The case for co-packaging of ORS and Zinc

The case for co-packaging ORS and Zinc for the treatment of diarrhoea can be summarised as follows:

The international recommendation[1] for the treatment of childhood diarrhoea is ORS combined with Zinc and Jul-19 the WHO Model Essential Medicines List (PDF, 1,7 MB) was revised to state that the two components of the treatment should be co-packaged.

ORS should be given as early as possible after the onset of the diarrhoea and continued until the diarrhoea stops. Zinc should be given daily for 10-14 days from the onset of the diarrhoea. This will mean that the Zinc will be administered for several days after the diarrhoea has stopped.
When ORS and Zinc are distributed separately there is a high likelihood that they will not be dispensed together for several reasons:
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
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%.

The co-packaging effect – the Mongu case study (2018)

The “co-packaging effect” was evident in a dispensing behaviours analysis conducted by ColaLife across health centres in Mongu District, Zambia, in October 2016 and October 2017.

In Nov/Dec-17 all health centres in Mongu District were visited (n=30) and stocking information for ORS and Zinc was gathered for the period Jan-15 to Oct-17 from the health centres’ own records. These health centres were then filtered according to the stock level or ORS and Zinc in the peak diarrhoea month (October) in 2016 and 2017. Of the 30 health centres only eight had both ORS and Zinc in stock as separate stock items in both Oct-16 and Oct-17. In Jan-17 the distribution of co-packaged ORS and Zinc to Mongu began. These eight health centres also had the co-pack in stock in Oct-17. So for these health centres all current treatment options for diarrhoea were available to those prescribing and dispensing. These eight health centres were re-visited in Feb-18 and the dispensing records for Oct-16 and Oct-17 were analysed with respect to diarrhoea treatments issued.

Before the introduction of co-packaged ORS and zinc in Jan-17, the co-administration of ORS and Zinc in Oct-16 was already very high – six times the global average – at 44% of childhood diarrhea cases treated with both ORS and zinc. However, this was only happening in 8 of the 30 centres. In the other 22 centres, diarrhoea cases were not being given both ORS and Zinc as one or the other was out of stock.

The relatively high level of dispensing of ORS together with Zinc in Oct-16 (44%) doubled to 87% in Oct-17 when co-packaged ORS and zinc was made available with nearly 90% of co-treatments being given in the form of co-packaged ORS and zinc.

Proportion of children younger than 5 years treated with both oral rehydration salts and zinc packaged separately versus co-packaged, Mongu District, Zambia.

There was also evidence that antibiotic usage was reduced. See the full analysis which can be downloaded here: An analysis of diarrhoea treatments in Mongu districts following the introduction of the GRZ ORS/Zinc co-pack(PDF, 223 KB).

When asked in December 2017, whether anything had changed since receiving co-packaged ORS and zinc, and if so what, a district health director in Zambia replied:

Yes, what has changed is the availability especially of zinc, which is a part of [the co-pack] because I know previously we have never had problems with ORS availability but we have had problems when it came to zinc availability. But now that everything has been put into one kit, that has greatly improved the availability of zinc, which we know is important to limit the number of diarrhea cases and the duration of diarrhea. So the kit is really making an impact and it also serves as a reminder for us, as we are prescribing as health workers, that we do not forget zinc being an important component in the treatment of diarrhea.

Update: Link to publications.

This case study supported earlier findings in ColaLife’s work and by subsequent published work.

The Final Evaluation Report of the ColaLife Trial (COTZ), produced by Ruralnet Associates and commissioned by UNICEF Zambia, published via DfID as part of the UK Government’s Aid Programme here. This reports the endline survey against baseline and discusses the increase in Zinc, reported by users, administered with ORS, from from close to zero at baseline to 45 per cent at endline.
The doctoral thesis of Rohit Ramchandani, our Principle Investigator in the COTZ Trial, published by Johns Hopkins University in 2016, here.
A peer reviewed article in the British Medical Journal, published in 2022, here.

An article on Design Thinking is in preparation and a future link will be added here.

An article on Vertical Scale Up – Institutionalising co-packaged ORS and Zinc in Zambia and globally is in preparation and a future link will be added here.

[1] WHO (2005) The treatment of diarrhoea – a manual for physicians and other senior health workers. ISBN: 9241593180
Download here

Updated Jun 2022