarrhoea and the duration of the episode significantly.
WHO/UNICEF JOINT STATEMENT Clinical Management of Acute Diarrhoea
Recommendations for Mothers and Other Caregivers
Prevent dehydration through the early administration of increased amounts of appropriate fluids available in the home, and ORS solution, if on hand
Continue feeding (or increase breastfeeding) during, and increase all feeding after the episode
Recognize the signs of dehydration and take the child to a health-care provider for ORS or intravenous electrolyte solution, as well as familiarize themselves with other symptoms requiring medical treatment (e.g., bloody diarrhoea)
Provide infants with 20 mg per day of zinc supplementation for 10 –14 days (10 mg per day for infants under six months old)
Recommendations for Health-Care Workers
Counsel mothers to begin administering suitable available home fluids immediately upon onset of diarrhoea 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 diarrhoeal episode Use antibiotics only when appropriate, i.e. in the presence of bloody diarrhoea or shigellosis, and abstain from administering anti-diarrhoeal drugs Provide infants 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.
Next Steps (1) Ongoing Research
Acceptability of zinc as an adjunct therapy for the management of acute diarrhoea in health facilities (Brazil, Egypt, Ethiopia, India and Philippines)
Intervention Studies to evaluate the effectiveness of adding zinc to the management of diarrhoea (India, Mali and Pakistan)
Controlled Clinical Trials to evaluate the safety/efficacy of zinc supplementation in the management of diarrhoea in infants below 6 months of age (Ethiopia, India and Pakistan)
Next Steps (2) Zinc Tablet Production
Inclusion of zinc in the WHO model list of Essential Drugs
Development of product specification for allowing UNICEF to procure zinc tablets
Transfer of Technology for the production of zinc tablets
Next Steps (3) Planning for Implementation of Zinc for Treatment of Diarrhoea
Development of draft guidelines for introduction of zinc for diarrhoea in a country
Development of a guide for formative research
Development of educational materials on diarrhoea