We welcome the 2013 Lancet
Series on Chilhood Diarrhoea and Pneumonia. Although the Series recognises the stagnant coverage of oral rehydration solution (ORS),1
we have concerns about its emphasis and policy implications.
In Africa, children have on average 3·3 diarrhoea episodes per year.2
This requires frequent administration of rehydration fluid. Use of ORS plus zinc requires a well-functioning supply chain and excellent coverage by community health workers (CHWs). Even in countries with large national CHW programmes such as Rwanda and Ethiopia, ORS coverage is 29% and 26%
respectively, and this masks inequalities—coverage was only 10% among the poorest people in Ethiopia.
An assessment of integrated community case management (ICCM) supply-chain barriers in Ethiopia, Malawi, and Rwanda in 2011, showed that more than half of CHWs were out of stock of at least one ICCM essential medicine, and most CHWs travel on foot (Ethiopia and Rwanda) or bicycle (Malawi) to collect supplies.3
In many parts of Africa, supplies are much worse.
the large scale production of ORS—developed over the past two decades—has many unique features, including the establishment by large non-governmental organisations of substantial pharmaceutical manufacturing capacity.1
Bangladesh now produces 97% of key commodities locally—a situation not possible to replicate in most countries in the medium term.
Since the 1980s in Bangladesh and Zimbabwe, and now in Niger, CHWs or volunteers promote household use of sugar-salt solution or similar (lobon and gur) as a first step before referral for ORS. The failure to recommend home fluids in The Lancet Series undermines these efforts.
We could only find one review of recommended home fluids which concluded that there is insufficient evidence to recommend their use.5
Little research has been done providing insufficient and low quality evidence. Yet recommended home fluids are being used and are still recommended (albeit
half-heartedly) in the latest WHO/UNICEF Global Action Plan for Pneumonia and Diarrhoea
Do we not have an ethical obligation to also train CHWs to promote recommended home fluids (including sugar-salt solution or cereal-based fluids) in the common situation where ORS is unavailable?
We urgently need more research on home fluids. Furthermore, we need clear strategies, commitments, and financial investments in community mobilisation and intersectoral actions for prevention of diarrhoea through improved water quality and availability, improved sanitation, and handwashing with soap.
We declare that we have no conflicts of interest.