[e-drug] Is it time for a re-think of the WHO EML with respect to ORS and Zinc?

e-drug
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E-DRUG: Is it time for a re-think of the WHO EML with respect to ORS and Zinc?
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Dear e-druggers, your views on this please.

We have an international recommendation for the treatment of diarrhoea
which is now 12 years old (WHO/UNICEF). The recommendation is a combined
therapy of Oral Rehydration Salts (ORS) and Zinc. This recommendation
covers home treatment and treatment in institutions.

12 years on, 99% of diarrhoea cases are NOT treated with ORS and Zinc and
diarrhoea remains the second biggest infectious killer of under 5 children.

It is clear from our work, that while ORS and Zinc are listed as separate
items on the Essential Medicines List (EML) they will be supplied
separately and very rarely dispensed together (as per the international
recommendation). There are several reasons for this and these include:

   1. The supply of ORS and Zinc may be unbalanced so that either or both
   may be out of stock (see below)
   2. In resource-poor situations there may be a tendency to hold back Zinc
   for cases judged to be ‘severe’ and so Zinc is not given as a routine (when
   it should be)
   3. The person dispensing may not be aware of the correct treatment
   4. When ORS and Zinc are distributed separately, there is less chance
   that they will both be in stock at the same time. If the stocking rate for
   ORS is 50% and the stocking rate for Zinc is 40%, the stocking rate for
   both will be just 20%.

Having them as separate items on the EML also means that those procuring
ask for one and not the other. Let me give you an example:

In Zambia the Ministry of Health asked UNICEF to help with the supply of
ORS. Without questioning this request, UNICEF supplied. So we went from a
situation where there was no ORS and a situation where there was plenty.

At this time a local pharmaceutical company started shipping an ORS/Zinc
co-pack to the Ministry but some health centres said they couldn't accept
it as they had so much ORS. So in effect UNICEF undermined it's own
recommendation by flooding the 'market' with ORS only.

So, my question is, can we include co-packaged ORS and Zinc on the EML?
And if not, why not?

In my opinion, if we did this, it would transform the prospects of getting
the recommended treatment for diarrhoea to under five children and would
save thousands of lives.

I am very interested to read your comments.

Simon

Simon Berry
Counterpart programme manager
Kit Yamoyo Transition to Scale (KYTS)*
Simon Berry <simon@colalife.org>

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E-DRUG: Is it time for a re-think of the WHO EML with respect to ORS and Zinc? (2)
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[it is timely that this addition to the WHO EML is considered. See E-drug Jan 25 Applications for 2017 WHO EML
http://www.who.int/selection_medicines/committees/expert/21/en/ BS]

Dear colleagues,

Simon from KYTS presents a compelling case for a new presentation of ORS/Zinc co- pack. This position is based on good experience on the KYTS project as well as post pilot experience and reports. The evidence that treatment of childhood diarrhoea is best treated with ORS and Zinc is irrefutable.

To encourage and promote this combined treatment, WHO could list the ORS/Zinc co- pack in the EML, to stress the importance of this treatment strategy. Otherwise, as Simon has argued, we shall continue seeing care- givers not using this combination to treat childhood diarrhoea.

Regards,
Bonnie

Bonface Fundafunda PhD., MBA., B.PharmL
Zambia
BONFACE FUNDAFUNDA <bcfunda@hotmail.com>

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E-DRUG: Is it time for a re-think of the WHO EML with respect to ORS and Zinc? (5)
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[Please contact Simon directly if you would like to assist. BS]

Thanks Dr Fundafunda for his thoughts and to the e-drug moderator for
pointing us to E-drug Jan 25 Applications for 2017 WHO EML
http://www.who.int/selection_medicines/committees/expert/21/en/

I have drafted the following: Is there anyone on this list who can:

   1. advise and/or
   2. would be willing to support (ie add their signature to the following
   request?

=BEGIN=

The Secretary
Expert Committee on the Selection and Use of Essential Medicines
Innovation, Access and Use (IAU)
Department of Essential Medicines and Health Products
20 Avenue Appia
CH-1211 Geneva 27
Email: emlsecretariat@who.int

Dear Sir/Madam

We wish to propose that the 'Expert Committee on the Selection and Use of
Essential Medicines' consider the following proposition at their meeting in
Geneva from 27 to 31 March 2017. We regard this as a very important issue
and are at your disposal to provide any additional information needed prior
to the meeting to support this submission.

*Inclusion of co-packaged ORS/Zinc for the treatment of Childhood diarrhoea
in the EMLc*

*Background*
WHO/UNICEF (2004) have an international recommendation for the treatment of
diarrhoea which is now 12 years old. The recommendation is a combined
therapy of Oral Rehydration Salts (ORS) and Zinc Sulphate. This
recommendation covers institutions and is the treatment of choice in the
home too.

12 years on, 99% of diarrhoea cases are NOT treated with ORS and Zinc and
diarrhoea remains the second biggest infectious killer of under 5 children
and stunting levels are running at 40% in sub-Saharan Africa.

It is clear from our work, and the work of others, that as long as ORS and
Zinc are listed as separate items on the Essential Medicines List for
Children (EMLc) they will continue to be be supplied separately and very
rarely dispensed together (as per the international recommendation). There
are several reasons for this and these include:

   1. The supply of ORS and Zinc may be unbalanced so that either or both
   may be out of stock at any particular time (see below)
   2. In resource-poor situations there may be a tendency to hold back Zinc
   for cases judged to be 'severe' and so Zinc is not given as a routine (when
   the recommendation is that it should be)
   3. The person dispensing may not be aware of the correct treatment
   4. When ORS and Zinc are distributed separately, there is less chance
   that they will both be in stock at the same time. If the stocking rate for
   ORS is 50% and the stocking rate for Zinc is 40%, the stocking rate for
   both will be just 20%.

Case study
Having ORS and Zinc as separate items on the EMLc also means that those
procuring ask for one and not the other. Let me give you an example:

In Zambia the Ministry of Health asked UNICEF to help with the supply of
ORS. Without questioning this request, UNICEF supplied. So Zambia went from
a situation where there was a severe shortage of ORS to a situation where
there was plenty. At this time a local pharmaceutical company started
shipping an ORS/Zinc co-pack to the Ministry but some health centres said
they couldn't accept it as they had so much ORS (from UNICEF). So in effect
UNICEF undermined its own recommendation by flooding the 'market' with ORS
only.

Proposal
Our proposal is that *co-packaged* ORS and Zinc should be included as an
item on the Essential Medicines for Children (EMLc).

Expected outcomes from the implementation of this proposal

   1. Reduction in chronic diarrhoea
   2. Reduction in under 5 stunting
   3. Reduction in mortality due to dehydration from diarrhoea

All three due to:

   - A transformational increase in the percentage of under 5 diarrhoea
   cases treated with the recommended combination therapy of ORS and Zinc
   Sulphate (currently 99% of diarrhoea cases are not treated with ORS and
   Zinc) as a result of:

   1. An increase in awareness of the recommended treatment for diarrhoea
   throughout the delivery chain (from those who procure through medicine
   suppliers to those who prescribe and dispense)
   2. Increased availability of the two therapy components in the same
   place at the same time (because they would be co-packaged)

Please confirm receipt of this email and let us know how we might format
this proposal to meet the requirements of the Expert Committee on the
Selection and Use of Essential Medicines in time for the next meeting in
March.

Yours faithfully

=END=

Simon Berry
Counterpart programme manager
Kit Yamoyo Transition to Scale (KYTS)*
Simon Berry <simon@colalife.org>