Scaling up oral rehydration salts and zinc for the treatment of diarrhoeaBMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e940 (Published 10 February 2012) Cite this as: BMJ 2012;344:e940
- Oliver Sabot, executive vice president for global programs1,
- Kate Schroder, director of essential medicines initiative1,
- Gavin Yamey, lead, evidence to policy initiative 2,
- Dominic Montagu, lead, health systems initiative2
- 1Clinton Health Access Initiative, Boston, MA, USA
- 2Global Health Group, University of California San Francisco, San Francisco, CA 94105, USA
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,5 and other preventive interventions are relatively costly or difficult to scale up quickly.6 7 Treatment with ORS and zinc could rapidly and cost efficiently avert most of the deaths not prevented by vaccines.6
A systematic review estimated that universal coverage with ORS would reduce diarrhoea related deaths by 93%.8 A second systematic review estimated that in zinc deficient populations, zinc treatment reduces diarrhoea related deaths by 23%.9 Yet only about 30% of children with diarrhoea in high burden countries receive ORS,10 and fewer than 1% receive ORS plus zinc.6 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.10
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,3 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.4 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.11 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,12 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.
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.