Fontaine Zink
-
Upload
ashadi -
Category
Health & Medicine
-
view
532 -
download
4
Transcript of Fontaine Zink
Update on Diarrhoea Management
What is New?
O. Fontaine, WHO – GenevaOn behalf of the Zinc task Force
A Workshop to Support the Introduction of Zinc as part of Diarrhoea Management in Indonesia
Jakarta, Indonesia
26-28 September 2006
Epidemiology
Diarrhoea Mortality
• 1980: 4.6 million child deaths from diarrhoea
• 2003: 1.8 million child deaths from diarrhoea
Black, Morris, Bryce. Lancet 2003.
Jones, Steketee, Black et al. Lancet 2003.
Diarrhoea prevalence in under-five children by socioeconomic status in
selected countries
0
5
10
15
20
25
30
Bangladesh Viet Nam Benin Tanzania
Country
Dia
rrh
oea p
revale
nce
Poorest 20%
Richest 20%
Diarrhoea Treatment Policy
Global Diarrhoea Treatment Policy
• Treatment of dehydration with ORS solution (or with an intravenous electrolyte solution in cases of severe dehydration)
• Continue feeding or increase breastfeeding during , and increase feeding after the diarrhoeal episode
• Use antibiotics only when appropriate (i.e. bloody diarrhoea) and abstain from administering anti-diarrhoeal drugs
• Advise mothers of the need to increase fluids and continue feeding during future episodes
• Provide children with 20mg per day of zinc for 10-14 days
WHO/UNICEF. Joint statement on the clinical management of acute diarrhoea. 2004.
Global Diarrhoea Treatment Policy
• Treatment of dehydration with ORS solution (or with an intravenous electrolyte solution in cases of severe dehydration)
• Continue feeding or increase breastfeeding during , and increase feeding after the diarrhoeal episode
• Use antibiotics only when appropriate (i.e. bloody diarrhoea) and abstain from administering anti-diarrhoeal drugs
• Advise mothers of the need to increase fluids and continue feeding during future episodes
• Provide children with 20mg per day of zinc for 10-14 days
WHO/UNICEF. Joint statement on the clinical management of acute diarrhoea. 2004.
Global Diarrhoea Treatment Policy
• Treatment of dehydration with ORS solution (or with an intravenous electrolyte solution in cases of severe dehydration)
• Continue feeding or increase breastfeeding during , and increase feeding after the diarrhoeal episode
• Use antibiotics only when appropriate (i.e. bloody diarrhoea) and abstain from administering anti-diarrhoeal drugs
• Advise mothers of the need to increase fluids and continue feeding during future episodes
• Provide children with 20mg per day of zinc for 10-14 days
WHO/UNICEF. Joint statement on the clinical management of acute diarrhoea. 2004.
Recent Scientific Advancesabout Zinc in the Treatment of
Diarrhoea
Zinc for the Treatment of DiarrhoeaHistory of Research
• Ongoing research from the 1990s until today
• 13 trials in acute diarrhoea
• 5 trials in persistent diarrhoea
• Age groups: 3-60 mo
• Dose of zinc: ≈ 20 mg/d (range 5-45 mg/d)
Zinc for the Treatment of DiarrhoeaResearch Findings
• 15% reduction in duration of acute diarrhoea
• 24% reduction in duration of persistent diarrhoea
• 42% reduction in treatment failure or death in persistent diarrhoea
Zinc Investigators’ Collaborative Group. AJCN 2000.
Effect of Zinc Supplementation on Duration of Acute Diarrhoea/Time to Recovery
*Bangladesh, 1999
Pooled
1*Difference in mean and 95% CI
Relative Hazards and 95% CI
*India, 1988
*India, 2000*Brazil, 2000*India, 2001
Indonesia, 1998India, 1995
Bangladesh, 1997India, 2001
India, 2001
Nepal, 2001
Bangladesh, 2001
Therapeutic Effects of Zinc on Diarrhoea Severity
CountryDiarrhoea Outcome
Percent Reduction
India Frequency 18
India Frequency 39
Bangladesh Output 28
India Output 38
Brazil Frequency 59
Additional Preventive Aspects of Zinc Treatment
• Zinc supplementation for 10-14 days has longer term effects on childhood illnesses in the 2-3 months after treatment
• 34% reduction in prevalence of diarrhoea
• 26% reduction in incidence of pneumonia
Zinc Investigators’ Collaborative Group. Pediatrics. 1999.
Preventive Effect of Zinc Supplementation on Diarrhoea Incidence in Short - Course
Supplementation Trials Bangladesh (I)
Bangladesh (II)
Pakistan
Bangladesh (III)
Pooled
0 0.25 0.5 0.75 1 1.25 1.5 1.75 2 2.25 2.5
Odds Ratio and 95% CI
Community-based Trial Demonstrates Zinc Effectiveness in
Treating Diarrhoea
• 30 health worker areas in rural Bangladesh randomized to ORS alone or ORS + zinc (20mg/d for 14 days) for diarrhoea treatment
• 11,880 child-years of observation during the 2 year study
• 23% decrease in duration of all diarrhoea episodes in zinc treatment clusters compared to control clusters (RH 0.77, 95% CI 0.69-0.86)
Baqui, Black, Arifeen. BMJ 2003.
Community-based Trial Demonstrates Longer-term Benefits of Zinc
• Zinc supplementation decreased:• Overall diarrhoea prevalence by 15% (RR
0.85, 95% CI: 0.76, 0.96)• Hospitalization from diarrhoea by 19% (RR
0.81, 95% CI: 0.65, 1.00)• ALRI prevalence by 7% (RR 0.93, 95% CI:
0.78, 1.10)• Hospitalization from ALRI by 19% (RR 0.81,
95% CI: 0.53, 1.23)
Community-based Trial Demonstrates Longer-term Benefits
of Zinc
• Decreased overall mortality by 51% (RR 0.49 95% CI: 0.25, 0.94), non-injury deaths
• Decreased antibiotic use rate from 34% in control clusters to 13% in zinc clusters (p<0.01)
• Increased ORS use from 50% in control clusters to 75% in zinc clusters (p<0.01)
Safety of Zinc Supplementation
• 9,100 children less than 5 years of age studied in 18 published clinical trials
• 11,880 child yrs of observation in 1 large community trial
• Vomiting is the only reported adverse effect– 5/7 trials report no differences between zinc and
placebo– 2 trials report slightly higher vomiting rates in zinc
supplemented children
• 4 trials show no difference in copper status after 2 weeks of zinc supplementation
Cost Effectiveness of ORS and Zinc Supplementation
• Decreases the duration and severity of the episode
• Decreases the need for expensive hospitalization
• Decreases the use of unnecessary antibiotics and other drugs
• Further cost-benefit analyses are underway• Robberstad, Strand, Sommerfelt, and Black. Bull WHO 2004.
Baqui, Black, Arifeen. J Health Pop Nutr. 2004.
ORS and Zinc
Treatment is now more effective
This is the chance to make a difference