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Zinc and other micronutrients
ORS and Zinc: Treatment of diarrhoea is now more effective

Zinc treatment is a simple, inexpensive, and critical new tool for treating diarrheal episodes among children in the developing world. This important micronutrient becomes depleted during diarrhea, but recent studies suggest that replenishing zinc with a10- to 14-day course of treatment can reduce the duration and severity of diarrheal episodes and may also prevent future episodes for up to three months. It is important that the full-course of zinc is taken, and that follow-up and behavior change messages for caregivers are given to ensure full compliance. In 2004, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) issued a joint statement regarding the clinical management of acute diarrhea. This statement recommended the use of zinc treatment, as well as a new formulation of oral rehydration solution (ORS), as a two-pronged approach to treatment. Vitamin A supplementation is another important and low-cost intervention for controlling severe and potentially fatal diarrheal episodes. The relative risk of dying from diarrhea increases two-fold in children with vitamin A deficiency. In countries where under-five mortality rates are high, giving semi-annual vitamin A supplements to children six to 59 months old decreases overall mortality from all childhood diseases by 23 percent and mortality from diarrhea by 32 percent. A dose of vitamin A for newborns has been found to be effective in reducing early mortality, and may soon be widely recommended.

Other micronutrients may be important to maintain the integrity of immune function and appetite during an episode of diarrhea. Iron deficiency, for example, depresses appetite and may increase the risk of malnutrition associated with diarrhea. PATH is working with country partners to implement a comprehensive approach to diarrheal disease control that incorporates new technologies like zinc with proven interventions. For more information, please visit the PATH website. UNICEF is helping countries with registration of zinc and collaborating with WHO to provide guidelines for its use in treating diarrhea.

Key resources

Below are some key documents on zinc. Please also browse our list of helpful websites for more resources.

Below is a key document on vitamin A. Please also browse our list of helpful websites for more resources.

Other helpful websites

References
1Bhutta ZA, Bird SM, Black RE, et al. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: Pooled analysis of randomized controlled trials. American Journal of Clinical Nutrition. 2000. 72(6):1516-1522.

Photo: PATH/Carib Nelson.


Reproduced from the PATH Resources for Diarrheal Disease Control website at www.eddcontrol.org, [6 November, 2009].


ORS Containing Zinc Does Not Reduce Duration or Stool Volume of Acute Diarrhea in Hospitalized Children
Wadhwa, Nitya*; Natchu, Uma Chandra Mouli†; Sommerfelt, Halvor‡; Strand, Tor A.‡; Kapoor, Vishal*; Saini, Savita*; Kainth, Udaypal S.§; Bhatnagar, Shinjini*

Journal of Pediatric Gastroenterology & Nutrition: August 2011 - Volume 53 - Issue 2 - p 161–167 - doi: 10.1097/MPG.0b013e318213ca55
Original Articles: Gastroenterology



Background and Aim: The World Health Organization recommends oral zinc (tablets or syrups) as adjunct therapy with oral rehydration solution (ORS) for acute childhood . Mixing zinc with ORS can be an attractive approach for simultaneous provision of these 2 effective interventions. This double-masked randomized controlled trial evaluated the efficacy of ORS containing 40 mg/L elemental zinc per liter (zinc-ORS) in reducing stool weight and duration of diarrhea.

Patients and Methods: Five hundred northern Indian children ages 1 to 35 months with diarrhea <7 days’ duration were randomized to zinc-ORS or ORS. The primary outcomes were total stool output and time to recovery.

Conclusions: The World Health Organization–recommended daily dose of zinc for diarrhea was not achieved in most children beyond the first day of treatment. This is the likely explanation for the lack of improvement in outcomes from zinc-ORS when compared with ORS alone. Our findings do not support a change from using zinc syrup or dispersible tablets for treatment of acute diarrhea in children.


Zinc Supplementation - ORS and Zinc: Treatment of diarrhoea is now more effective

ORS and Zinc: Treatment of diarrhoea is now more effective

ZINC SUPPLEMENTS REDUCE THE SEVERITY AND DURATION OF DIARRHOEA

Twelve studies examined the impact of zinc supplements on the management of acute diarrhoea. Eleven of these showed a reduction in the duration of the diarrhoeal episode; in eight of these, the reduction was statistically significant. Five of the above studies also collected data on stool volume or frequency, and found that zinc supplements reduced stool output or frequency. The data shows that zinc supplementation during and until cessation of diarrhoea (either syrup containing 20 mg of elemental zinc per 5 ml, or tablets of 20 mg zinc such as zinc sulphate, gluconate or acetate) has a significant and beneficial impact on the clinical course of acute diarrhoea, reducing both its duration and severity. Recent studies suggest that a 10- to 14-day therapy of zinc treatment can considerably reduce the duration and severity of diarrhoeal episodes, decrease stool output, and lessen the need for hospitalization. Zinc may also prevent future diarrhea episodes for up to three months.


Diarrhea: The Great Zinc Breakthrough - 17 August, 2009

Can One Pill Tame the Illness
No One Wants to Talk About?


17 August 2009

Diarrhea: The Great Zinc Breakthrough - 17 August, 2009
It is hard to grasp the impact diarrhea has on people's lives across Africa and Asia. The disease kills more children than either malaria or AIDS, stunts growth, and forces millions — adults and children alike — to spend weeks at a time off work or school, which hits both a country's economy and its citizens' chances of a better future.

Taming a Devastating Illness with a Simple Pill
See pictures of of how zinc is saving lives in Mali.
Zinc tablets help African communities fight diarrhea, a scourge that claims the lives of an astonishing 1.6 million children every year

Healing: The Unexpected Properties of Zinc


ZINC SUPPLEMENTS PREVENT SUBSEQUENT EPISODES OF DIARRHOEA

Other studies evaluating the effect of zinc supplementation on diarrhoeal diseases found a preventive and long-lasting impact. These studies show that 10 mg to 20 mg of zinc per day for 10–14 days reduced the number of episodes of diarrhoea in the 2–3 months after the supplementation regimen.

WHO and UNICEF therefore recommend daily 20 mg zinc supplements for 10–14 days for children with acute diarrhoea, and 10 mg per day for infants under six months old, to curtail the severity of the episode and prevent further occurrences in the ensuing 2-3 months.


Pediatric Zinc as Treatment for DiarrheaPediatric Zinc as Treatment for Diarrheapdf

In May 2004, WHO/UNICEF issued a joint statement recommending the use of zinc, an essential micronutrient for human growth, development and maintenance of the immune system, and a new formulation oral rehydration solution (ORS), with reduced levels of glucose and salt, as a two-pronged approach to improved case management of acute diarrhoea in children. Zinc supplements reduce the duration of an episode of diarrhoea and protect against future bouts of diarrhoea for two to three months after the episode.

This document as Pediatric Zinc as Treatment for Diarrheapdf 1 page 49 kb

Every year approximately 1.7 million children die as a result of diarrhea and dehydration. In the majority of cases, this is preventable through exclusive breastfeeding, improved hygiene and sanitation and access to clean water, yet diarrhea is still one of the leading causes of death among children under five.

In May 2004, WHO/UNICEF issued a joint statement recommending the use of zinc, an essential micronutrient for human growth, development and maintenance of the immune system, and a new formulation oral rehydration solution (ORS), with reduced levels of glucose and salt, as a two-pronged approach to improved case management of acute diarrhea in children.

Dispersible zinc tablets, which dissolve easily in a tablespoon of clean water or breastmilk, can be used for zinc supplementation for children aged one to 59 months. WHO and UNICEF recommend 20 mg of zinc per day for ten -14 days for infants and children, ten mg for infants under six months of age.

For more than 20 years researchers have been assessing the benefit of zinc supplementation during diarrhea episodes. Studies have shown that zinc supplementation results in a 25% reduction in duration of acute diarrhea and 40% reduction in treatment failure or death in persistent diarrhea. These studies also revealed that children receiving zinc experience a decrease in the severity of their diarrhea episodes. A ten day course has proven to provide a prophylactic protection against future bouts of diarrhea for two to three months after the episode.

The combined recommendation of zinc and ORS is a safe, effective and inexpensive diarrhea treatment for children in the developing world. The only known side effect of zinc use is vomiting, which is rarely reported and is typically attributed to a metallic taste in the zinc. Use of high-quality zinc products easily avert this side effect.

Zinc manufacture requires only simple technology and no expensive ingredients. Zinc can be produced in both syrup and tablet form. Efforts are already underway to transfer the technology from French developer and patent holder, Nutriset/Rodael, to local manufacturers in the developing world, who will be able to take over production, thus keeping costs affordable for the poorest of the poor.

Pilot programs have begun in several countries, testing various approaches to training both health facility staff and community health workers, developing and delivering behavior change communication messages and consumer educational materials, and monitoring program progress. Private sector zinc programs are testing the feasibility of marketing zinc tablets and ORS as stand alone products or packaging them together as a Diarrhea Treatment Kit (DTK).

For more information visit the POUZN (Social Marketing for Diarrheal Disease Prevention and Treatment) website: www.pouzn.com

Cost-effectiveness of zinc as adjunct therapy for acute childhood diarrhoea in developing countriespdf
A Public-Private Partnership for the Introduction of Zinc for Diarrhea Treatment in Benin - Results and Lessons Learnedpdf
Fourniture d’une eau potable grâce au programme Aquatabs du POUZN au Bénin - Résultats et leçons apprisespdf
Un partenariat public-privé pour l’introduction du zinc pour le traitement de la diarrhée au Bénin : Résultats et leçons apprisespdf
Assuring Rural Access to Water Treatment Products in Kenya’s Coast Province - Results and Lessons Learnedpdf
Assuring Access to Pediatric Zinc for Diarrhea Treatment Through the Private Sector in Madagascar - Results and Lessons Learnedpdf
Assurer l’accès au zinc pédiatrique pour le traitement des diarrhées au moyen du secteur privé à Madagascar : Résultats et leçons apprisespdf
Passage à l’échelle du traitement de l’eau au point d’utilisation au moyen de plusieurs filières au Rwanda : Résultats et leçons apprisespdf


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Production of zinc tablets and zinc oral solutions

Guidelines for programme managers and pharmaceutical manufacturers

Production of zinc tablets and zinc oral solutions Authors: World Health Organization, UNICEF, Johns Hopkins Bloomberg School of Public Health, USAID
Number of pages: 28
Publication date: 2007
Languages: English, French, Russian
ISBN: 9241594942 (English), 9789242594942 (French), 9789244594940 (Russian)


English [pdf 668kb] pdf French [pdf 256 Kb] pdf Russian [pdf 244Kb] pdf


Overview

These guidelines were prepared to assist policy makers and programme managers in the selection and procurement of quality zinc products (zinc tablets and zinc oral solutions) for use in the prevention and treatment of diarrhoea in children under the age of five. These guidelines can also be used by pharmaceutical manufacturers to develop quality zinc products.



Zinc Supplementation On-line Resources:

Zinc for the treatment of diarrhoea: effect on diarrhoea morbidity, mortality and incidence of future episodes
Christa L Fischer Walker and Robert E Black
Zinc supplementation for the treatment of diarrhoea has been shown to decrease the duration and severity of the diarrhoeal episode, diarrhoea hospitalization rates and, in some studies, all-cause mortality. Using multiple outcome measures, we sought to estimate the effect of zinc for the treatment of diarrhoea on diarrhoea mortality and subsequent pneumonia mortality.


A complete and up-to-date list of the following and related resources can be found at
DefeatDD.org Controlling Diarrheal Disease



Literature on zinc research (2006)
A comprehensive list of research articles and related literature on the benefits of zinc supplementation, including information on the use of zinc for children in developing-country settings.
International Centre for Diarrhoeal Disease Research, Bangladesh


Zinc publications and reference materials
Stemming from years of work conducted through the USAID program aimed at exploring the health benefits of zinc supplementation, this website contains many helpful resource and research materials.
USAID Micronutrient Program

Clinical management of acute diarrhoea (2004)
This official statement updates previous WHO/UNICEF recommendations on the management of acute diarrhea, taking into consideration new research findings that indicate the success of interventions incorporating reduced-osmolarity ORS and zinc supplementation.
World Health Organization (WHO), UNICEF
Clinical management of acute diarrhoea (2004)pdf English 241 kb


Diarrhoea treatment guidelines including new recommendations for the use of ORS and zinc supplementation for clinic-based healthcare workers (2005)
These guidelines were developed to advise clinic-based health workers on implementing the latest WHO/UNICEF recommendations for ORS and zinc supplementation in the clinical management of diarrhoea.
US Agency for International Development (USAID) Micronutrient Program
Diarrhoea treatment guidelines including new recommendations for the use of ORS and zinc supplementation for clinic-based healthcare workers (2005)pdf English 401 kb
Guidelines for new diarrhea treatment protocols for community-based healthcare workers (2005)
These guidelines were developed to advise community health care workers who assist parents with home treatment of children with diarrhea with regard to the latest WHO/UNICEF recommendations.
USAID Micronutrient Program
Guidelines for new diarrhea treatment protocols for community-based healthcare workers (2005)pdf English 128 kb

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General information

The role of zinc in child health (2004)
This report provides an overview of the rationale for providing zinc supplements to reduce severe diarrheal episodes and as an overall intervention for child health in the developing world.
The International Zinc Nutrition Consultative Group
The role of zinc in child health (2004)pdf English 191 kb
Zinc: From research to programs (2004)
This presentation summarizes research findings on the effects of zinc supplementation on diarrhea and also discusses advances in policy addressing diarrhea treatment.
USAID Micronutrient Program
Zinc: From research to programs (2004)pdf English 60 kb

Treatment guidelines

Introducing zinc in a diarrheal control program: A manual for conducting formative research (revised 2004)
Originally developed to inform a multicenter zinc trial in Asia and Africa, this guide is a useful resource for planning zinc intervention trials, as well as the introduction of zinc and other supplements and/or medicines into clinic or community settings.
Nichter M, Acuin C, Vargas A.
Introducing zinc in a diarrheal control program: A manual for conducting formative research (revised 2004)pdf English 550 kb
Monograph for zinc sulfate tablets (2005)
This proposed monograph is under consideration by the US Pharmacopeia to ensure quality manufacturing standards for zinc tablets.
US Pharmacopeia
Monograph for zinc sulfate tablets (2005)pdf English 62 kb
The Treatment of Diarrhoea. A manual for physicians and other senior health workers (2005)
Developed for physicians treating infectious diarrhea in young children, this manual has been updated to include guidelines for the use of reduced-osmolarity ORS and zinc supplements.
WHO
The Treatment of Diarrhoea. A manual for physicians and other senior health workers (2005)pdf English 1 mb
Zinc supplementation for the treatment of diarrhea: Moving from research to practice (2005)
This report provides a brief history of ORS and the inclusion of zinc supplementation; outlines case studies proving the benefits of zinc for diarrhea treatment; and discusses programmatic challenge points.
USAID Micronutrient Program

Zinc supplementation for the treatment of diarrhea: Moving from research to practice (2005)pdf English 81 kb

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Research


Substantial reduction in severe diarrheal morbidity by daily zinc supplementation in young North Indian children (2002)
This study concluded that episodes of severe diarrhea were significantly reduced when daily zinc supplements were provided to children. The authors also call for reliable estimates of zinc deficiency levels among children in developing countries, in order to facilitate intervention with zinc supplementation.
Bhandari N, et al. Pediatrics. 109(6):e86.


Zinc supplementation in acute diarrhea is acceptable, does not interfere with oral rehydration, and reduces the use of other medications: A randomized trial in five countries (abstract only; 2006)

This study determined that adding zinc to management of acute watery diarrhea does not affect overall ORS use and decreases use of antibiotics and other antidiarrheal medicines.
INCLEN Childnet Zinc Effectiveness for Diarrhea (IC-ZED) Group. Journal of Pediatric Gastroenterology & Nutrition. 42(3):300-305.


Cost-effectiveness of zinc as adjunct therapy for acute childhood diarrhoea in developing countries (2004)

This study analyzed the cost-effectiveness of adding zinc to diarrheal disease treatment interventions, as compared to the cost-effectiveness of oral rehydration solution as a stand-alone treatment.
Robberstad B, Strand T, Black R, Sommerfelt H. Bulletin of the World Health Organization. 82(7):523-531.
Cost-effectiveness of zinc as adjunct therapy for acute childhood diarrhoea in developing countries (2004)pdf English 519 kb
Effect of zinc supplementation between 1 and 6 mo of life on growth and morbidity of Bangladeshi infants in urban slums (2002)
The authors of this study evaluated the effect of zinc supplementation on growth and morbidity in poor Bangladeshi infants.
Osendarp S, Santosham M, Black R, Wahed M, van Raaij J, Fuchs G. American Journal of Clinical Nutrition. 76(6):1401–1408.
Effect of zinc supplementation between 1 and 6 mo of life on growth and morbidity of Bangladeshi infants in urban slums (2002)pdf English 110 kb
Effect of zinc supplementation on clinical course of acute diarrhoea (2001)
This report reviews published studies addressing the efficacy of zinc supplementation in reducing severity of diarrheal disease episodes. The report concludes that sufficient evidence supports the use of zinc supplementation and also encourages further study.
Bahl R, Baqui A, Bahn M, et al. Journal of Health, Population and Nutrition. 19(4):338-346.
Effect of zinc supplementation on clinical course of acute diarrhoea (2001)pdf English 118 kb
Effectiveness and efficacy of zinc for the treatment of acute diarrhea in young children (2002)
This study in India evaluated the administration of three Recommended Daily Allowances of zinc among children with acute diarrhea in Nepal and recorded substantial reduction of diarrheal duration. The investigators also determined that the effect of zinc was not dependent on or enhanced by concomitant vitamin A administration.
Strand T, Chandyo R, Bahl R. Pediatrics. 109(5):898–903.
Effectiveness and efficacy of zinc for the treatment of acute diarrhea in young children (2002)pdf English 130 kb
Formative research in preparation for promotion of zinc treatment for childhood diarrhea: Cross-country comparison of diarrhea treatment practices and implications for programs (2004)
This summary of research was prepared for a discussion of global planning to implement zinc for diarrheal treatment, held at the 2004 meeting Planning for Implementation of Zinc for Treatment of Diarrhea.
Winch P, FitzGerald M. USAID Micronutrient Program
Formative research in preparation for promotion of zinc treatment for childhood diarrheapdf English 126 kb
Lessons learned in a pilot introduction of zinc treatment for childhood diarrhea in Bougouni District, Mali (2005)
Geared toward program planners and managers who are considering introducing zinc treatment for diarrhea into existing child health and nutrition interventions, this report discusses key lessons learned through a pilot project and offers conclusions and recommendations for future zinc programs.
Gilroy K, Kuszmerski N, Winch P. USAID
Lessons learned in a pilot introduction of zinc treatment for childhood diarrhea in Bougouni District, Mali (2005)pdf English 566 kb
Low risk of adverse effects from zinc supplementation (2005)
This brief reviews evidence on the safety of zinc supplementation in children, including reports of adverse effects from both long-term and short-term studies, and concludes that zinc supplementation is a safe and effective treatment for diarrhea.
Fischer C, Harvey P. USAID Micronutrient Program
Low risk of adverse effects from zinc supplementation (2005)pdf English 85 kb
Randomized control trial of zinc supplementation in malnourished Bangladeshi children with acute diarrhea (1997)
This study determined that zinc supplementation is a safe and effective method for management of acute diarrhea in children who are malnourished.
Roy SK, Tomkins AK, Akramuzzaman SM, Haider R, Mahalanabis D, Fuchs G. Archives of Disease in Childhood. 77:196–200.
Randomized control trial of zinc supplementation in malnourished Bangladeshi children with acute diarrhea (1997)pdf English 183 kb


Therapeutic and preventive effects of zinc on serious childhood infectious diseases in developing countries (1998)
This review provides details on the therapeutic and preventive effects of zinc supplementation on diarrheal disease episodes, as evidenced by published studies. The author also briefly discusses the effects of zinc on malaria and acute lower respiratory infections.
Black R. American Journal of Clinical Nutrition. 68(suppl):476S–479S.
Therapeutic and preventive effects of zinc on serious childhood infectious diseases in developing countries (1998)pdf English 138 kb
Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: Pooled analysis of randomized controlled trials (2000)
The authors of this review performed a comprehensive analysis of published studies to determine the efficacy of zinc supplementation given during episodes of acute diarrhea.
Zinc Investigators’ Collaborative Group, American Journal of Clinical Nutrition. 72:1516-1522.
Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countriespdf English 99 kb


Zinc therapy for diarrhoea increased the use of oral rehydration therapy and reduced the use of antibiotics in Bangladeshi children (2004)
This study conducted by partners from the Johns Hopkins School of Public Health and the International Centre for Diarrhoeal Disease Research concluded that use of zinc supplementation during diarrheal episodes led to a reduction in the use of antibiotics, overuse of which has been shown to increase antimicrobial resistance in developing countries.
Baqui A, Black R, El Arifeen S, et al. Journal of Health, Population and Nutrition; 22(4):440-442.
Zinc therapy for diarrhoea increased the use of oral rehydration therapy and reduced the use of antibiotics in Bangladeshi children (2004)pdf English 116 kb

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A complete and up-to-date list of the following and related resources can be found at
http://www.mostproject.org/whatsnew.htm


ZINC Publications and Reference Materials In May 2004, a WHO/UNICEF Joint Statement on the Clinical Management of Acute Diarrhea was issued. This statement called for the adoption of new recommendations for zinc supplementation together with a new ORS formula for the clinical management of diarrhea. On behalf of USAID, MOST is supporting the rapid scale-up of this high impact, child survival intervention. A component of this support is to increase the accessibility of information about the use of zinc supplementation as an adjuvant treatment for diarrhea.

Key Documents

The first eight documents provide key evidence in support of USAID's decision to encourage the rapid global rollout of this new, high-impact child survival intervention.

The WHO/UNICEF Joint Statement May 2004 on the Clinical Management of Acute Diarrhoea. These new recommendations, formulated by UNICEF and WHO in collaboration with USAID and experts worldwide, take into account new research findings while building on past recommendations. PDF filepdf

Bhutta et al. Am J Clin Nutr 2000. Presents the meta-analyses of efficacy studies demonstrating that 10-14 days of zinc supplementation reduce the duration and severity of diarrhea episodes. PDF pdf

Baqui et al. BMJ 2002. Presents evidence from a community-based trial confirming the shorter duration of diarrhea with zinc supplementation, and other benefits of zinc including reduced incidence of both diarrhea and acute lower respiratory tract infections, and fewer admissions to hospital in children with diarrhea. PDF pdf

Robberstad et al. Bull WHO 2004. Presents a cost-effectiveness analysis in terms of DALYs and child deaths averted using a simulation technique with cost data from health facilities in Tanzania. The authors concluded that zinc for diarrhea treatment is highly cost-effective. PDF pdf

Application for the inclusion of zinc sulphate in the WHO Model List of Essential Medicines. Approved March 2005. It presents an update to March 2003 of further efficacy studies published and presents more detail on safety. PDFpdf

Low Risk of Adverse Effects from Zinc Supplementation. This brief reviews the available evidence on the safety of zinc supplementation in children, summarizes reports of adverse effects from both long-term and short-term studies, and concludes that zinc supplementation is a safe and effective treatment for diarrhea. PDFpdf

US Pharmacopeia. The definition of the zinc tablet is developed to enable quality assurance. PDFpdf

The dispersible 20 mg zinc tablets now recommended by WHO and UNICEF for use with ORT in treating all forms of diarrhea may be obtained from Nutriset at www.nutriset.fr or by e-mail at [email protected]. USAID grantees and cooperative agreements are able to use USAID funds to purchase the tablets from NUTRISET under a waiver available for that purpose. For information on the waiver write to Jill Boezwinkle at [email protected].


Manuals, Guidelines, Statements Concerning Diarrhea Treatment

Guidelines for Clinic-Based Health Workers - Not yet field tested.
Guidance on how to implement the new WHO/UNICEF recommendations for the use of ORS and zinc supplementation in the clinical management of diarrhea. The guidelines presented in this document are generic; that is, they will be most effective when modified to support the particular strategy being used to introduce the new recommendations in each country. (no. 135) (PDF file in English)pdf, (PDF file in Spanish)pdf

Introducing Zinc in a Diarrheal Control Program: A Manual for Conducting Formative Research. Describes the methods used for formative assessment in a multi-country clinical trial coordinated by INCLEN. The purpose of the trial was to assess acceptance by the global community of zinc supplementation as an adjuvant treatment to ORS prior to its introduction as a policy. The manual was developed to provide a standardized approach to developing appropriate and effective messages to use both ORS and zinc together. This clinical trial was conducted in seven sites: 1) Lucknow and 2) Nagpur in India, 3) Manila, Philippines, 4) Pretoria, South Africa, 5) Cairo, Egypt, 6) Addis Ababa, Ethiopia, and 7) Fortazena, Brazil. (Available at http://www.inclentrust.org. Look under What's New.)

The Treatment of Diarrhoea – A manual for physicians and other senior health workers has been updated to include these changes and should serve as the reference for the management of diarrhoea. This guide is distributed by WHO

UNICEF/WHO Joint statement on ORS, March 2002. This document was prepared to inform national authorities on the position of the United Nations Children’s Fund (UNICEF) and of the World Health Organization (WHO) with respect to issues such as flavoring, coloring, and rice-based ORS. It is based on a document first published in July 1996 that was revised to take into account results of studies on ORS formulation and zinc supplementation. PDFpdf

Other Zinc Links and Documents

Lessons learned in a pilot introduction of zinc treatment for childhood diarrhea in Bougouni District in Mali.
This April 2005 report is written for program managers and planners interested in the lessons learned about operational issues in the pilot introduction of zinc supplementation as an adjunct treatment for childhood diarrhea in Mali. PDFpdf

Zinc Supplementation for the Treatment of Diarrhea: Moving from Research to Practice. A five-page document describing the history of ORS and the inclusion of zinc supplementation, case studies proving the benefits of zinc, using zinc for diarrhea treatment, and programmatic challenge points. PDFpdf

MOST summary article 2005. Cost-effectiveness of zinc supplementation as an adjunct treatment for childhood diarrhea PDF

New diarrhea treatment guidelines could save more lives, article on pages 3-4 of the 2004/4 Nutriview Newsletter

Effect of Zinc Supplementation on Clinical Course of Acute Diarrhoea. Report of a Meeting, New Delhi, 7-8 May 2001

SUZY - Scaling Up Zinc Treatment for Young Children with Diarrhoea in Bangladesh. A large national program to introduce new guidelines for the management of diarrhea in Bangladesh.

IZiNCG Technical Document – The first IZiNCG Technical Document has been compiled by the Steering Committee, and published as a supplement to the United Nations University Food and Nutrition Bulletin (March, volume 25, supplement 2:S94-S204; 2004).

Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania. Lancet. 2004 Oct 30;364(9445):1583-94.

Integrated Management of Childhood Illness (IMCI) in Bangladesh: Early findings from a cluster-randomized study. Lancet. 2004 Oct 30;364(9445):1595-602.

Summary Document from June 2004 Zinc Implementation Meeting in Baltimore, the purpose of which was to bring together experts in zinc research and program design/implementation to review recent research on zinc in treatment of diarrhea; learn about WHO/UNICEF/USAID plans for rolling-out zinc for treatment of diarrhea; and strategize next steps for the scaling up of zinc supplementation through NGOs, public and private sectors PDF file pdf

In preparation for promotion of zinc treatment for childhood diarrhea: Cross-country comparison of diarrhea treatment practices and implications for programs. Summary document developed for the June 2004 Zinc Implementation Meeting in Baltimore. PDFpdf

PowerPoint presentation given at USAID in September 2004 regarding zinc and ORS. Document is in the form of a handout, six slides to a page. PDF

FAQs

A series of questions,
to date, that has arisen in the field regarding the promotion of ORS/zinc treatment. PDF file pdf

Frequently asked questions concerning the "NEW ORS" - i.e. low osmolarity ORS. Developed by WHO, May 2004. PDF file (in English)pdf, PDF file (in French)pdf

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Zinc Links


Weekly zinc supplements can reduce deaths in young children
Giving young children in developing countries a weekly dose of zinc can substantially reduce their risk of illness and death, according to a study published online today (Tuesday August 23, 2005) by THE LANCET...

New diarrhea treatment guidelines could save more lives, article on pages 3-4 of the 2004/4 Nutriview Newsletter

Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania. Lancet. 2004 Oct 30;364(9445):1583-94.

Integrated Management of Childhood Illness (IMCI) in Bangladesh: Early findings from a cluster-randomized study. Lancet. 2004 Oct 30;364(9445):1595-602.

Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: pooled analysis of randomized controlled trials. Am J Clin Nutr. 2000 Dec;72(6):1516-22.

Effect of Zinc Supplementation on Clinical Course of Acute Diarrhoea. Report of a Meeting, New Delhi, 7-8 May 2001

The Treatment of Diarrhoea – A manual for physicians and other senior health workers has been updated to include these changes and should serve as the reference for the management of diarrhoea. This guide is distributed by WHODownload pdf version

SUZY - Scaling Up Zinc Treatment for Young Children with Diarrhoea in Bangladesh. A large national program to introduce new guidelines for the management of diarrhea in Bangladesh.

IZiNCG Technical Document – The first IZiNCG Technical Document has been compiled by the Steering Committee, and published as a supplement to the United Nations University Food and Nutrition Bulletin (March, volume 25, supplement 2:S94-S204; 2004).



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IVACG 2004


The following publications were distributed at the 2004 meetings of the International Vitamin A Consultative Group (IVACG), the International Nutritional Anemia Consultative Group (INACG), and the International Zinc Nutrition Consultative Group (IZiNCG), held in Lima, Peru, November 15-19, 2004.
A Strategic Approach to Anemia Control.
Describes the MOST Project’s experiences together with the options now available for addressing anemia in developing countries. (no. 133)
Download pdf versionPDF file


Improving the Performance of Maternal Anemia Interventions in Africa. Describes the process used to develop a comprehensive program to control anemia in pregnant women in four districts of Uganda in 2002. (no. 134)
Download pdf versionPDF file


Overcoming Barriers to Effective Anemia Interventions during Antenatal Services in Uganda . [Reprinted] Describes the process and results of a study undertaken to identify barriers to implementation of effective interventions aimed at addressing anemia in pregnancy. (no. 131)
Download pdf versionPDF file
Elements of a National Food-Fortification Program / Bangladesh. This study’s primary objective is to identify major elements of a food-fortification strategy in Bangladesh, including micronutrient formulation for the food vehicles as suitable for fortification. (no. 138)
Download pdf versionPDF file
Micronutrients Lead the Way: Making Gains in Nutrition and Health. Discusses options and strategies for improving micronutrient health in deficient populations. Provides details on USAID's efforts to reduce micronutrient deficiency through supplementation, fortification, and food-based programs. Updated in 2004 to include zinc as a significant public health issue. (no. 118)
Download pdf versionPDF file
Cost Study Synthesis - Ghana, Zambia and Nepal. Although a variety of vitamin A supplementation programs have been implemented in developing countries, little is known to date about their costs. The major objective of this study is to provide researchers and policymakers with that cost information. (no. 136)
Download pdf versionPDF file
Ghana Cost Study. [Reprinted] The overall objective of this study is to provide the Ministry of Health in Ghana with cost information on the vitamin A supplementation program. The MOH intends to use this information to integrate the vitamin A supplementation program into routine primary health care services over the next five years. (no. 128)
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Zambia Cost Study. This study provides policymakers in Zambia with cost information on vitamin A supplementation — information that may help answer questions concerning the efficiency and sustainability of the campaign approach vis-à-vis other modes of delivering vitamin A supplementation. Specific objectives are to document the Child Health Week and National Immunization Days programs as they presently operate, and to analyze the two programs’ cost structures. (no. 137)
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Modules for the Induction Training of Anganwadi Workers in Uttaranchal. These are training modules aimed at developing capacity in community day care centers, which are an important source for extending nutrition and health-related service in the remotest areas of India’s Uttaranchal state among children up to six years of age, adolescent girls, and pregnant/lactating women. (no. 141)
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Zambia Five Year Strategy. This five-year strategic plan to prevent and control vitamin A deficiency in Zambia serves as a model of a comprehensive strategic plan for any country wishing to develop a micronutrient deficiency prevention and control program. (no. 143)
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National Micronutrient Survey 2000 Summary Report – Nicaragua. The Government of Nicaragua has paid special attention to micronutrient deficiencies, particularly those of vitamin A, iron, and iodine, since the 1993 National Micronutrient Survey. This summary report of the subsequent 2000 survey provides information about the evolution of these deficiencies, which are considered to be significant public health problems in Nicaragua. (no. 139)
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Prototipo de Sistema de Gestión Logística de Suplementos de Micronutrientes / El Salvador El objetivo del presente documento, preparado por el proyecto USAID/MOST como resultado de la experiencia reciente en El Salvador, es presentar y divulgar un prototipo de sistema de gestión logística de suplementos de micronutrientes que se ha implantado exitosamente por el Ministerio de Salud y Asistencia Social (MSPAS), con asistencia técnica de USAID/MOST, y que podría ser útil como modelo para ser adaptado en otros países. (no. 140)
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Enquête sur la carence en vitamine A / Madagascar. L’objectif de l’enquête est de fournir: (a) Des données de référence représentatives au niveau national pour la carence en vitamine A chez les enfants de 6 à 59 mois, (b) Des données de référence représentatives au niveau national pour la carence en vitamine A chez les femmes de 15 à 49 mois, (c) Données de référence sur l’anémie chez les écoliers de 6 à 14 ans par rapport auxquelles le projet SEECALINE peut évaluer l’impact de ses activités de nutrition scolaire. (no. 142)
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updated: 21 April, 2014

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