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Role of home fluids (as compared to ORS, especially when not available) in diarrhoea management

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  • Anant Bhan
    Interesting exchange in the Lancet on the role of home fluids (as compared to ORS) in diarrhoea management
    Message 1 of 1 , Jul 25, 2013
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      Interesting exchange in the Lancet on the role of home fluids (as compared to ORS) in diarrhoea management

      Copyright © 2013 2013 Elsevier Ltd Pavel Rahman/AP/Press Association Images All rights reserved.

      Excellent can be the enemy of good: the case of diarrhoea management

      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.
      In Bangladesh,4 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.
      Click to toggle image size
      Full-size image (30K) Pavel Rahman/AP/Press Association Images
      We declare that we have no conflicts of interest.


      1 Chopra MMason EBorrazzo J, et alEnding of preventable deaths from pneumonia and diarrhoea: an achievable goalLancet20133811499-1506Summary | Full Text | PDF(298KB) CrossRef | PubMed
      2 Walker CLRudan ILiu L, et alGlobal burden of childhood pneumonia and diarrhoeaLancet 20133811405-1416SummaryFull Text | PDF(264KB) CrossRef | PubMed
      3 Chandani YNoel MPomeroy AAndersson SPahl MKWilliams TFactors affecting availability of essential medicines among community health workers in Ethiopia, Malawi, and Rwanda: solving the last mile puzzleAm J Trop Med Hyg 201287120-126.CrossRef | PubMed
      4 Chowdhury AMKarim FSarkar SKCash RABhuiya AThe status of ORT (oral rehydration therapy) in Bangladesh: how widely is it used?Health Policy Plan 19971258-66CrossRef | PubMed
      5 Munos MKWalker CLBlack REThe effect of oral rehydration solution and recommended home fluids on diarrhoea mortality.Int J Epidemiol 201039i75-i87PubMed
      a School of Public Health, University of the Western Cape, Cape Town, 7535 South Africa
      b Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
      c Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA
      d University of the Witwatersrand, Johannesburg, South Africa
      e Institute for Global Health, University College London, London, UK

      Copyright © 2013 Elsevier Ltd All rights reserved.

      Excellent can be the enemy of good: the case of diarrhoea management — Authors' reply

      We thank David Sanders and colleagues for their comments focusing on the need for community health workers to promote home fluids for the management of diarrhoea in countries with weak health systems and supply change. This debate is not new.
      Children with diarrhoea should receive fluids and continued feeding, but no evidence shows that the use of home fluids can save lives.
      In the review by Munos and colleagues,1 the studies were based on dehydrated patients in hospital or clinic settings and assessed sugar-salt solution and cereal-salt solutions; none assessed other fluids such as plain water or rice water. Although evidence from clinical studies shows that sugar and salt solutions when prepared in the hospital pharmacy work for hydration,2 translation of this intervention to community application has been a failure. Most sugar-salt programmes have been abandoned because of variability in ingredients quality and concentrations, and risks of electrolyte abnormalities in children with severe diarrhoea.3Furthermore, the broadening of recommended home fluids—from semi-quantified mixtures of sugar and salt to soups, juices, and even plain water—led to the reporting of almost universal diarrhoea treatment coverage, whereas children continued to die of dehydration.
      We focused on interventions that have a clear effect on mortality, and standard oral rehydration solutions have clear benefits in contrast to other alternatives including recommended home fluids.
      Despite challenges with supplies, substantial progress has been made in coverage of oral rehydration solution (ORS). Recent analysis of ORS use from relevant population-based national surveys shows a slow but steady increase overall (appendix). Not only Bangladesh, but also Thailand and Mexico have been able to scale up appropriate use of ORS for childhood diarrhoea and to reduce the proportion of diarrhoea deaths in children.4 Wilson and colleagues5 noted that one of the clearest differentiators between countries that have successfully scaled up ORS and those that have not was the choice to promote a clear, unambiguous message about the treatment of choice.
      That many children still have more than three episodes of diarrhoea per year stresses that they need to receive treatments of proven effectiveness instead of haphazardly prepared home solutions. Why is ORS being singled out as a problematic intervention when community health-worker programmes in Africa and Asia are providing much more complex interventions, such as antiretroviral drugs, antimalarial drugs, and antibiotics for pneumonia?
      We declare that we have no conflicts of interest.

      Supplementary Material

      Supplementary appendix
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      1 Munos MKWalker CLBlack REThe effect of oral rehydration solution and recommended home fluids on diarrhoea mortality.Int J Epidemiol 201039i75-i87PubMed
      2 Snyder JDYunus MWahed MAChakraborty JHome-administered oral therapy for diarrhoea: a laboratory study of safety and efficacyTrans R Soc Trop Med Hyg 198276329-333CrossRef | PubMed
      3 Bhutta ZADas JKWalker N, et alInterventions to address deaths from childhood pneumonia and diarrhoea equitably: what works and at what cost?Lancet 20133811417-1429Summary | Full Text | PDF(478KB) CrossRef | PubMed
      4 Nathoo KJGlyn-Jones RNhembe MSerum electrolytes in children admitted with diarrhoeal dehydration managed with simple salt sugar solutionCent Afr J Med 198733200-204PubMed
      5 Wilson SMorris SSGilbert SS, et alScaling up access to oral rehydration solution for diarrhea: Learning from historical experience in low- and high-performing countriesJ Glob Health 2013310404PubMed
      a Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
      b SickKids Center for Global Child Health, Toronto, Canada
      c Johns Hopkins University School of Public Health, Baltimore, MD, USA
      d UNICEF, New York, USA
      e Bill & Melinda Gates Foundation, Seattle, WA, USA
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