Transcript Diarrhoeal morbidity over 90 days of observation by treatment group.

caling Up Zinc for
Young Children
(SUZY) Project
What is the
esearch telling us?
Updated Findings to 2011
Ongoing Gaps in Knowledge
Alternative supplementation strategies
– Length of treatment
– Treatment followed by daily
supplementation
– Household distribution of blister packs
– NGO-unregulated providers partnership
• Sustainability of scale up efforts
– Long-term impact
SUZY Project - ICDDRB
RCT 5 vs. 10 days of zinc treatment
Community-based, rural, effectiveness study
Alam DS et al. J Nutr. 2011 Feb;141(2):312-5.
Comparison of diarrheal incidence and burden over 90
days of follow up after treatment
Treatment group
Number of
episodes
Duration of
diarrhea
Mean ± SD
5 days
(n=819)
1.02 ± 1.35
10 days
(n=803)
1.08 ± 1.38
Mean ± SD
2.9 ± 5.6
3.1 ± 5.6
SUZY Project - ICDDRB
Zinc Side Effects:
Vomiting
Zinc 5-d % vomited
Zinc 10-d % vomited
Zinc 5-d % regurgitated
Zinc 10-d % regurgitated
14
Percent of children
12
10
8
6
*
4
*
*
*
7
8
9
*
2
0
1
2
3
4
5
6
10
Treatment day
*Significantly different from placebo
group
SUZY Project - ICDDRB
Alternative strategies: Zinc treatment
followed by zinc supplementation
Larson CP, et al. Trop Med Int Health. 2010 Jun;15(6):754-61
Dhaka urban slum effectiveness RCT
Zinc treatment vs.
Zinc treatment + supplementation x 3 months
Outcome: ACD incidence density
(# episodes/child-year fu)
SUZY Project - ICDDRB
Results
Diarrhea Incidence
(# episodes/child-year)
%
Interval ZT
ZT+S
difference reduced p-value
0-3 mo
3.60
2.64
0.96
27
.012
0-9 mo
2.53
2.00
0.53
21
.028
SUZY Project - ICDDRB
Alternative strategies: Household
distribution of zinc blister packs
Feikin D, et al
CDC/KEMRI/ICDDR,B
Rural Kisumu, Kenya
34 Villages randomized to receive either
Intervention Group: ORS + Zinc distributed to
households
Control Group: ORS in households
Zinc distributed to clinics
SUZY Project - ICDDRB
Effect of intervention on drug use
and healthcare use
P value*
Post-intervention
Intervention Comparison
n (%)
n (%)
Zinc
ORS
Antimalarial
Antibiotic
Sought care**
976 (62.0)
947 (60.1)
178 (11.3)
276 (17.5)
399 (25.3)
80 (5.1)
916 (58.8)
255 (16.4)
352 (22.6)
536 (34.5)
<.0001
.5732
.0136
.0256
.0874
Were zinc tablets misused?
Post-intervention
Intervention
n (%)
Comparison
n (%)
14 (0.2)
1475 (24.8)
1983 (33.4)
1 (0.0)
1640 (25.4)
2173 (33.7)
Cough without diarrhea
Zinc
10 (0.2)
Antimalarial
841 (16.2)
Sought care**
1399 (27.0)
1 (0.0)
854 (17.2)
1384 (27.9)
Fever without diarrhea
Zinc
Antimalarial
Sought care**
.
NGO – Unregulated Providers
Partnership
Fact: Unregulated providers are the dominant health
seeking choice of caretakers
Question: Can NGOs influence diarrhea management
practices of unregulated providers (village doctors/
drug vendors)?
Strategy:
1. Networking and orientation
2. Training
3. FU support
NGO-Drug Vendors Study:
Crude estimates of the relative risk of a child
receiving zinc treatment
Control sites
Baseline
Endline
Zinc Received
Yes
No
142
452
97
539
%
23.9
15.2
RR
Zinc Received
Yes
No
134
474
184
425
%
22.0
30.2
RR
95% CI
1.4
(1.1, 1.7)
95% CI
.64 (.49, .83)
Intervention sites
Baseline
Round 2
SUZY Project - ICDDRB
Ongoing Monitoring
Mass media promotion x 2 years
Larson CP, et al. Impact monitoring of the national scale up of zinc treatment
for childhood diarrhea in Bangladesh: repeat ecologic surveys.
PLoS Med. 2009 Nov;6(11):e1000175.
What happens once the promotion ends?
awareness
coverage
Caretaker awareness of zinc treatment for
childhood diarrhea
100%
90%
80%
70%
Pre-launch Dec 06
60%
1-3 months
50%
4-6 months
40%
7-10 months
30%
11-14 months
20%
15-18 months
10%
27-30 months
0%
City slum
City non- Municipal
slum
Rural
Awareness among rural caretakers follows a much more
protracted course and does not appear to be dependent upon
continued mass media promotion
Zinc treatment coverage by location of household
35%
30%
Pre-Launch Dec 06
25%
1-3 months
20%
4-6 months
15%
7-10 months
10%
11-14 months
5%
15-18 months
0%
27-30 months
City slum City non-slumMunicipal
Rural
No drop-off in zinc coverage, but no gains either
Conclusions
1. 5 days of zinc treatment may be as efficacious as
10 in terms of preventive effects
2. Daily zinc supplementation following zinc
treatment offers further reduction in repeat ACD
episodes
3. Household distribution of blister packs will
greatly increase coverage, with low risk of
misuse.
SUZY Project - ICDDRB
Conclusions
4. NGO-Unregulated provider partnerships do
work
5. There is a need for longer term planning
and on-going private sector incentives
and/or sustained consumer demand
SUZY Project - ICDDRB