Zinc/ORS Co-packaging: A Step Towards Bridging the Gap in Preventable Childhood Diarrhoeal Deaths in India : Indian Journal of Community Medicine

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Letter to Editor

Zinc/ORS Co-packaging: A Step Towards Bridging the Gap in Preventable Childhood Diarrhoeal Deaths in India

Behera, Priyamadhaba; Pradhan, Somen Kumar; Behera, Surama Manjari1; Rao, E. Venkata2

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Indian Journal of Community Medicine 48(3):p 505-506, May–Jun 2023. | DOI: 10.4103/ijcm.ijcm_1006_22
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Diarrhoeal disease is one of the leading causes of mortality and morbidity among children aged five years and below in the world. It accounted for approximately 9% of all deaths among children aged under five worldwide in 2019.[1] The majority of the burden of morbidity as well as mortality associated with diarrhea has been borne by developing countries worldwide.[2] India is the country with the second highest burden of deaths from diarrhea among those under-five where 7% of all under-five deaths are caused by diarrhea.[3]

In 2004, the World Health Organization (WHO) issued a global recommendation to formalize ORS + zinc as the gold standard for the treatment of diarrheal disease. According to this, ORS along with Zinc for 10-14 days can significantly reduce the incidence of diarrhea among under-five children.[4] In 2013, WHO and UNICEF devised the “Global Action Plan for Prevention and Control of Pneumonia and Diarrhoea” to end diarrheal deaths among children by 2025. The “Protect-Prevent-Treat” strategy focused on ORS and Zinc as an essential components in diarrhea treatment.[5] Oral Zinc has been shown to reduce both the duration and frequency of diarrhea among under-5 children.[6] There has been enough evidence on the cost as well as clinical effectiveness of Zinc in controlling acute and bloody diarrhea.[7] In a Lower Middle-Income country (LMIC) like India, where the prevalence of undernutrition is high, the role of Zinc in the prevention of diarrheal death is even more significant.[8] However, the recent National Family Health Survey-5 (NFHS-5) from India reported that only 30.5% of the under-5 children suffering from diarrhea received Zinc as compared to 60.6% who received ORS.[9] Under these circumstances, India is yet to incorporate zinc-ORS co-packaging into its national diarrhea control strategy.

Co-packaging can help in scaling up the Zinc uptake along with ORS among under-five suffering from acute diarrhea and reduce the gap between compliance to ORS and Zinc during episodes of diarrhea.[10] This strategy has also been shown to reduce the irrational use of antibiotics during acute diarrhea management helping in tackling the threat of anti-microbial resistance.[11] Co-packaging and rebranding it in the form of a “diarrhoea kit” can help in improving the medical prescription practice among healthcare providers for diarrhea patients.[12] The zinc/ORS co-pack can further facilitate Zinc utilization by frontline health workers during community-based management of diarrhea.[13] This would also help correct the inventory management issues related to Zinc at the primary care level through combined stock management and dispensation along with ORS.[14]

Panel 1:
Priorities for zinc/ORS co-packaging implementation

There are certain issues that need to be addressed based on previous experiences before introducing zinc/ORS co-pack into the healthcare delivery system. Strengthening the functional supply chain management should be one of the utmost priorities for the delivery of zinc/ORS co-pack at the grassroots level. The introduction of zinc/ORS co-pack into the health system and market will need upgrading national drug policy under the appropriate regulatory framework. A national-level action plan for the integration of the co-packaged product into national guidelines for diarrhea management and health programs would be the first step in this direction.[15] Utilization of zinc/ORS co-pack would require the sincere engagement of both the providers and community through IEC and capacity building respectively. Partnerships with the private sector and professional bodies would assist in scaling up this strategy effectively. Designating zinc/ORS co-pack as an Over counter (OTC) product would be essential in the implementation of the strategy as this would improve its accessibility for beneficiaries. On the other hand, incorporating flavored Zinc tablets and making the co-packaged product more affordable would improve the acceptability as well as compliance at the consumer level.

Long-term interventions like improving WASH practices and Rotavirus vaccination have been instrumental in reducing the burden of preventable diarrhoeal deaths. However, the existing opportunity for further reduction in childhood diarrhea mortality through greater coverage of ORS/zinc co-packaging has received several calls for action worldwide. World Health Organization has already added zinc/ORS co-pack to the Essential Medicine List in 2019. It’s time that other LMIC countries including India introduce the zinc/ORS co-pack under their national health programs as this would go a long way in reducing the burden of diarrhoeal deaths worldwide.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1. United Nations International Children's Emergency Fund Diarrhoea 2022. Available from:https://data.unicef.org/topic/child -health/diarrhoeal-disease/.
2. Bulled N, Singer M, Dillingham R. The syndemics of childhood diarrhoea:A biosocial perspective on efforts to combat global inequities in diarrhoea-related morbidity and mortality. Glob Public Health 2014;9:841–53.
3. Ugboko HU, Nwinyi OC, Oranusi SU, Oyewale JO. Childhood diarrhoeal diseases in developing countries. Heliyon 2020;6:e03690.
4. WHO-UNICEF. WHO/UNICEF Joint statement: Clinical management of acute diarrhoea 2004.
5. UNICEF. The Integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD) 2013.
6. Bhutta ZA, Bird SM, Black RE, Brown KH, Gardner JM, Hidayat A, et al. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries:Pooled analysis of randomized controlled trials. Am J Clin Nutr 2000;72:1516–22.
7. World Health Organisations Implementing the new recommendations on the clinical management of diarrhoea:Guidelines for policy makers and programme managers Geneva World Health Organization 2006. Available from:http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle: Implementing+the+New+Recommendations+on+the+Clinical+Management+of+Diarrhoea.+Guidelines+for+Policy+Makers+and+Programme+Managers#0.
8. Lazzerini M, Wanzira H. Oral zinc for treating diarrhoea in children. Cochrane Database Syst Rev 2016;12:CD005436.
9. International Institute for Population Sciences (IIPS) and ICF.2021 National Family Health Survey (NFHS-5), India, 2019-21:IIPS Mumbai (2022).
10. Ezezika O, Ragunathan A, El-Bakri Y, Barrett K. Barriers and facilitators to implementation of oral rehydration therapy in low- And middle-income countries:A systematic review. PLoS One 2021;16:1–23.
11. Baqui AH, Black RE, Arifeen SEl, Yunus M, Zaman K, Begum N, et al. Zinc therapy for diarrhoea increased the use of oral rehydration therapy and reduced the use of antibiotics in Bangladeshi children. J Heal Popul Nutr 2004;22:440–2.
12. Behera P, Bhatia V, Sahu DP, Sahoo DP, Kamble R, Panda P, et al. Adherence of doctors to standard diarrhoeal management guideline during treatment of under-five diarrhoeal episodes:A study from Eastern India. Cureus 2021;13:e13433.
13. Habib MA, Soofi S, Sadiq K, Samejo T, Hussain M, Mirani M, et al. A study to evaluate the acceptability, feasibility and impact of packaged interventions (“Diarrhea Pack”) for prevention and treatment of childhood diarrhea in rural Pakistan. BMC Public Health 2013;13:922.
14. Lam F, Kirchhoffer D, Buluma DM, Kabunga L, Wamala-Mucheri PN, Schroder K, et al. A retrospective mixed-methods evaluation of a national ORS and zinc scale-up program in Uganda between 2011 and 2016. J Glob Health 2019;9:010504.
15. Child Health Division, Ministry of Health and Family Welfare G of I. IDCF 2014, Intensified Diarrhoea Control Fortnight, Operational Plan for States, UTs and Districts 2014. Available from: https://nhm.gov.in/images/pdf/IDCF/Important_Document/IDCF_Guidelines_for_States.pdf.
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