Zinc as a micronutrient supplement in the developing countries including Bangladesh
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 1.01�E.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: 1120�E0.
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:
999�E004.
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
Competing interests:
No competing interests
25 January 2008
Dewan S. Billal
Ph.D Post Doctoral Fellow, Microbiologist
Professor Noboru Yamanaka MD, Ph.D
Department of Otolaryngology, Wakayama Medical University, Wakayama 641-8509, Japan
Rapid Response:
Zinc as a micronutrient supplement in the developing countries including Bangladesh
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 1.01�E.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: 1120�E0.
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:
999�E004.
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
Competing interests: No competing interests