Published online May 1, 2008
PEDIATRICS Vol. 121 No. 5 May 2008, pp. e1279-e1285 (doi:10.1542/peds.2007-1939)
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ARTICLE

Effectiveness of Zinc Supplementation Plus Oral Rehydration Salts Compared With Oral Rehydration Salts Alone as a Treatment for Acute Diarrhea in a Primary Care Setting: A Cluster Randomized Trial

Nita Bhandari, PhDa, Sarmila Mazumder, PhDa, Sunita Taneja, PhDa, Brinda Dube, MSca, RC Agarwal, MDb, Dilip Mahalanabis, MDc, Olivier Fontaine, MDd, Robert E. Black, MDe and Maharaj K. Bhan, MDf

a Society for Applied Studies, New Delhi, India
b Badshah Khan Hospital, Faridabad, Haryana, India
c Society for Applied Studies, Kolkata, India
d Department of Child and Adolescent Health and Development, World Health Organization, Geneva, Switzerland
e Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
f Department of Biotechnology, Government of India, New Delhi, India

OBJECTIVE. The purpose of this work was to evaluate whether education about zinc supplements and provision of zinc supplements to caregivers is effective in the treatment of acute diarrhea and whether this strategy adversely affects the use of oral rehydration salts.

PATIENTS AND METHODS. Six clusters of 30 000 people each in Haryana, India, were randomly assigned to intervention and control sites. Government and private providers and village health workers were trained to prescribe zinc and oral rehydration salts for use in diarrheal episodes in 1-month-old to 5-year-old children in intervention communities; in the control sites, oral rehydration salts alone was promoted. In 2 cross-sectional surveys commencing 3 months (survey 2) and 6 months (survey 3) after the start of the intervention, care-seeking behavior, drug therapy, and oral rehydration salts use during diarrhea, diarrheal and respiratory morbidity, and hospitalization rates were measured.

RESULTS. In the 2 surveys, zinc was used in 36.5% (n = 1571) and 59.8% (n = 1649) and oral rehydration salts in 34.8% (n = 1571) and 59.2% (n = 1649) of diarrheal episodes occurring in the 4 weeks preceding interviews in the intervention areas. In control areas, oral rehydration salts were used in 7.8% (n = 2209) and 9.8% (n = 2609) of episodes. In the intervention communities, care seeking for diarrhea reduced by 34% (survey 3), as did the prescription of drugs of unknown identity (survey 3) and antibiotics (survey 3) for diarrhea. The 24-hour prevalences of diarrhea and acute lower respiratory infections were lower in the intervention communities (survey 3). All-cause, diarrhea, and pneumonia hospitalizations in the preceding 3 months were reduced in the intervention compared with control areas (survey 3).

CONCLUSIONS. Diarrhea is more effectively treated when caregivers receive education on zinc supplementation and have ready access to supplies of oral rehydration salts and zinc, and this approach does not adversely affect the use of oral rehydration salts; in fact, it greatly increases use of the same.

Key Words: zinc • diarrhea • cluster randomization • hospitalization

Abbreviations: ORS—oral rehydration salts • PHC—primary health center • WHO—World Health Organization • ALRI—acute lower respiratory infection • IQR—interquartile range • OR—odds ratio • CI—confidence interval

Accepted Oct 16, 2007.