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[e-drug] Scaling up oral rehydration salts and zinc for the treatment of diarrhoea

E-DRUG: Scaling up oral rehydration salts and zinc for the treatment of 
diarrhoea
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[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

http://www.bmj.com/content/344/bmj.e940

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 
initiative,(yameyg@globalhealth.ucsf.edu) 
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 
coverage.

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 
development goals.

Notes
Cite this as: BMJ 2012;344:e940

Footnotes
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.

References
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3. WHO/Unicef. Joint statement: clinical management of acute diarrhoea
(WHO/FCH/CAH/04.07). 2004.
www.wpro.who.int/internet/resources.ashx/CHD/docs/ENAcute_Diarrhoea_reprin
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Global, regional, and national causes of child mortality in 2008: a
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