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

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Countries: Bangladesh (4), Brazil, India (6), Indonesia, Nepal

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Age groups: 1-60 months

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Dose of zinc: 5 to 40 mg/day (1 to 4 RDA)

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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)

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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

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Prevent dehydration through the early administration of increased amounts of appropriate fluids available in the home, and ORS solution, if on hand

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Continue feeding (or increase breastfeeding) during, and increase all feeding after the episode

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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)

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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

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Acceptability of zinc as an adjunct therapy for the management of acute diarrhoea in health facilities (Brazil, Egypt, Ethiopia, India and Philippines)

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Intervention Studies to evaluate the effectiveness of adding zinc to the management of diarrhoea (India, Mali and Pakistan)

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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

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Inclusion of zinc in the WHO model list of Essential Drugs

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Development of product specification for allowing UNICEF to procure zinc tablets

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Transfer of Technology for the production of zinc tablets

Next Steps (3) Planning for Implementation of Zinc for Treatment of Diarrhoea

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Development of draft guidelines for introduction of zinc for diarrhoea in a country

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Development of a guide for formative research

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Development of educational materials on diarrhoea