Bottleneck analysis and strategic planning using Tanahashi model for childhood diarrhea management in Gujarat, Western India.

In spite of continued efforts, India is still lagging behind in achieving its MDG goals. The objectives of this study were to identify stake-holders who have a role to play in childhood diarrhea management, to identify gaps in childhood diarrhea management and to propose strategic options for relieving these gaps. Bottleneck analysis exercise was carried out based on the Tanahashi model in six High Priority Districts (HPDs) of Gujarat in period between July-November 2013. The major bottlenecks identified for Childhood Diarrhea management were poor demand generation, unsafe drinking water, poor access to improved sanitation facility and lack of equitable distribution and replenishment mechanisms for Oral Rehydration Solution (ORS) packets and Zinc tablets till the front-line worker level. The main strategic options that were suggested for relieving these bottlenecks were Zinc-ORS roll out in scale-up districts, develop Information Education Communication/Behaviour Change Communication (IEC/BCC) plan for childhood diarrhea management at state/district level, use of Drug Logistics Information Management System (DLIMS) software for supply chain management of Zinc-ORS, strengthening of chlorination activity at household level, monitoring implementation of Nirmal Bharat Abhiyaan (NBA) for constructing improved sanitation facilities at household level and to develop an IEC/BCC plan for hygiene promotion and usage of sanitary latrines. Use of Zinc tablets need to be intensified through an effective scale-up. Adequate demand generation activity is needed. There is need to address safe drinking water and improved sanitation measures at household levels. Multi-sectoral engagements and ownership of Zinc-ORS program is the need of the hour.

Scaling-up public sector childhood diarrhea management program: Lessons from Indian states of Gujarat, Uttar Pradesh and Bihar.

BACKGROUND: Diarrhea remains a leading cause of death among children under five in India. Public health sector is an important source for diarrhea treatment with oral rehydration salts (ORS) and zinc. In 2010, Micronutrient Initiative started a project to improve service delivery for childhood diarrhea management through public health sector in Gujarat, Uttar Pradesh (UP) and Bihar. This paper aims to highlight feasible strategies, experiences and lessons learned from scaling-up zinc and ORS for childhood diarrhea management in the public sector in three Indian states. METHODS: The project was implemented in six districts of Gujarat, 12 districts of UP and 15 districts of Bihar, which includes 10.5 million children. Program strategies included capacity building of health care providers, expanding service delivery through community health workers (CHWs), providing supportive supervision to CHWs, ensuring supplies and conducting monitoring and evaluation. The lessons described in this paper are based on program data, government documents and studies that were used to generate evidence and inform program scale-up. RESULTS: 140 000 health personnel, including CHWs, were trained in childhood diarrhea management. During three years, CHWs had sustained knowledge and have treated and reported more than three million children aged 2-59 months having diarrhea, of which 84% were treated with both zinc and ORS. The successful strategies were scaled-up. CONCLUSION: It is feasible and viable to introduce and scale-up zinc and ORS for childhood diarrhea treatment through public sector. Community-based service delivery, timely and adequate supplies, trained staff and pro-active engagement with government were essential for program success.

Appropriate Management of Acute Diarrhea in Children Among Public and Private Providers in Gujarat, India: A Cross-Sectional Survey.

Diarrhea remains a leading cause of morbidity and mortality among children under 5 years of age in low- and middle-income countries. In 2006, the Indian government formally endorsed the World Health Organization guidelines that introduced zinc supplementation and low-osmolarity oral rehydration salts (ORS) for the treatment of diarrhea. Despite this, zinc is rarely prescribed and has not been available in the public sector in India until very recently. The Diarrhea Alleviation Through Zinc and ORS Treatment (DAZT) project was implemented in Gujarat between 2011 and 2013 to accelerate the uptake of zinc and ORS among public and private providers in 6 rural districts. As part of an external evaluation of DAZT, we interviewed 619 randomly selected facility- and community-based public and private providers 2-3 months after a 1-day training event had been completed (or, in the case of private providers, after at least 1 drug-detailing visit by a pharmaceutical representative had occurred) and supplies were in place. The purpose of the interviews was to assess providers' knowledge of appropriate treatment for diarrhea in children, reported treatment practices, and availability of drugs in stock. More than 80% of all providers interviewed reported they had received training or a drug-detailing visit on diarrheal treatment in the past 6 months. Most providers in all cadres (range, 68% to 100%) correctly described how to prepare ORS and nearly all (range, 90% to 100%) reported routinely prescribing it to treat diarrhea in children. Reported routine prescription of zinc was lower, ranging from 62% among private providers to 96% among auxiliary nurse-midwives. Among providers who reported ever not recommending zinc (n = 242), the 2 most frequently reported reasons for not doing so were not completely understanding zinc for diarrhea treatment and not having zinc in stock at the time of contact with the patient. In a multiple logistic regression analysis, recent training or drug-detailing visits and having zinc in stock were associated with reported zinc prescribing (P<.05). Recent training among public providers was significantly associated with having correct knowledge of zinc treatment duration and dosage, but the same was not true of drug-detailing visits among private providers. Treating diarrhea with zinc and low-osmolarity ORS is new for public and private providers in India and other low- and middle-income countries. Sufficient training and logistics support to ensure consistent supplies are critical if providers are to begin routinely treating all diarrhea episodes with zinc and ORS.

Zinc deficiency-associated dermatitis in infants during a nationwide shortage of injectable zinc - Washington, DC, and Houston, Texas, 2012-2013.

Injectable zinc, a vital component of parenteral nutrition (PN) formulations, has been in short supply in the United States since late 2012. In December 2012, three premature infants with cholestasis hospitalized in Washington, DC, experienced erosive dermatitis in the diaper area and blisters on their extremities, a condition that can be associated with zinc deficiency. All three infants were receiving PN because they had extreme cholestasis and were unable to be fed by mouth or tube. The PN administered to each infant was zinc deficient. Injectable zinc normally is added to PN for premature or medically compromised infants (e.g., those with cholestasis) by the hospital pharmacy because the amount of zinc needed by each patient differs; however, the pharmacy had run out of injectable zinc. No alternatives were available; other preparations of parenteral trace elements either contained insufficient zinc to meet infants' requirements or had the potential to cause trace element toxicity in infants with cholestasis (2). The dermatitis of one infant resolved after the patient was able to take nutrition by mouth. The other two infants were found to have low serum zinc levels. In January 2013, CDC was notified of four additional cases of zinc deficiency among infants with cholestasis who received zinc-deficient PN in a hospital in Houston, Texas. In collaboration with the Food and Drug Administration (FDA), the two hospitals obtained emergency shipments of injectable zinc. No additional cases were reported. Current injectable zinc supplies have been increasing as FDA collaborates with pharmaceutical companies to import emergency supplies. FDA is working to establish temporary backup sources should future shortages occur.

Estudo da associação de micronutrientes ( zinco, cobre e ferro) na infecção, e ou progressão para leishmaniose tegumentar em duas comunidades rurais do Estado da Bahia / Study of micronutrients Association (zinc, copper and iron) in infection and or progression to cutaneous leishmaniasis in two rural communities in the state of Bahia

A leishmaniose tegumentar (LT) é um problema de saúde pública nas Américas, não somente por sua alta incidência e ampla distribuição geográfica, mas também, pela possibilidade de produzir úlceras persistentes e desfigurantes. É endêmica no Brasil, ocorrendo em ambientes florestais e extraflorestais. A detecção de áreas de alto risco para a infecção humana pode auxiliar na implementação de estratégias de controle mais eficientes nas áreas endêmicas rurais. Objetivos: descrever as características epidemiológicas, prevalência da infecção por Leishmania ssp nas populações do povoado de São Gonçalo/Contendas do Sinçorá - Bahia e no Distritode Florestal/Município de Jequié, Bahia, correlacionando os fatores de risco estabelecidos na literatura com os diferentes grupos estudados (indivíduos infectados, não infectados, e doentes) e avaliar a influencia da desnutrição na infecção e ou progressão para a doença, para isso, foram avaliados parâmetros bioquímicos como dosagem de fosfatase alcalina e ferritina, além dos níveis de metais Zn, Cu e Fe no plasma dos indivíduos.Material e Métodos - desenvolveu-se um estudo de corte transversal, através de inquérito epidemiológico, e imunoalérgico (exames intradermorreação de Montenegro/IDRM, e sorológico/ELISA). Foram cadastradas 36 famílias (170 indivíduos) de São Gonçalo e 129 famílias (480 indivíduos) de Florestal...

The cutaneous leishmaniasis (CL) is a public health problem in the Americas, not only for its high incidence and wide geographical distribution, but also by the possibility of establishing persistent and disfiguring ulcers. It is endemic in Brazil, occurring in forest and around environments. The detection of high-risk areas for human infection may assist in implementing strategies for more efficient control in rural endemic areas. Objectives -.This study aimed to describe the epidemiological characteristics, prevalence of Leishmania spp, infection in populations of São Gonçalo a rural communities/Contendas do Sincorá - Bahia and Florestal (District/Jequié, Bahia), correlating risk factors established in the literature with different groups studied (infected individuals not infected, and patients) and assess the influence of malnutrition on infection and progression for disease, for that biochemical parameters will be evaluated as measure alkaline phosphatase and ferritin, beyond the levels of metals Zn, Cu and Fe in the plasma of subjects. Materials and Metholds.- We developed a cross-sectional study through epidemiologic and immunological investigation (Montenegro skin tests/MST, and serological/ELISA). 36 families (170 individuals) of São Gonçalo and 129 families (480 individuals) were registered in Florestal District...

Zinc y desnutrición / Zinc and undernutrition

Son cuatro los nutrientes en que su deficiencia es importante en niños: hierro, yodo, vitamina A y zinc. Más o menos se calcula que hay 2 billones de personas en el mundo con algún grado de déficit de zinc. Los pacientes que están en riesgo de presentar deficiencias de zinc son los recién nacidos con bajo peso al nacimiento, bien sea prematuros, desnutridos in útero o hijos de madres desnutridas, en los cuales sus depósitos están reducidos. A diferencia de otros oligoelementos o micronutrientes, determinar el estado de déficit no es fácil. Los niveles séricos de zinc, están influenciados por factores no dietarios como infección, estrés o actividad física extenuante; al igual que por el ciclo circadiano.

Four nutrient deficiency that is important in children, iron, iodine, vitamin A and zinc. More or less it is estimated that 2 billion people in the world with some degree of zinc deficiency. Patients who are at risk for zinc deficiency are infants with low birth weight, either premature or malnourished in utero, undernourished mothers, in which their deposits are reduced. Unlike other trace elements or micronutrients, determine the deficit is not easy. Serum levels of zinc are not influenced by dietary factors such as infection, stress or strenuous physical activity, as well as by the circadian cycle.

Zinc en la infancia: rompiendo paradigmas / Zinc in childhood: breaking paradigms

El zinc es un ejemplo de un micronutriente esencial, cuya deficiencia juega un papelimportante en la comprensión de las altas tasas de mortalidad y morbilidad infantil en países en desarrollo. Tanto la deficiencia intermedia de zinc como de vitamina A, pueden pasar inadvertidas clínicamente. Con respecto a la inmunidad, el zinc es fundamental para las funciones de tejidos de alto recambio, especialmente en el sistema inmunitario, y su deficiencia se asocia a alteraciones de la inmunidad innata, la inmunidad humoral y la inmunidad celular. Existe evidencia que avala la s u p l eme n t a c i o n d e z i n c d u r a n t e e inmediatamente después de un episodio de diarrea aguda, con lo que se disminuye su tiempo de duración y la gravedad, con reducción en la incidencia de diarrea en los dos o tres meses siguientes.Aun no se conoce exactamente cuál es el mecanismo que explique por qué se encuentra limitada la proliferación celular ante la deficiencia de zinc.

Zinc is an example of an essential micronutrient whose deficiency plays an important role in understanding the high rates of infant mortality and morbidity in developing countries. Both intermediate zinc deficiency and vitamin A, may go unnoticed clinically.With respect to immunity, zinc is essential for the functions of tissues of high turnover, especially in the immune system, and its deficiency is associated with alterations of innate immunity, humoral immunity and cellular immunity. There is evidence supporting zinc supplementation during and immediately after an episode of acute diarrhea, which shortens their duration and severity, with a reduction in the incidence of diarrhea in the two or three months. Still not known exactly what the mechanism that explains why it is limited to cell proliferation in zinc deficiency.

Discontinuation of penicillamine in the absence of alternative orphan drugs (trientine-zinc): a case of decompensated liver cirrhosis in Wilson's disease.

OBJECTIVES: To report a case of early-decompensated liver cirrhosis secondary to discontinuation of penicillamine therapy in a patient with Wilson's disease. CASE SUMMARY: A 33-year-old Chinese female patient was diagnosed with Wilson's disease, for which penicillamine 250 mg p.o. once daily was prescribed. However, the patient developed intolerance and penicillamine was discontinued without alternative treatment. Five months later, she developed decompensated liver cirrhosis with hepatic encephalopathy. Eventually, the patient died because of the complications of sepsis and decompensated liver failure. DISCUSSION: Chelating agent is the mainstay of treatment in Wilson's disease, which is an inherited disorder of hepatic copper metabolism. Therapy must be instituted and continued for life once diagnosis is confirmed. Interruption of therapy can be fatal or cause irreversible relapse. Penicillamine given orally is the chelating agent of first choice. However, its unfavourable side-effects profile leads to discontinuation of therapy in 20-30% of patients. In most case reports, cessation of penicillamine without replacement treatment causes rapid progression to fulminant hepatitis, which is fatal unless liver transplantation is performed. CONCLUSION: In this, we highlight a case of discontinuation of penicillamine in a patient with Wilson's disease without substitution with alternative regimen. This was caused by unavailability of the alternative agents such as trientine in our country. Consequently, the patient progressed to decompensated liver cirrhosis with encephalopathy and eventually passed-away within 5 months. One recent study supports a combination of trientine and zinc in treating patient with decompensated liver cirrhosis. This combination is capable of reversing liver failure and prevents the need of liver transplantation. Both trientine and zinc are not registered in Malaysia. Therefore, liver transplantation was probably the only treatment option for this patient. Hence, non-availability of orphan drugs in clinical practice is certainly a subject of serious concern. Systems for better management of patients with rare diseases need to be instituted by all the institutions concerned.

Papel del zinc en la nutrición / Paper of zinc in the nutrition

El conocimiento acerca del metabolismo del zinc y de su participación bioquímica en diversas funciones fisiológicas, han permitido explicar de este nutrimiento; es así como surge la necesidad de proteger a los grupos de población más vulnerables, empleando en la dieta alimentos que contienen este elemento. En el presente informe se abordan estos temas