Promoting Leadership to Scale Up of Oral Rehydration Salts with Zinc Uptake and Reduce Diarrhea Mortality Globally in Children Under 5 Years

Abstract

Every minute one child under the age of 5 years dies of diarrhea, the second-leading cause of death in this age group. These deaths are preventable, and inexpensive, effective treatments are available that can be administered at home: oral rehydration salts and zinc (ORS/Z). Oral rehydration salts prevent up to 93% of childhood diarrhea deaths, while zinc can reduce the duration of the illness by 20% and prevent recurrence for 2 to 3 months. Targeted efforts to increase combined ORS/Z treatment support Sustainable Development Goals and global efforts. A multi-pronged approach is needed to achieve large-scale and sustained increases in this type of treatment, according to the following strategies: (1) facilitating a strong, enabling environment; (2) increasing the availability of high-quality and affordable supplies; (3) improving the knowledge and skills of health providers; and (4) generating demand among families and caregivers. Simultaneous improvements in the supply of and demand for ORS/Z in both the public and private sectors are needed to prevent deaths. Furthermore, there is a need for a concerted investment from multiple partners, including national governments, development partners, donors, and research institutions. Appointing a U.S. global "children's champion" is critical to coordinate U.S. and international activities in reducing mortality and morbidity from diarrhea among children younger than 5 years, and this individual can serve as a global leader in planning and financing integration of diarrhea treatment programming into all children' mortality reduction, nutrition, and early childhood "survive and thrive" development initiatives.

Relationship to Existing APHA Policy Statements

This policy relates to existing APHA policy statements in two ways. First, it supports APHA's efforts to reduce child mortality by building on existing APHA policies addressing that issue. This policy statement seeks to fill a gap in current APHA policy, as none of the current policy statements focusing on this issue specifically address diarrhea management and treatment among children younger than 5 years in low- and middle-income countries. Second, the policy promotes one of APHA's overarching priorities: building public health infrastructure and capacity in the global arena.

APHA currently supports two policies that provide an overarching umbrella for support of maternal and child health and reduction of global maternal, neonatal, and child morbidity and mortality. However, these policies are not specific to childhood diarrhea.

• APHA Policy Statement 201113: Call to Action to Reduce Global Maternal, Neonatal and Child Morbidity and Mortality. This policy focuses on increasing the political and financial commitments of the United States and all world governments to improving global maternal, neonatal, and child health.
• APHA Policy Statement 20094: Ensuring the Achievement of the Millennium Development Goals: Strengthening US Efforts to Reduce Global Poverty and Promote Public Health. This policy supported achievement of the Millennium Development Goals (MDGs), one of which was reduction of child mortality (with diarrhea specified as a major cause of death among children younger than 5 years). It is important to note that this policy is now outdated, as the MDGs for 2015 have been replaced by the United Nations (UN) Sustainable Development Goals (SDGs) for 2030, a 15-year development blueprint with goals and targets that will be mentioned in this policy statement.

APHA also supports three policies that address diarrhea prevention strategies but do not specify diarrhea treatments, including treatment with ORS and zinc as a proven and focused strategy to reduce child mortality.

• APHA Policy Statement 20145: Supporting Breastfeeding Worldwide through Maternity Protection. Breastfeeding is the optimal evidence-based strategy to prevent diarrhea and other common causes of child mortality.
• APHA Policy Statement 20026: Access to Safe Water, Sanitation, and Hygiene Promotion in Developing Countries. Safe water, sanitation, and hygiene are also considered vital complementary strategies for diarrhea and disease prevention.
• APHA Policy Statement 20157: Public Health Opportunities to Address the Health Effects of Climate Change. This policy mentions lack of available safe water as a climate change–related risk and describes diarrhea as a morbidity factor that can be affected by climate change.

APHA also recently approved two policies that address health system and public health infrastructure and could support prevention and treatment with respect to child environmental health; however, neither specifies diarrheal illnesses or children younger than 5 years.

• APHA Policy Statement 201710: Protecting Children's Environmental Health: A Comprehensive Framework. This policy takes a systems and multidisciplinary approach to addressing children’s environmental health that could also be used in advancing diarrhea prevention and treatment among children younger than 5 years.
• APHA Policy Statement 201713: Establishing Environmental Public Health Systems for Children at Risk or with Environmental Exposures in Schools. This policy addresses environmental exposures in schools and urges testing of water in schools to assess waterborne contaminants, which can lead to diarrhea among children.

Finally, several additional APHA policies address health system and public health infrastructure that could support diarrhea prevention and treatment but do not specify child health.

• APHA Policy Statement 20089: Strengthening Health Systems in Developing Countries. This policy supports the importance of health systems, including supply systems, in providing high-quality prevention and treatment services that could include diarrhea prevention and treatment.
• APHA Policy Statement 9022(PP): Medicines in Developing Countries: A Global Health Concern. As diarrhea treatment requires availability of oral rehydration salts and zinc (ORS/Z), this policy supports the availability of key medicines and commodities (although not specifically these two commodities).
• APHA Policy Statement 201117: APHA Endorses the World Health Organization’s Global Code of Practice on the International Recruitment of Health Personnel. Although not specifically addressed in this policy, trained health providers are needed to treat diarrhea appropriately.
• APHA Policy Statement 9212: The Health of Refugees and Displaced Persons: A Public Health Priority. Refugees and displaced persons, particularly children in these designated special populations, are at an increased risk for diarrhea. This policy focuses on and supports these populations as a public health priority.

Problem Statement

The under-5 mortality rate continues to challenge families and communities across the globe. A total of 5.8 million children 5 years or younger died in 2015, and one in 10 childhood deaths were due to diarrhea, a preventable cause of death.[1,2] Every day, diarrhea causes 1,400 preventable deaths among children younger than 5 years.[3] Since 1990, when there were 12.7 million deaths, there has been demonstrated global success in reducing the number of deaths among children in this age group.[4] Despite this drop, the MDG of a two-thirds reduction between 1990 and 2015 was not met.[4]

Waterborne illnesses cause the most childhood deaths worldwide. Diarrhea is responsible for the deaths of approximately 525,000 children younger than 5 years each year due to severe dehydration and fluid loss, and it is the second-leading cause of death among children in this age group.[5] Diarrhea is caused by a variety of bacterial, viral, and parasitic organisms, and these infections spread through contaminated food and drinking water or person-to-person contact.[5] Loss of nutrients from frequent stools, vomiting, and lack of appetite contributes to declines in the nutritional status of children with diarrhea, increasing their risks for diseases and death.[5] The burden of diarrhea is disproportionately distributed worldwide. Epidemiological evidence indicates that 10 countries (across sub-Saharan Africa and Southeast Asia) account for more than half of all diarrhea incidence worldwide.[6]

Prevention can reduce diarrhea-related deaths substantially: “58% of diarrhea deaths (842,000 deaths) in low- and middle-income countries [are] attributed to inadequate [water, sanitation, and hygiene].”[7] Preventive interventions based on water, sanitation, and hygiene can play a significant role in reducing child deaths. Rotavirus vaccinations and exclusive breastfeeding also prevent diarrhea and its associated mortality.[2]

However, prevention must take into account causes other than physical infrastructure. Decades of experience in development and research shows that support for women economically and educationally strengthens families.[8] While half of child deaths in sub-Saharan Africa and Southeast Asia can be reduced by focusing directly on diarrhea and respiratory causes, another third could be prevented by addressing the socioeconomic issues of nutrition, poverty, and maternal education.[9] Children dying of diarrhea most often live in low- and middle- income countries and are frequently malnourished,[10] pointing to the need to address prevention at the levels of community and global socioeconomics.

When prevention fails, management of diarrhea via ORS/Z is a straightforward treatment strategy that deserves all possible support. If scaled to 100% coverage, ORS could prevent up to 93% of diarrhea deaths.[11] Zinc could reduce the duration of illness by 20%, reduce persistent illness by 15% to 30%,[12] and prevent recurrence of disease by 2 to 3 months.[13] This combined treatment is highly cost effective and easily administered by caregivers at home.[6,10–15] Because of this effectiveness, strategies to increase use of ORS/Z should be incorporated into the early childhood care and development policies of multilateral organizations, donors, government aid agencies, pediatric and related professional and scientific associations, and nongovernmental organizations.[16–19]

Together, oral rehydration salts and zinc have been demonstrated to significantly reduce the duration and severity of diarrheal episodes and prevent future episodes. Oral rehydration replaces lost fluids and essential salts, thereby preventing or treating dehydration and preventing the risk of death. Glucose contained in ORS enables the intestine to more effectively absorb fluids and salts. Low-osmolarity oral rehydration salts reduce the need for intravenous fluids (required in the most severe cases) and shorten the duration of diarrheal episodes. Zinc supplementation, added to ORS as an adjunct therapy, has been proven to decrease diarrhea duration and severity as well as risk of subsequent infections in the 2 to 3 months after treatment.[20]

All children with diarrhea who have no signs of dehydration should receive both ORS and zinc at the beginning of a diarrheal episode. The duration of treatment with ORS and zinc differs; provision of zinc continues for 10 to 14 days, while ORS is provided only through the resolution of diarrhea symptoms. This “plan A” is appropriate for administration by community health workers and by caregivers in the home. In “plan B,” the recommended treatment for children with some degree of dehydration is also both ORS and zinc administration. In this plan, the zinc regimen is the same as in plan A, but the guidance regarding low-osmolality ORS is different. Instead of administering ORS as in Plan A, the ORS in the first 4 hours is administered according to the weight of the child.

The World Health Organization (WHO)/United Nations Children’s Fund (UNICEF) Global Action Plan for Pneumonia and Diarrhea (GAPPD) emphasizes prevention and control of pneumonia and diarrhea through integrated programs and supports the implementation of a more collaborative and coordinated approach across countries, regions, districts, communities, and hospitals. Building on this momentum, some national governments and local partners have launched large-scale efforts addressing local barriers to access and leading to successful outcomes.[6] In spite of these efforts, there is a significant gap in ORS/Z coverage, especially in countries with the greatest need.[6] Many countries have had ORS/Z coverage of less than 50% for several decades, indicating a need to find new ways to close existing coverage gaps.[13,21–23]

Several specific problems have been identified as contributing to this lack of coverage. Differences in the quality of ORS/Z provision services persist across the globe, with great disparities according to whether care is sought at a public or private facility.[24,25] Inadequate public health awareness of the efficacy of ORS/Z and health care provider decision making based on the ability to make economic gains with other medications contribute to poor global coordination in efforts to reduce childhood diarrheal deaths.[26] Furthermore, insufficient supply chains in low-resource countries affect people’s ability to receive ORS/Z, especially in remote areas, where most children die from diarrhea. Simultaneous improvements in supply and demand in both the public and private sectors will maximize impact.[27] Finally, clinical protocols provided by WHO on treatment with zinc, particularly those regarding weight-specific doses and duration of treatment, must be updated to align with current standards.[12,28]

With data on the effectiveness of ORS/Z, new global initiatives and frameworks have elevated the profile of this treatment as a key child health intervention. The Diarrhea and Pneumonia Working Group, composed of representatives from development agencies, donors, nongovernmental organizations, and the private sector, has led the way. This group set a target of achieving 60% to 80% treatment coverage for diarrhea and pneumonia among children younger than 5 years by 2015.[29] The GAPPD program promotes and monitors the reduction of diarrhea and pneumonia to end preventable deaths among children.[2] The emergence of the new Diarrhea Innovations Group (DIG) emphasizes public health stakeholders’ urgency in promoting leadership and action.[30] Since the release of the WHO/UNICEF Joint Statement for Clinical Management of Acute Diarrhea in 2004,[20] strong political attention and technical support have been mobilized to facilitate the use of ORS/Z. The UN-initiated Diarrhea and Pneumonia Working Group is among the leading consortia advocating for urgent further action to reduce mortality.[29] Given the uneven progress to date, however, a powerful global champion is urgently needed.

Opposing Arguments

Examples of potential arguments opposing this policy are outlined in the paragraphs to follow.

Availability: A scale up is not needed because these products are already available; the problem resides elsewhere. The UN Diarrhea and Pneumonia Working Group has developed a complex framework for understanding the distribution of ORS/Z treatment within countries.[2,28] It requires not only supply but also provider demand, caregiver demand, and an enabling environment.

Cost: This intervention is not cost effective. According to a Centers for Disease Control and Prevention (CDC) report titled Common Illness, Global Killer, “every $1 invested to prevent diarrhea yields an average return of $25.50,” thus reflecting not only the moral and humanitarian rationale for enhanced efforts to mitigate diarrhea-related morbidity and mortality but also the economic benefit.[31]

Prevention: ORS/Z treatment does not focus on prevention of diarrhea. The roles of secondary and tertiary prevention are well established across a spectrum of prevention. Treatment with ORS/Z is an evidence-based strategy to treat diarrhea as part of a secondary prevention approach to care. Zinc supplementation has been associated with reduced acute diarrheal disease among children for periods of at least 3 months.[14,32,33]

Narrow focus: ORS/Z treatments are only one intervention among many. Why not incorporate all interventions? Each intervention requires its own review of the best ways to implement it. This policy focuses on an identified specific need to scale up use of ORS/Z.

Cultural acceptability: ORS/Z may not be culturally acceptable in every region. Evidence shows that locally developed, culturally specific statements promoting ORS/Z treatment are acceptable and lead to reductions in the use of other medications.[34] This simple public health intervention is widely acceptable in high-priority countries, and it can be scaled up with effective promotion through social marketing and mass media tools.[35]

Market strategies: Oral rehydration salts and zinc are commodities, and implementation of these treatments should be market based. This policy includes market-based strategies to scale up the availability of ORS/Z. The UN Commission on Life-Saving Commodities for Women and Children includes ORS/Z among 12 life-saving commodities that must reach every child with diarrhea (and pneumonia in the case of zinc).[28] DIG is driving an effort to include co-packed ORS/Z in the 2019 WHO List of Essential Medicines as a market-based approach to scaling up these treatments.

Harmful practices in management of diarrhea: There should be a focus on preventing mismanagement of diarrhea, which results in worse outcomes. There are several harmful practices in management of childhood diarrhea that can result in treatment failure, poor nutritional outcomes, and increased mortality. Examples include restriction of fluids, breast milk, and/or food intake during diarrhea episodes and incorrect usage of modern medicines. These practices are common among health workers, relatives, and community members, indicating an important challenge in implementation in low- and middle- income countries.[36] Such practices can be addressed through increased support for correct usage of ORS/Z treatment.

U.S. global champion: Countries will not accept the United States as a champion. While diarrhea is not a leading cause of child mortality in this country, the United States does provide large amounts of aid to countries where diarrhea is a leading cause of child deaths. U.S.-led relief for HIV/AIDS in Africa provides a good example. Although HIV/AIDS is not a leading cause of mortality in the United States, yet the US President’s Emergency Plan for AIDS Relief demonstrates US leadership in global health that matters.[37] We could expect the same for child health and diarrhea prevention-treatment continuum, specifically.

Evidence-Based Strategies to Address the Problem

Many approaches should be taken to treat diarrheal illnesses, but the advantages of ORS/Z treatment in terms of ease, effectiveness, and cost have been well established.[2,3,5,6,10–14,21,33,38–43] While substantial progress has been made over the past 25 years, MDG goals have not been met, and countries in southern Asia and sub-Saharan Africa have the highest mortality rates and are most in need of interventions.[4] ORS/Z treatment is a measurable, evidence-based approach to minimizing further diarrhea-related deaths among children in these regions, which should be a key priority. There is a clear need for strategies that address the use of ORS/Z in Africa[44] and Southeast Asia.[45] Focusing on making ORS/Z treatment available does not obviate the need to implement interventions for more fundamental prevention in terms of poverty or maternal education, which also would have substantial effects on child mortality.[9]

While ORS/Z treatment coverage rates are increasing, challenges remain with respect to increasing the pace of change and meeting the SDG for child mortality. This calls for coordinated action, increased investments, and sustained energy.[6] Successful implementation of such programs requires a concerted investment from multiple partners, including national governments, development partners, donors, the private sector, and research institutions. When possible, new cross-sectoral efforts should align with existing national strategic frameworks and leverage existing structures (e.g., integrated community case management). With the Diarrhea and Pneumonia Working Group’s framework as a guideline for assessing outcomes, interventions designed to increase use of ORS/Z can be categorized in four ways[6]: (1) those that facilitate a strong, enabling environment; (2) those that improve the availability of high-quality and affordable supplies; (3) those that improve the knowledge and skills of health providers; and (4) those that generate demand among caregivers. All of these strategies are most effective in the presence of cooperation between partners in every sector, as recommended in the GAPPD and other policies.[2,46]

To facilitate a strong, enabling environment, one evidence-based intervention is providing information corners at health centers that inform families about ORS/Z and how to administer these treatments.[21,28] Another is facilitating ORS/Z treatment through use of integrated community case management.[2,46,47] In such instances, communities need to have a clear understanding regarding ORS/Z. For example, there may be a cultural norm to use traditional medicine or to use costly ready-made pediatric rehydration drinks. Packaging of ORS/Z supplements needs to take local norms into account.[44]

Several market strategies can be employed to improve the availability of high-quality and affordable supplies of ORS/Z. These strategies should aim particularly at increasing availability in the most remote areas and in locations where most children die from diarrhea. They should also aim at meeting caregivers’ identified needs, particularly affordability.[27] One such strategy is to ensure the quality of products across national borders.[28] Another is to market ORS/Z in combination.[28] Most important, regulation of ORS/Z treatments should make them easier to acquire. They should no longer be classified as medicinal products, which causes confusion. Most regulators classify ORS/Z in the food supplement category, enabling fast registration and wider distribution (e.g., outside pharmacies). This is in line with action taken by international stakeholders to classify ORS/Z treatments as over-the-counter products as opposed to prescribed treatments (as in the past). To further remove this barrier to increasing coverage, this policy proposes that both zinc and ORS be taken off the WHO List of Essential Medicines for Children and be classified for all procurement purposes as nutrients.[27]

Several strategies have proven useful in improving the knowledge and skills of health providers. Financial incentives to providers to recommend ORS/Z treatments can increase their use.[28] Even families who take their children to health care facilities do not always get the recommended treatment,[10,24] and primary health care providers need more training to gain essential knowledge of diagnosis and proper treatment of diarrhea and prolonged diarrhea.[47,48] This, too, requires cooperation at all levels and across sectors. As noted, WHO should revise and update the 2004 clinical protocols on treatment with zinc, particularly with respect to weight-specific doses and duration of treatment.[12,28] The WHO/UNICEF 2004 normative guidelines on low-osmolarity ORS formulations supplemented by 10 to 14 days of zinc as a treatment for acute diarrhea are also due for review. Sufficient new evidence suggests that knowledge, considerations, and practices should be assessed in revising and updating the WHO/UNICEF guidelines. Also, new guidelines will help bring health providers up to date in terms of their knowledge.

Several strategies have been found effective in improving demand among caregivers. Public health campaigns can change perceptions and increase demand[49] in efforts with manufacturers to market new products (e.g. co-packaged products) as a means of increasing consumer uptake of ORS/Z.[28] Marketing approaches such as more attractive packaging and affordable pricing can increase uptake and should be further investigated. In addition, messages should be market focused,[13,28] and social networking can be usefully and economically employed to market ORS/Z.[45]

Outcomes measures for these strategies should address both clinical and economic outcomes. Clinical outcomes should include both overall mortality rates among children younger than 5 years and the proportion of these deaths due to diarrheal diseases. Cost effectiveness should be addressed in terms of costs of treatment for families and systems, including training of clinical providers when applicable. In addition, sales of ORS/Z can bring economic benefits to communities, which should be included in analyses. Measuring community-based intervention outcomes in terms of maternal and child health is useful in tracking integrated community case management program outcomes.[50]

Action Steps

APHA recommends that the U.S. Congress, the executive branch, federal agencies, and partners:

• Appoint a United States global “children’s champion” (e.g., at the U.S. Agency for International Development [USAID] Bureau for Global Health) within 1 year to (1) align efforts with countries experienced in addressing diarrheal morbidity and mortality and coordinate U.S. activities in reducing mortality and morbidity from diarrhea among children younger than 5 years; (2) serve as a global leader and voice in international organizations and networks (e.g., the United Nations, the Partnership for Maternal, Newborn, and Child Health), urging, planning, and financing integration of diarrhea programming into all children’s mortality reduction, nutrition, and early childhood “survive and thrive” development initiatives; (3) help bring together agencies from different sectors (e.g., different levels of government, the private sector, nongovernmental organizations, donors, and research institutions) to cooperate on projects; and (4) encourage other regions and countries to also appoint champions.
• Facilitate collaboration among global health programs (e.g., USAID and CDC programs) addressing maternal and child health to (1) fund investments with local impact to improve the supply of ORS/Z (including co-packaging); (2) fund innovation in home-based diarrhea treatment provided by caregivers using ORS/Z; (3) introduce definitive language about the need for scaling up ORS/Z and reducing diarrhea mortality among children younger than 5 years in programmatic and advocacy documents developed by the U.S. government, its subsidiaries, and contractors in global health; (4) provide training for local health providers on treatment guidelines; (5) fund integrated community case management programs with a focus on family-provided treatment; and (6) fund maternal education and poverty reduction measures.
• Support international organizations in doubling ORS/Z procurements and promoting national leadership to reduce diarrhea mortality globally among children younger than 5 years.

APHA calls on public health professionals and national and international organizations to:

• Support the agenda for reducing diarrhea among children younger than 5 years through scaling up of ORS/Z uptake and support ongoing leadership initiatives in this area (i.e., the Diarrhea and Pneumonia Working Group, DIG, Every Woman Every Child, First 1,000 Days, the American Academy of Pediatrics, and the Partnership for Maternal, Newborn, and Child Health).
• Work toward increasing by at least 30% the efforts of public-private partnerships in scaling up ORS/Z uptake within 3 years.
• Include diarrhea-related mortality and morbidity reduction innovations at annual U.S.-led forums.
• Improve access to maternal education around diarrhea treatment in the context of breastfeeding, nutrition, immunizations, and early childhood development.
• Conduct more research on diarrhea treatment, prevention, and protection guidelines, including reviewing the WHO/UNICEF 2004 normative guidelines on low-osmolarity ORS formulations supplemented by 10 to 14 days of zinc for treatment of diarrheal illnesses.
• Conduct more research on family, community, and regional interventions for maternal education and general economic and political development and their effects on child mortality.
• Innovate incorporation of water, sanitation, and hygiene issues and diarrhea treatment into countries’ maternal, newborn, and child health initiatives, along with integrated community case management, economic and community development policies, and program development.
• Support UNICEF in actively searching for potential suppliers of ORS/Z worldwide with the aim of expanding qualified suppliers by 10%, 20%, and 30% over the next 3 years.

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