Tracey Koehlmoos: The rationale against ORS fortified with zinc

Tracey KoelhmoosThe SUZY Project aims to introduce dispersible zinc tablets as a treatment for diarrhoea in young children in Bangladesh. Due to my role in the project, I frequently receive questions from people embarking on a zinc scale up in their own country or catchment area.

Within the zinc world, there is a definite sense of community, and I am happy to be asked and happy to respond to these questions. Scaling up anything is challenging—and I know that the developer of the SUZY Project, the visionary Dr. Charles Larson, in co-ordination with the government of Bangladesh, spent years trying to find suitable partners and a suitable product. It took time to create a policy environment which made it possible to get a ten day course of zinc into every child between 6-59 months in Bangladesh.

What worries me the most is that I often receive the same question from those about to scale up zinc. “Why can’t the zinc be mixed into the oral rehydration solution (ORS)?” they ask. ORS is a simple recipe of a handful of sugar and a pinch of salt in a pitcher of water that can save the life of a diarrhoea patient by preventing dehydration. ORS is either prepared from the homemade recipe or from a pre-packaged mixture, and should be given during the course of diarrhoea and discontinued when it stops. 

Before the introduction of ORS in developing countries, diarrhoea was the leading cause of death in children. (If you are from the US or UK and do not know about ORS—you might think of it as homemade Pedialyte or Dioralyte.)

So, why can’t we mix zinc into ORS rather than introducing a new separate product?
ORS is only used during the diarrhoeal disease episode. This might be for around 3 days. To be effective the zinc must be given for 10-14 days according to the joint World Health Organization-UNICEF recommendation of 2004.

However, this does not mean that zinc and ORS should not be co-packaged or co-marketed. In Bangladesh, every zinc message includes clarity on the need for ORS. (When our scale up started, there was sincere concern that care takers would stop using ORS in favor of zinc; however, these fears did not come to fruition and ORS rates remain high). In Benin, ORS packets are co-packaged with a ten day course of zinc therapy in dispersible table form. It is also discussed that zinc and ORS could be co-packaged with the clean water necessary to prepare both mixtures.

Zinc shortens the duration of diarrhoeal disease, lessens the severity of the present episode and prevents future episodes of diarrhoea and pneumonia for up to three months. Zinc as treatment for childhood diarrhoea is both cost effective and evidence based—and should be a priority for child health service delivery programmes in developing countries.

Tracey Koehlmoos is programme head for health and family planning systems at ICDDR,B and adjunct professor at the James P. Grant School of Public Health, BRAC University.