1. Solomon Islands Ministry of Health & Medical Services 2. Centre for International Child Health, University of Melbourne

Upscaling Zinc Sulphate in Solomon Islands

Nunan, M1,2., Pirpinias, M1., Zinihite, J1

Background Despite a strong body of evidence supporting its use in children with diarrhoea, the availability of Zinc Sulphate remains low across the Pacific region.

The Solomon Islands introduced Zinc Sulphate onto the national Essential Medicines List in 2009 but anecdotal evidence suggested it was not widely available at the Primary Healthcare Level and was not being used. The National Pharmacy Services Division sought to examine this and undertake interventions to improve both the availability and knowledge of Zinc Sulphate amongst Primary Healthcare workers.

It was determined to start this with a pilot project in the Western Province of Solomon Islands.

Results Comprehension Knowledge of what Zinc Sulphate is used for increased from 16% to 88%. All other indicators of comprehension also increased.

Comprehension Indicator! Baseline!N = 19!

Post-intervention!

N = 17!

Change!

What is the main indication for Zinc in children? ! 16%! 88%! +72% (p<0.05)!

What is the benefit of giving a child Zinc for diarrhoea? ! 5%! 65%! +60% (p<0.05)!

What is the benefit of giving a child ORS for diarrhoea?! 89%! 94%! +5%!

Can Zinc be taken at the same time as ORS?! 11%! 82%! +71% (p<0.05)!

Should the child be given less ORS if they are being given Zinc?! 11%! 18%! +7%!

What is the recommended dose of Zinc in diarrhoea?! 5%! 35%! +30%!

What is the duration of Zinc therapy in diarrhoea?! 0%! 65%! +65% (p<0.05)!

Where can you check the dose and duration of treatment for Zinc? ! 84%! 88%! +4%!

KNOWLEDGE HUBS FOR HEALTH STRENGTHENING HEALTH SYSTEMS THROUGH EVIDENCE IN ASIA AND THE PACIFIC

Zinc Sulphate is effective in1: •  Reducing the severity and duration of acute diarrhoea2

•  Reducing the severity of cholera3

•  Decreasing mortality and improving weight gain among children with severe malnutrition4

•  Preventing diarrhoea in low birth weight babies5

•  Reducing the severity and duration of dysentery (bloody diarrhoea) from Shigella6

Methodology A survey was written by the Pharmacy Services Division, the Child Health Program and the Nutrition Department of the SI Ministry of Health to examine indicators for health worker’s comprehension of Zinc Sulphate and ORS use in children with diarrhea; and to examine actual availability of the agents.

20 of Western Province’s 45 facilities were randomly selected for a baseline data survey in September 2011. One nurse from each clinic was interviewed and one clinic was not open (N = 19)

Following the initial survey, the Pharmacy Services Division undertook a series of low-cost interventions (see Box below) to improve availability and knowledge of the agent across Western Province over a period of 6 months to March 2012.

20 further clinics were then randomly selected from the remaining 25 for follow-up in April 2012. Three of these clinics were not open during the survey (N= 17).

Comprehension was measured by a series of questions about Zinc Sulphate; the correctness of answers was determined by the touring Pharmacist and all answers were recorded for verification. Availability was measured by a physical stock-check in clinics. Zinc Sulphate was recorded as being ‘available’ if stock was physically available in the clinic at the time of survey.

A qualitative survey was carried out in 5 additional facilities in December 2011 to assess comprehension of the training materials being disseminated. Using the results of this survey, the training and promotional materials were adjusted and continued to be rolled out.

Interventions Staff Education: Feature articles in major health newsletter, UHF radio programs Patient Education: Clinic Posters, Patient Information Cards Supply Chain Improvements: Updated order sheets disseminated, Provincial Pharmacy supply staff briefed on the importance of Zinc

Availability The availability of Zinc Sulphate in clinics increased from 0% to 65%. All stock was recorded as being in date. The availability of ORS increased from 84% to 88% but there was an increase in the number of clinics holding expired stock at the time of follow-up; this suggests problems in the Supply Chain.

Item! Baseline!N = 19!

Post-intervention!

N = 17!

Change!

Zinc Sulphate!0%! 65%! +65% (p<0.05)!

Oral Rehydration Salts!84%! 88%! +4%!

Implications We have demonstrated it is possible to increase the availability and comprehension of Zinc Sulphate for use in children with diarrhoea, with a series of low-cost, contextually appropriate interventions. This pilot study will now be rolled out across all provinces; further work may also focus on all 30 WHO Priority Medicines for Mothers & Children. This work is likely to be reproducible in similar settings across the Pacific but more methodological rigour is needed in larger studies.

We believe that these low-cost interventions, which incorporate patient education simultaneously with staff education and supply chain mechanism improvements are more effective and considerably less expensive than staff workshops, which are often used by vertical programs and external agencies. More research is needed in this area.

Survey tours in Western Province, Solomon Islands

Acknowledgements The Centre for International Child Health (CICH) is a World Health Organization Collaborating Centre for Child and Neonatal Health, and along with the Burnet Institute and the Menzies School of Health Research makes up the Women’s and Children’s Health Knowledge Hub. This research has been funded by AusAID. The views represented are not necessarily those of AusAID or the Australian Government. We acknowledge WHO and UNFPA for supporting our attendance at APCNMP 2012.

Contact: michael.nunan@rch.org.au Centre for International Child Health, University of Melbourne, Royal Children’s Hospital, Flemington Rd, Parkville Australia 3052.

References 1. Duke, T. Zinc Sulphate for prevention and treatment of diarrhoea, and other conditions in children in PNG, Briefing Paper, Compass Women and Children’s Health Knowledge Hub, AusAID, 2011 2. Lazzerini M, Ronfani L. Oral zinc for treating diarrhoea in children. Cochrane Database of Systematic Reviews 2008; Issue 3. Art. No.: CD005436. DOI: 10.1002/14651858.CD005436.pub2. 3. Roy SK, Hossain MJ, Khatun W, Chakraborty B, Chowdhury S, Begum A et al. Zinc supplementation in children with cholera in Bangladesh: randomised controlled trial. Brit Med J 2008; 336(7638):266-268. 4. Makonnen B, Venter A, Joubert G. A randomized controlled study of the impact of dietary zinc supplementation in the management of children with protein-energy malnutrition in Lesotho. I: Mortality and morbidity. J Trop Pediatr 2003; 49(6):340-352. 5. Sur D, Gupta DN, Mondal SK, Ghosh S, Manna B, Rajendran K et al. Impact of zinc supplementation on diarrheal morbidity and growth pattern of low birth weight infants in kolkata, India: a randomized, double-blind, placebo-controlled, community-based study. Pediatrics 2003; 112:1327-1332. 6. Roy SK, Raqib R, Khatun W, Azim T, Chowdhury R, Fuchs GJ et al. Zinc supplementation in the management of shigellosis in malnourished children in Bangladesh. Eur J Clin Nutr 2008; 62(7):849-855.

KNOWLEDGE HUBS FOR HEALTH STRENGTHENING HEALTH SYSTEMS THROUGH EVIDENCE IN ASIA AND THE PACIFIC

Burnet InstituteCentre for International Child Health, University of Melbourne

Menzies School of Health Research