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Where are we now? WHO’s Perspective

Where are we now? WHO’s Perspective. Dr Olivier Fontaine World Health Organization Geneva. Demonstration of the increased efficacy of a new formulation for oral rehydration salts (ORS) containing lower concentrations of glucose and salt, and

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Where are we now? WHO’s Perspective

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  1. Where are we now?WHO’s Perspective Dr Olivier Fontaine World Health Organization Geneva

  2. Demonstration of the increased efficacy of a new formulation for oral rehydration salts (ORS) containing lower concentrations of glucose and salt, and • Success in using zinc supplementation in addition to rehydration therapy in the management of diarrhoeal disease Recent developments in the clinical management of acute diarrhoea

  3. Meta-analysis of unscheduled intravenous infusion among children randomized to reduced osmolarity and standard WHO rehydration solution Hahn S et al. BMJ 2001; 323:81-5

  4. Meta-analysis of stool output among children randomized to reduced osmolarity and standard WHO rehydration solution Hahn S et al. BMJ 2001; 323:81-5

  5. Meta-analysis of vomiting among children randomized to reduced osmolarity and standard WHO rehydration solution Hahn S et al. BMJ 2001; 323:81-5

  6. CONCLUSION (1) The group of experts recommended that a single ORS solution be used and that this ORS solution contain 75 mEq/l of sodium and 75 mmol/l of glucose, and have a total osmolarity of 245 mOsmol/l.

  7. Trials on the Therapeutic Effect of Zinc on Acute Diarrhea • Countries: Bangladesh (4), Brazil, India (6), Indonesia, Nepal • Age groups: 1-60 months • Dose of zinc: 5 to 40 mg/day (1 to 4 RDA) • Total number of children: • zinc 4965 • control 4351

  8. Effect of Zinc Supplementation on Duration of Acute Diarrhoea/Time to Recovery *India, 1988 *Bangladesh, 1999 *India, 2000 *Brazil, 2000 *India, 2001 Indonesia, 1998 India, 1995 Bangladesh, 1997 India, 2001 India, 2001 Nepal, 2001 Bangladesh, 2001 Meta-analysis 1 *Difference in mean and 95% CI Relative Hazards and 95% CI

  9. Effect of Zinc Supplementation on Duration of Episodes Lasting More than 7 Days Indonesia, 1998 India, 1995 Bangladesh, 1997 India, 2001 Nepal, 2001 Meta-analysis 1 Odds ratio and 95% CI

  10. Therapeutic Effects of Zinc Supplementation on Acute Diarrheal Severity (1) * p<0.05

  11. Country Outcome Measure Percent Reduction Bangladesh, 1997 Stool Output 28 India, 2000 Stool Output 38* India, 2001 Stool Output 28* Therapeutic Effects of Zinc Supplementation on Acute Diarrheal Severity (2) * p<0.05

  12. CONCLUSIONS (2) • Zinc supplementation given at a dose of about 2 RDAs per day (10-20 mg) for 10-14 days, is efficacious in reducing the severity of diarrhoea and the duration of the episode significantly.

  13. WHO/UNICEF JOINT STATEMENT Clinical Management of Acute Diarrhoea

  14. Recommendations for Mothers and Other Caregivers • Prevent dehydration through the early administration of increased amounts of appropriate fluids available in the home, and ORS solution, if on hand • Continue feeding (or increase breastfeeding) during, and increase all feeding after the episode • Recognize the signs of dehydration and take the child to a health-care provider for ORS or intravenous electrolyte solution, as well as familiarize themselves with other symptoms requiring medical treatment (e.g., bloody diarrhoea) • Provide infants with 20 mg per day of zinc supplementation for 10–14 days (10 mg per day for infants under six months old)

  15. Recommendations for Health-Care Workers • Counsel mothers to begin administering suitable available home fluids immediately upon onset of diarrhoea in a child • Treat dehydration with ORS solution (or with an intravenous electrolyte solution in cases of severe dehydration) • Emphasize continued feeding or increased breastfeeding during, and increased feeding after the diarrhoeal episode • Use antibiotics only when appropriate, i.e. in the presence of bloody diarrhoea or shigellosis, and abstain from administering anti-diarrhoeal drugs • Provide infants with 20 mg per day of zinc supplementation for 10–14 days (10 mg per day for infants under six months old) • Advise mothers of the need to increase fluids and continue feeding during future episodes.

  16. Next Steps (1)Ongoing Research • Acceptability of zinc as an adjunct therapy for the management of acute diarrhoea in health facilities (Brazil, Egypt, Ethiopia, India and Philippines) • Intervention Studies to evaluate the effectiveness of adding zinc to the management of diarrhoea (India, Mali and Pakistan) • Controlled Clinical Trials to evaluate the safety/efficacy of zinc supplementation in the management of diarrhoea in infants below 6 months of age (Ethiopia, India and Pakistan)

  17. Next Steps (2)Zinc Tablet Production • Inclusion of zinc in the WHO model list of Essential Drugs • Development of product specification for allowing UNICEF to procure zinc tablets • Transfer of Technology for the production of zinc tablets

  18. Next Steps (3)Planning for Implementation of Zinc for Treatment of Diarrhoea • Development of draft guidelines for introduction of zinc for diarrhoea in a country • Development of a guide for formative research • Development of educational materials on diarrhoea

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