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Zinc as a micronutrient supplement in the developing countries including Bangladesh
- Dewan S. Billal, Professor Noboru Yamanaka MD, Ph.D (25 January 2008)
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Inclusion of zinc in ORS
- Mike Jepson, Sam Ghebrehewet, Alex Keenan, Katy Elders (9 February 2008)
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Zinc supplementation in children with cholera.
- Ali Faisal Saleem (14 May 2008)
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Dewan S. Billal, Ph.D Post Doctoral Fellow, Microbiologist Department of Otolaryngology, Wakayama Medical University, Wakayama 641-8509, Japan, Professor Noboru Yamanaka MD, Ph.D
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Sir- S K Roy and colleagues1provided a double blind, randomised and placebo controlled trial regarding the supplementation of zinc in children with cholera in Bangladesh at the urban Dhaka Hospital of international Centre for Diarrhoeal Disease Research, Bangladesh between November 2000 and June 2002. The authors suggested addition of zinc as a supplement with medicine to reduce the duration of diarrhoea and stool output in children aged 3-14 years with cholera. In that issue, the intention to treat analysis, more children in the zinc group than in the control group clinically recovered from cholera by day two (54%v 33 37%, P=0.024) and by day three (83% v 62 70%, P=0.024)1. The median time until recovery was shorter among the zinc supplemented children than among the children in the control group (2 v 3 days, P=0.032). In the per protocol analysis, 49% children in the case (zinc supplement) group and 32% children in the control group recovered by two days of treatment (P=0.032) where as 81% in the study and 68% in the control group recovered by three days (P=0.032) respectively. The mean duration of recovery was shorter among the zinc supplemented children than among the children in the control group (2.68 v 3.06 days, P=0.032). Eleven percent children had less stool output in case group than the control group1. The national prevalence of zinc deficiency is high in south Asia including Bangladesh. In a meta analysis Aggarwal et al. showed that the pooled relative risk for morbidity associated with zinc deficiency is 1.09 (95% CI 1.01E.18) for diarrhoea, 1.25(95% CI 1.09- 1.43) for pneumonia, and 1.56 (95% CI 1.29-1.89) for malaria2. Based on a meta-analysis of a randomized control trials in Bangladesh reported that the relative risk for mortality due to zinc deficiency might be 1.27 (95% CI o.96 E1.63) for diarrhoea, 1.18 (95% CI 0.90-1.54) for pneumonia and 1.11(95% CI 0.94-1.30) for malaria in infants aged 1-59 months3. Zinc deficiency is resulted 4% death of under-5 in the world4. WHO/UNICEF recommendation that zinc can be used as a supplement with oral rehydration therapy for all children with diarrhoea, however preventive use of zinc supplementation or fortification is uncommon in the developing countries including Bangladesh. Although, zinc plays a great role to prevent infectious and noninfectious diseases, in the current issue the authors did not point out the significance of supplementing zinc as micronutrients in prospect of infectious diseases in Bangladesh. A follow-up survey by Baqui et al5 reported 828 deaths of children under-5 years occurring in the 1993-94 in Bangladesh. Among them, 311 deaths involved neonates, 232 occurred in the 1-11 month age group, and 285 were among children 12-59 months of age. Among them, 24.2% of deaths were associated with acute lower respiratory infection, 19.0% with diarrhoea, 8.8% were due to accidents, and 5.4% were related to neonatal tetanus. Drowning accounted for 18.9% of deaths among 1-4 year olds. Malnutrition (zinc, iron, vitamin A and other micronutrients) was associated with a third of the respiratory infections and half the diarrhoea deaths. Dying due to drowning, could be averted easily by awareness of parents and relatives, proper education of parents and upgrading the socioeconomic status. In conclusion, zinc supplementation is not only important to reduce diarrhoea but also for other infectious diseases like pneumonia, malaria which is prevalence in the developing countries like Bangladesh. Zinc fortification or preventive use of zinc can be expanded and funded by government policies, non-government organizations or other charitable organizations in the developing country including Bangladesh. World leader should be made efforts regarding maternal and child malnutrition, expansion of family education, awareness about health, better financial access for the poor, poverty reduction, and food security for all, are essential to satisfy the Millennium Development Goals 4 by 2015. References 1. Roy SK, Hossain MJ, Khatun W, Chakraborty B, Chowdhury S, Begum A,et al. Zinc supplementation in children with cholera in Bangladesh: randomised controlled trial. BMJ 2008;doi:10.1136/bmj.39416.646250.AE 2. Aggarwal R, Sentz J, Miller MA. Role of zinc administration in prevention of childhood diarrhoea and respiratory illnesses: A meta- analysis. Pediatrics 2007; 119: 1120E0. 3. Brooks WA, Santosham M, Naheed A, Goswami D, Wahed MA, Diener-West M, et al. Effect of weekly zinc supplements on incidence of pneumonia and diarrhoea in children younger than 2 years in an urban, low-income population in Bangladesh: randomised controlled trial. Lancet 2005; 366: 999E004. 4. Black RE, Allen LH, Bhutta ZA, et al. for the Maternal and Child Undernutrition Study group. Maternal and child undernutrition: global and regional exposure and heath consequences. Lancet 2008; 371:243-60. 5. Baqui AH, Black RE, Arifeen SE, Hill K, Mitra SN, al Sabir A. Causes of childhood deaths in Bangladesh: results of a nationwide verbal autopsy study. Bull World Health Organ 1998;76:161-71. Competing interests: None declared |
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Mike Jepson, F2 Public Health Cheshire and Merseyside Health Protection Unit, Sam Ghebrehewet, Alex Keenan, Katy Elders
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Dear Sir We read with interest S K Roy et al1 thorough research into severe diarrhoea caused by Vibrio cholerae in children aged 3-14yrs. We are encouraged by this publication addressing one of the most common and important global childhood diseases in less developed countries. A great deal of time and effort must have been expended collecting and analysing a large volume of data in difficult circumstances in this double blinded RCT. The authors did not, however, discuss any limitations of the study and we would like to raise a few issues. With regard to nutrition, on entry to the study the data relating to height/weight was taken but was not used other than proving that the study groups were not of statistically different composition. Would it have been appropriate to have stratified the participants into nutritional status considering their wide age range? For example, were the under 5 year olds (30% of study population) showing normal growth rates? Obviously malnourished children will have diminished immune systems and response resulting in a poorer outcome. Associated with the above is the socioeconomic status of participants, possibly the reason why no eligible patients refused to participate in the trial? During admission all patients received a standardised diet. The authors did not discuss what steps were taken to prevent differences in dietary intake (i.e. received from family) during the study period. The authors also did not compare IV fluid intake within their intervention and control groups which would have a significant difference in our view whether or not zinc was consumed. The endpoints of the study were either resolution of diarrhoea or drop-out. Resolution defined as the first formed stool or no stool for 24 hours. From the clinical procedures section we can only assume that this was assessed at 8 hourly intervals when stool output was measured. This could result in a dichotomy of data and source of error. For example child A, who has a formed stool, is recorded at ceasing diarrhoea at day 2 whereas child B, whose last diarrhoeal output was at day 2, is counted as not ceasing diarrhoea until day 3 (24hrs later) leaving a possible 16hr difference. This is especially important considering the conclusion of the study was that zinc reduced the average duration of diarrhoea by around 8 hours. Ethical approval was gained through the ICDDR, Bangladesh. One has to ponder the ethical position when as part of a study you deny a section of acutely unwell children a treatment (Zinc) recommended by global organisations such as UNICEF/WHO 2 without sufficient explanation. We feel that an important question that needs to be answered is the possibility of including zinc in oral rehydration solution (ORS). A small study including this has recently been completed concluding need for larger trials.3 Indeed, if cost is not going to be prohibitive, more would be gained if all ORS contained zinc. References; 1. Roy SK, Hossain MJ, Khatun W, Chakraborty B, Chowdhury S, Begum A, et al Zinc Supplementation in children with Cholera in Bangladesh: RCT BMJ 2008;336:266-268 (2 February). 2. Guidelines for Clinic-Based Health Workers, http://www.mostproject.org/ZINC/Zinc_Updates_Apr05/Diarrhoeaguidelines.pdf 3. Gregorio GV, Dans LF, Cordero CP, Panelo CA. Zinc supplementation reduced cost and duration of acute diarrhea in children. J Clin Epidemiol. 2007 June; 60(6):560-6. Dr. Mike Japson, F2 in Health Protection; Cheshire & Merseyside Health Protection Unit Countess of Chester Health Park Liverpool Road Chester CH2 1UL mjapson@nwhpa.nhs.uk Dr. Sam Ghebrehewet, Consultant in Communicable Disease Control; Cheshire & Merseyside Health Protection Unit Countess of Chester Health Park Liverpool Road Chester CH2 1UL sghebrehewet@nwhpa.nhs.uk Dr. Alex Keenan, Epidemiology and Surveillance Analyst; Cheshire & Merseyside Health Protection Unit Moorgate Point, Moorgate Road, Knowsley Industrial Park, Kirkby, Merseyside L33 7XW Alex.Keenan@liverpoolpct.nhs.uk Dr. Katy Elders, Consultant in Communicable Disease Control; Cheshire & Merseyside Health Protection Unit Countess of Chester Health Park Liverpool Road Chester CH2 1UL kelders@nwhpa.nhs.uk Conflict of interest: None declared Competing interests: None declared |
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Ali Faisal Saleem, Resident Pediatrics. Resident Pediatrics, The Aga Khan University hospital Karachi. 74800.
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this is in response to the article by SK Roy on zinc supplementation in children with cholera. i would like to congratulate the author on such a nice paper. i would like to respond on some issues regarding paper. **** in table 1. of baseline characteristics . (Weight (kg) 17.3 (6.1) 16.7 (5.1) 0.472); here there is difference in the mean weight among groups, although not statistically significant but clinically it has an impact. i would like to add also that it become statistically significant when author mentioned (Weight for age median (% of NCHS median) (74.9 (11.1) 71.7 (8.9) 0.033. i think it looks more explanation particularly in developing world. **** regarding Zinc dosages and duration of treatment. author mentioned that zinc supplementation of 30 mg/ day until resolution of diarrhea or for total 7 days. i am bit concern because the according to WHO recommendation the oral zinc therapy (age groups enrolled by author)is 20 mg / day for 14 days. although there must be some rationale of giving this dosage and duration in this study but unfortunately the readers were blinded for that. **** regarding table 3 since oral zinc therapy was introduced in one arm, the rationale of serum zinc level is not really looks understanding. it must be high in someone who received oral zinc therapy as compare to someone who did not. again it was not mentioned the mean duration of oral zinc therapy received by interventional arm, which causes a little discomfort in swallowing the results. Competing interests: None declared |
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