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Zinc Supplementation

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Zinc Supplementation

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

ORS and Zinc : Treatment of diarrhoea is now more effective

Prevent deaths from diarrhoea and decrease child susceptibility to diarrhoea after episodes by educating all health-care providers and mothers about zinc supplementation. Through focused and integrated campaigns, and through partnerships with local manufacturers, we will increase availability of zinc supplements.


Name: Zinc Supplementation
Theme: Health Education to Mothers Region and Country: Maharashtra, India
Partners: Beneficiaries:
Funding Need: Budget:
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Pediatric Zinc as Treatment for Diarrhea

This document as Pediatric Zinc as Treatment for Diarrheapdf 58 pages - 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:

Programme Activities:
In the majority of cases, diarrhoea is preventable through exclusive breastfeeding, improved hygiene and sanitation, and access to clean water, yet it is still one of the leading causes of death among children under five in India. A new Oral Rehydration Solution (ORS) formula and the introduction of zinc supplementation offer much improved outcomes for the treatment of childhood diarrhoea. The introduction of zinc supplementation in diarrhoea treatment provides for a high impact child survival intervention.

This programme looks to prevent deaths from diarrhoea and decrease child susceptibility to diarrhoea after episodes by educating all health-care providers and mothers about zinc supplementation. The programme will be two-fold. First, we will develop guidelines and training materials to educate health care providers, mothers, and the general public about zinc treatment in conjunction with ORS. The second focus of the programme will be to ensure and monitor the availability of zinc supplements, create standards for quality control of zinc tablets, and develop local delivery mechanisms for distribution of the treatment.

In the early 1980s, the introduction of ORS led to significant and continuing decreases in the rate of diarrhoea mortality that lasted for more than 20 years. Until recently, ORS, increased fluids, and continued feeding have been the only recommended treatments for episodes of non-complicated diarrhoea. Even though the accepted ORS formula was proven effective, researchers continued to work on developing an improved formula that would allow for more hydration while decreasing the amount of stool output. As a result, an ORS formula with lower glucose and sodium concentrations was developed, and it has proven to be more effective by decreasing the need for intravenous therapy, decreasing stool output, and decreasing the rate of vomiting. This new formula is recommended as one part of an improved diarrhoea therapy and treatment. Zinc is another part.

Zinc is an essential micronutrient for human growth, development, and maintenance of the immune system. The first cases of zinc deficiency were recognized in the 1960s in adolescent boys in Egypt who suffered from growth retardation. A recent assessment by the International Zinc Consultative Group estimated that 20% of the world’s population is at risk of inadequate zinc intake. In addition, high levels of zinc are lost in the stools during diarrhoea episodes. For more than 20 years, researchers have assessed the benefit of zinc supplementation during diarrhoea episodes. A meta-analysis of eight trials of acute and persistent diarrhoea  found a 15% reduction in the duration of acute diarrhoea and a 24% reduction in the duration of persistent diarrhoea among children receiving zinc supplementation when compared to children who received a placebo. These studies also revealed that children receiving zinc supplementation experienced a decrease in the severity of their diarrhoea episodes. Children who received 10–14 days of zinc supplementation also showed greater resistance to episodes of diarrhoea and other infectious diseases for the 2–3 month period following treatment.6 Eleven additional trials have confirmed these results, supporting the inclusion of 10–14 days of 10-20 mg of zinc supplementation as another element in the recommended diarrhoea therapy.

Intended Results:
Promotion and education of zinc supplementation with ORS in diarrhoea treatment will make it the responsibility of the state of Maharashtra to ensure that zinc is used to treat every diarrhoea episode in children under 5. There are several challenges that must be overcome to make this possible.

  • International and national level product availability
  • National and local level product coverage
  • Health worker/physician training and endorsement
  • Home-based treatment compliance

Zinc supplements are the new addition to diarrhoea treatment. Recommendations for zinc treatment are always given in conjunction with ORS and continued feeding. Introducing a new treatment, such as zinc, creates an opportunity to energize current diarrhoea training programs and provides an excellent opportunity to design enhanced or new programs where needed. This new treatment will increase ORS use rates and improve continued feeding practices.

Programme Management and Implementation:
Management and Implementation of this programme will occur after a careful assessment of the quality and consistency of currently available zinc products in Maharashtra. After this is assessed, programmatic endorsement and promotion will occur. Zinc is an essential micronutrient and may be available in local formulations. A careful assessment of the quality and consistency of currently available zinc products, which may include varieties of local tablets and syrups, should be complete before programmatic endorsement and promotion occur. Continuous monitoring of product quality may be needed to ensure children are receiving safe and effective zinc supplementation for the treatment of diarrhoea. Ensuring zinc supplements reach local level health clinics and health care providers will require the endorsement and commitment of national and local level governments by either providing financial backing or accepting and endorsing USAID missions and other aid agencies to procure and distribute zinc products.

Health care providers and mothers will be taught about the importance of zinc supplementation for diarrhoea treatment. This will take place in various training courses and printed materials.

Programme Monitoring and Evaluation:
Continuous monitoring of product quality may be needed to ensure children are receiving safe and effective zinc supplementation for the treatment of diarrhoea. Ensuring zinc supplements reach local level health clinics and health care providers will require the endorsement and commitment of national and local level governments by either providing financial backing or accepting and endorsing USAID missions and other aid agencies to procure and distribute zinc products. Evaluation of partnerships with local aid agencies will be monitored to achieve the highest product coverage rates in all areas of the country. There are many country-level decisions regarding the sale and/or dispersal of zinc supplements in addition to ORS. Programme monitoring will ensure that zinc and ORS are to be recommended together, zinc should never be promoted as a substitute of ORS. Ideally, zinc and ORS supplies would always be given or sold in the same location. The price of zinc supplements will be monitored and regulated if necessary. The programme will be revised and accommodated as necessary.

Learning and Dissemination:

Related Resources:

For an upto date list of Zinc Related Resources, kindly go to

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 the United States Agency for International Development (USAID) and experts worldwide, take into account new research findings while building on past recommendations. PDF file

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

Zinc Investigators' Collaborative Group. The Journal of Pediatrics 1999 (abstract only). Presents the evidence of reduction in incidence in diarrhea and pneumonia for 2-3 months following treatment of diarrhea with 10-14 days of zinc supplementation.

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

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

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. PDF

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. PDF

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

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 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 file in Spanish)

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 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. PDF

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. PDF

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. PDF

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

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. PDF

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

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.

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...


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

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

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) PDF 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) PDF 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) PDF 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) PDF 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) PDF 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) PDF 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) PDF file

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-�-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) PDF file

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) PDF file

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) PDF file

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) PDF file

Prototipo de Sistema de Gesti�n Log�stica 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 gesti�n log�stica de suplementos de micronutrientes que se ha implantado exitosamente por el Ministerio de Salud y Asistencia Social (MSPAS), con asistencia t�cnica de USAID/MOST, y que podr�a ser �til como modelo para ser adaptado en otros pa�ses. (no. 140) PDF file

Enqu�te sur la carence en vitamine A / Madagascar. L’objectif de l’enqu�te est de fournir: (a) Des donn�es de r�f�rence repr�sentatives au niveau national pour la carence en vitamine A chez les enfants de 6 � 59 mois, (b) Des donn�es de r�f�rence repr�sentatives au niveau national pour la carence en vitamine A chez les femmes de 15 � 49 mois, (c) Donn�es de r�f�rence sur l’an�mie chez les �coliers de 6 � 14 ans par rapport auxquelles le projet SEECALINE peut �valuer l’impact de ses activit�s de nutrition scolaire. (no. 142) PDF file



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