1. Scaling Up Zinc for Young Children (SUZY) Project What is the research telling us? Updated Findings to 2011

2. Ongoing Gaps in Knowledge Alternative supplementation strategies –Length of treatment –Treatment followed by daily supplementation –Household distribution of blister packs –NGO-unregulated providers partnership Sustainability of scale up efforts –Long-term impact SUZY Project - ICDDRB

3. RCT 5 vs. 10 days of zinc treatment Community-based, rural, effectiveness study Alam DS et al. J Nutr. 2011 Feb;141(2):312-5. Comparison of diarrheal incidence and burden over 90 days of follow up after treatment Treatment group 5 days (n=819) 10 days (n=803) Number of episodes Mean ± SD1.02 ± 1.351.08 ± 1.38 Duration of diarrhea Mean ± SD2.9 ± 5.63.1 ± 5.6 SUZY Project - ICDDRB

4. * * * * * *Significantly different from placebo group Zinc Side Effects: Vomiting SUZY Project - ICDDRB

5. Alternative strategies: Zinc treatment followed by zinc supplementation Larson CP, et al. Trop Med Int Health. 2010 Jun;15(6):754-61 Dhaka urban slum effectiveness RCT Zinc treatment vs. Zinc treatment + supplementation x 3 months Outcome: ACD incidence density (# episodes/child-year fu) SUZY Project - ICDDRB

6. Diarrhea Incidence (# episodes/child-year) % Interval ZT ZT+S difference reduced p-value 0-3 mo 3.60 2.64 0.96 27.012 0-9 mo 2.53 2.00 0.53 21.028 Results SUZY Project - ICDDRB

7. Alternative strategies: Household distribution of zinc blister packs Feikin D, et al CDC/KEMRI/ICDDR,B Rural Kisumu, Kenya 34 Villages randomized to receive either Intervention Group: ORS + Zinc distributed to households Control Group: ORS in households Zinc distributed to clinics SUZY Project - ICDDRB

8. Effect of intervention on drug use and healthcare use Post-intervention P value* Intervention n (%) Comparison n (%) Zinc ORS Antimalarial Antibiotic Sought care** 976 (62.0) 947 (60.1) 178 (11.3) 276 (17.5) 399 (25.3) 80 (5.1) 916 (58.8) 255 (16.4) 352 (22.6) 536 (34.5) <.0001.5732.0136.0256.0874

9. Fever without diarrhea Zinc Antimalarial Sought care** 14 (0.2) 1475 (24.8) 1983 (33.4) 1 (0.0) 1640 (25.4) 2173 (33.7) Cough without diarrhea Zinc Antimalarial Sought care** 10 (0.2) 841 (16.2) 1399 (27.0) 1 (0.0) 854 (17.2) 1384 (27.9). Post-intervention Intervention n (%) Comparison n (%) Were zinc tablets misused?

10. NGO – Unregulated Providers Partnership Fact: Unregulated providers are the dominant health seeking choice of caretakers Question: Can NGOs influence diarrhea management practices of unregulated providers (village doctors/ drug vendors)? Strategy: 1.Networking and orientation 2.Training 3.FU support

11. NGO-Drug Vendors Study: Crude estimates of the relative risk of a child receiving zinc treatment Control sites Zinc Received Yes No %RR 95% CI Baseline 14245223.9 Endline 9753915.2.64 (.49,.83) Intervention sites Zinc Received Yes No %RR 95% CI Baseline 13447422.0 Round 2 18442530.21.4 (1.1, 1.7) SUZY Project - ICDDRB

12. Ongoing Monitoring Mass media promotion x 2 years Larson CP, et al. Impact monitoring of the national scale up of zinc treatment for childhood diarrhea in Bangladesh: repeat ecologic surveys.Impact monitoring of the national scale up of zinc treatment for childhood diarrhea in Bangladesh: repeat ecologic surveys. PLoS Med. 2009 Nov;6(11):e1000175. What happens once the promotion ends? awareness coverage

13. Caretaker awareness of zinc treatment for childhood diarrhea Awareness among rural caretakers follows a much more protracted course and does not appear to be dependent upon continued mass media promotion

14. Zinc treatment coverage by location of household No drop-off in zinc coverage, but no gains either

15. Conclusions 1.5 days of zinc treatment may be as efficacious as 10 in terms of preventive effects 2.Daily zinc supplementation following zinc treatment offers further reduction in repeat ACD episodes 3.Household distribution of blister packs will greatly increase coverage, with low risk of misuse. SUZY Project - ICDDRB

16. Conclusions 4. NGO-Unregulated provider partnerships do work 5. There is a need for longer term planning and on-going private sector incentives and/or sustained consumer demand SUZY Project - ICDDRB