Presented at the Asia Pacific Conference on National Medicines Policies, Sydney, Australia, 26-29 May 2012.

1. Upscaling Zinc Sulphate in Solomon Islands
Nunan, M1,2., Pirpinias, M1., Zinihite, J1
1. Solomon Islands Ministry of Health & Medical Services
2. Centre for International Child Health, University of Melbourne
Background Results
Despite a strong body of evidence supporting its use in children with diarrhoea, the Comprehension
availability of Zinc Sulphate remains low across the Pacific region.
Knowledge of what Zinc Sulphate is used for increased from 16% to 88%. All other
The Solomon Islands introduced Zinc Sulphate onto the national Essential Medicines indicators of comprehension also increased.
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 Comprehension Indicator! Baseline! Post- Change!
availability and knowledge of Zinc Sulphate amongst Primary Healthcare workers. N = 19! intervention!
It was determined to start this with a pilot project in the Western Province of Solomon N = 17!
Islands. What is the main indication for Zinc
16%! 88%! +72% (p<0.05)!
Zinc Sulphate is effective in1: in children? !
What is the benefit of giving a child
• Reducing the severity and duration of acute diarrhoea2 5%! 65%! +60% (p<0.05)!
Zinc for diarrhoea? !
What is the benefit of giving a child
• Reducing the severity of cholera3 ORS for diarrhoea?!
89%! 94%! +5%!
• Decreasing mortality and improving weight gain among Can Zinc be taken at the same time
11%! 82%! +71% (p<0.05)!
children with severe malnutrition4 as ORS?!
Should the child be given less ORS
11%! 18%! +7%!
• Preventing diarrhoea in low birth weight babies5 if they are being given Zinc?!
What is the recommended dose of
• Reducing the severity and duration of dysentery (bloody Zinc in diarrhoea?!
5%! 35%! +30%!
diarrhoea) from Shigella6 What is the duration of Zinc therapy
0%! 65%! +65% (p<0.05)!
Methodology in diarrhoea?!
Where can you check the dose and
84%! 88%! +4%!
A survey was written by the Pharmacy Services Division, the Child Health Program duration of treatment for Zinc? !
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 Availability
diarrhea; and to examine actual availability of the agents.
The availability of Zinc Sulphate in clinics increased from 0% to 65%. All stock was
20 of Western Province’s 45 facilities were randomly selected for a baseline data recorded as being in date. The availability of ORS increased from 84% to 88% but
survey in September 2011. One nurse from each clinic was interviewed and one there was an increase in the number of clinics holding expired stock at the time of
clinic was not open (N = 19) follow-up; this suggests problems in the Supply Chain.
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 Item! Baseline! Post- Change!
agent across Western Province over a period of 6 months to March 2012. N = 19! intervention!
20 further clinics were then randomly selected from the remaining 25 for follow-up in N = 17!
April 2012. Three of these clinics were not open during the survey (N= 17). Zinc Sulphate!
0%! 65%! +65% (p<0.05)!
Comprehension was measured by a series of questions about Zinc Sulphate; the
correctness of answers was determined by the touring Pharmacist and all answers Oral Rehydration Salts!
84%! 88%! +4%!
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
Implications
assess comprehension of the training materials being disseminated. Using the We have demonstrated it is possible to increase the availability
results of this survey, the training and promotional materials were adjusted and
continued to be rolled out.
and comprehension of Zinc Sulphate for use in children with
diarrhoea, with a series of low-cost, contextually appropriate
Interventions interventions. This pilot study will now be rolled out across all
provinces; further work may also focus on all 30 WHO Priority
Staff Education: Feature articles in major health Medicines for Mothers & Children. This work is likely to be
newsletter, UHF radio programs reproducible in similar settings across the Pacific but more
methodological rigour is needed in larger studies.
Patient Education: Clinic Posters, Patient Information
Cards We believe that these low-cost interventions, which incorporate
patient education simultaneously with staff education and supply
Supply Chain Improvements: Updated order sheets chain mechanism improvements are more effective and
disseminated, Provincial Pharmacy supply staff considerably less expensive than staff workshops, which are often
briefed on the importance of Zinc used by vertical programs and external agencies. More research
is needed in this area.
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.
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 Burnet Institute
Health Knowledge Hub. This research has been funded by AusAID. The views represented are not necessarily those of AusAID or
Centre for International Child Health, University of Melbourne
Menzies School of Health Research
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, KNOWLEDGE HUBS FOR HEALTH
Royal Children’s Hospital, Flemington Rd, Parkville Australia 3052. STRENGTHENING HEALTH SYSTEMS THROUGH EVIDENCE IN ASIA AND THE PACIFIC