E-DRUG: Scaling up oral rehydration salts and zinc for the treatment of
[This is a very important article. There is good evidence that adding zinc to
ORS can reduce child mortality. Zinc is cheap. So why is it so hard to
introduce? Zinc is hardly available in developing countries. Let us remember
the scepticism when ORS was first proposed: many doctors thought that such a
simple thing of salt sugar and water could not be a life saving medicine. The
Lancet then called ORS the discovery of the century. Let us embrace zinc, and
ask our drug companies to make it available! Copied as fair use. WB]
Scaling up oral rehydration salts and zinc for the treatment of diarrhoea
BMJ 2012; 344 doi: 10.1136/bmj.e940 (Published 10 February 2012)
Cite this as: BMJ 2012;344:e940
1. Oliver Sabot, executive vice president for global programs
2. Kate Schroder, director of essential medicines initiative,
3. Gavin Yamey, lead, evidence to policy
4. Dominic Montagu, lead, health systems initiative
In the years after the launch of the millennium development goals, the health
economist Jeffrey Sachs emphasised investment in malaria control as the “lowest
hanging fruit” in the battle to reduce child mortality.1 Such investment is
paying off: cases of malaria and deaths from the disease, which mostly occur in
young children, have fallen by more than 50% in nine African countries since
2000 through scaling up of malaria control tools.2 Yet despite this progress in
controlling malaria and in scaling up other interventions such as vaccines,
most countries are still not on track to achieve millennium development goal
4—that of reducing child mortality by two thirds from 1990 to 2015. With only
four years until the deadline, we must now pursue other “low hanging fruit”
that can rapidly reduce child mortality in developing countries.
Investment in the treatment of diarrhoea with oral rehydration salts (ORS) plus
zinc is one of the best opportunities to achieve such rapid impact.3 Acute
diarrhoea is the second biggest cause of death in children worldwide, causing
1.2 million deaths each year.4 Rotavirus vaccines, clean water, sanitation, and
other preventive measures are important in reducing this burden. However,
vaccines are only partially effective and will not prevent many deaths, and
other preventive interventions are relatively costly or difficult to scale up
quickly. Treatment with ORS and zinc could rapidly and cost efficiently avert
most of the deaths not prevented by vaccines. A systematic review estimated
that universal coverage with ORS would reduce diarrhoea related deaths by 93%.
A second systematic review estimated that in zinc deficient populations, zinc
treatment reduces diarrhoea related deaths by 23%. Yet only about 30% of
children with diarrhoea in high burden countries receive ORS, and fewer than 1%
receive ORS plus zinc. The use of ORS has stagnated globally since 1995; this
could partly be because of its lack of impact on the symptoms of diarrhoea and
the decline in funding for diarrhoea control programmes.
Scaling up the provision of zinc and ORS could rapidly reduce child mortality
for four reasons. Firstly, although it has been almost eight years since the
World Health Organization recommended combination treatment with zinc and ORS,
few countries have implemented basic interventions to increase the currently
low use of adjunctive zinc. Such interventions would include marketing zinc to
caregivers and distributing it in large volumes through both public and private
facilities. Even limited additional investment in such interventions could have
a large effect.
Secondly, children with diarrhoea can be reached and given appropriate
treatment easily. Most children currently obtain some form of treatment for
diarrhoea, but most of them receive inappropriate treatments such as
antibiotics and antidiarrhoeal agents. Merely switching the treatments children
receive, which is less challenging than trying to change caregivers’ treatment
seeking behaviour, could therefore drive substantial increases in ORS and zinc
Thirdly, and in contrast to treatments for malaria or pneumonia, effective
treatment of diarrhoea does not need to be carefully targeted to selected
children in whom a definitive diagnosis is made. A strategy of “flooding the
market” with ORS and zinc—distributing them through all outlets where
caregivers seek treatment—could be pursued safely, with no threat of drug
resistance, for example.
Lastly, a full course of zinc and ORS treatment costs less than $0.50 (£0.3;
€0.38), and the marketing, training, and distribution necessary to drive
product uptake could also be implemented at comparatively modest cost.
Moreover, public funding for procurement of zinc and ORS in many countries
would be further moderated by the fact that most treatment for diarrhoea is
delivered through the private sector and paid for out of pocket.
Recent programmes in Bangladesh, Benin, India, and Nepal (summarised at
www.zinctaskforce.org/programmatic-experiences) achieved rapid increases in
zinc or ORS coverage over a short period, with relatively limited funds, by
implementing targeted interventions that created demand for—and widespread
supply of—the products. Although these countries still face obstacles to
achieving high coverage with both treatments, such as entrenched preferences
for antibiotics, these are small compared with the challenges that have been
successfully overcome in recent years to scale up treatment for malaria and HIV.
What will it take to scale up the delivery of ORS and zinc for the treatment of
diarrhoea worldwide? An essential first step is to focus attention on the
problem. The United Nations will shortly be launching the Commission on
Commodities for Women’s and Children’s Health to mobilise the health community
to identify new ways to increase access to essential health products such as
zinc and ORS. Furthermore, for the first time, the 10 countries with the
highest burden of diarrhoea have developed ambitious plans to scale up coverage
of effective treatments of diarrhoea and pneumonia.
Dedicated resources and practical operational support are now needed to
translate those countries’ plans into success. ORS and zinc treatment for
diarrhoea should appeal to any donor seeking a high return on investment and
the ability to have a rapid effect on child mortality. Those donors who have an
interest in pursuing private sector approaches would be particularly well
placed to offer initial support.
Contributions from early donors could be leveraged with other private and
public contributions to realise a tremendous dividend: a dramatic reduction in
child deaths from diarrhoea and a further leap towards achieving the millennium
Cite this as: BMJ 2012;344:e940
Competing interests: All authors have completed the ICMJE uniform
disclosure form at www.icmje.org/coi_disclosure.pdf (available on
request from the corresponding author) and declare: no support from any
organisation for the submitted work; the Clinton Health Access
Initiative has received funding from the Bill and Melinda Gates
Foundation to support national scale up of oral rehydration salts and
zinc in several countries; GY declares that the evidence to policy
initiative has received funding from the Bill and Melinda Gates
Foundation, the Clinton Health Access Initiative, and the Partnership
for Maternal, Newborn and Child Health, which all support diarrhoea
control initiatives; DM has received funding from the Bill and Melinda
Gates Foundation for travel to an unpaid expert consultation on
diarrhoea control held at the foundation in 2011; GY is a former
assistant editor at the BMJ and is on the BMJ’s editorial board.
Provenance and peer review: Commissioned; peer reviewed.
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