Academic journal article Journal of Health Population and Nutrition

Effect of HIV/AIDS and Malaria on the Context for Introduction of Zinc Treatment and Low-Osmolarity ORS for Childhood Diarrhoea*

Academic journal article Journal of Health Population and Nutrition

Effect of HIV/AIDS and Malaria on the Context for Introduction of Zinc Treatment and Low-Osmolarity ORS for Childhood Diarrhoea*

Article excerpt


Over a quarter-century has passed since the introduction of oral rehydration therapy (ORT) for diarrhoea in 1978 (1). ORT, including both prepackaged oral rehydration salts (ORS) and local recipes for home-fluids, remains the cornerstone of management of diarrhoea. ORT enables caregivers to manage dehydration in the home, decreases the need for intravenous fluids, and decreases rates of hospitalization and mortality. In 1980, diarrhoea was estimated to account annually for 4.6 million deaths of children aged less than five years (under-five children) (2), while recent estimates for 2003 attribute 18% or 1.9 million of 10.6 million annual deaths to diarrhoea, representing 3% of neonatal mortality and 17% of mortality in children aged 1-59 month(s) (3). Two-Africa and South-East Asia-of the six regions of the World Health Organization (WHO) account for approximately 40% and 31% deaths due to diarrhoea among children respectively, or almost three-quarters of the global annual deaths of children aged less than five years (under-five deaths) attributable to diarrhoea (3). This decrease in mortality is a great public-health success story, yet there has been limited or no decrease in rates of incidence of diarrhoea and morbidity (4). Improved case management is an important strategy to decrease the remaining 1.9 million childhood deaths attributable to diarrhoeal illness.

In May 2004, the WHO and United Nations Children's Fund (UNICEF) issued new recommendations for the management of all episodes of childhood diarrhoea, including new low-osmolarity oral rehydration salts (ORS) and supplementation of zinc for 10-14 days (5). When properly deployed, these two advances in treatment will decrease morbidity and enable further reductions in mortality due to diarrhoea. Low-osmolarity ORS continues to prevent and treat dehydration and also decreases stool volume by 25-30%, decreases the prevalence of vomiting by 30%, and decreases the need for unscheduled intravenous therapy by 30% (6-8). Supplementation of zinc for 10-14 days decreases the duration and severity of the diarrhoea episode and decreases morbidity from diarrhoea and pneumonia in the 2-3 months following treatment (9,10).

Zinc is an effective treatment for diarrhoea and resembles a modern pharmaceutical (tablets or syrup); therefore, zinc has the potential to reduce inappropriate use of antimicrobials for childhood diarrhoea through a replacement effect. Results of a community-based trial in Bangladesh showed that, in areas where zinc was introduced into the management of diarrhoea, inappropriate use of antibio-tics was significantly less than in control areas without zinc treatment (11). Preliminary evidence from Mali and India also suggests that the introduction of zinc treatment may reduce the unnecessary use of antibiotics for diarrhoea (12,13). Child-health and nutrition programmes will not only need to develop strategies to promote low-osmolarity ORS and supplementation of zinc, they can also work to discourage antibiotic use for simple diarrhoea through replacement with zinc.

There are now calls for a sustained effort to roll-out zinc and the new formulation of ORS and to ensure that it is in the hands of low-income and marginalized populations who most need it (14,15). Such efforts should also promote continued feeding, appropriate home-fluids, and breastfeeding.

Rates of ORS use for the management of diarrhoea vary greatly throughout sub-Saharan Africa and South Asia, reflecting regional variations in promotion and acceptance of ORS. High rates of incidence of HIV and malaria represent an added burden to already struggling health systems. This paper focuses on how these three factors-(a) current childhood diarrhoea-management practices, (b) prevalence of HIV, and (c) endemicity of malaria- affect the context of introduction of low-osmolarity ORS and supplementation of zinc at various levels: national policy, health programmes, health facilities, and households. …

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