The curious case of zinc for diarrhea: Unavailable, unprescribed, and unused

• B. Gitanjali^1*,
• K. Weerasuriya²

1. ¹Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.
2. ²Essential Medicines and Pharmaceutical Policies, World Health Organization, 20 avenue Appia, 1211, Geneva 27, Switzerland Commentary Diarrhea kills nearly 650 children below the age of 5 years each day in India. Oral rehydration solution (ORS) and oral zinc have been recommended for the treatment of acute diarrhea in children by the Indian Academy of Paediatrics (IAP) National task force for use of ORS and zinc in the year 2003[1] and later endorsed in 2006.[2] Zinc was included in the National Programme for the treatment of Diarrhea in 2007.[3] The Integrated Management of Neonatal and Childhood Illness (IMNCI) advocates the use of these two drugs in the treatment of acute diarrhea.[4] The evidence for the use of ORS and zinc as fi rst-line treatment in children in resource limited countries is overwhelming.[5,6] If given early on during an episode of diarrhea it would help save 50% of children who would otherwise die. The treatment is effective, safe, cheap, and easily tolerated by children.[6] More importantly, there are no other alternatives to this treatment. Recognizing the importance of this, the National Rural Health Mission (NRHM) has included ORS and zinc in the list of medicines to be available at the subcenters.[3] Yet, unfortunately, it is hardly available in the public[7-9] and private[7,8] health facilities in India. Only 34.2% of children with diarrhea in India receive ORS[10] and a miniscule 1% are prescribed zinc during an episode of diarrhea.[11] The lack of availability in public health facilities[7-9] points to the fact that zinc was probably not procured at all, or if procured it was not done in suffi cient quantities. Why does this state of affairs persist? We explore some of the regulatory and other issues which prevent access to zinc in India. REGULATORY ISSUES It is evident that in order to promote wide use of zinc and ORS these should be available as over the counter (OTC) drugs. The consequence of having it as OTC is that people will be able to buy these two medicines at any shop and not only from licensed chemists. Importantly, there are rules and regulations for that specifi c category. For example, the packaging is defi ned; OTC drugs have to be sold in the original packaging so that the consumer can easily identify the drug. Promotion is defi ned; they can usually be advertised in the general media but for specifi c conditions (e.g. headache, fever) and not for specifi c diseases. The generic name must appear in any advertisement. The sales channel is defi ned; in most countries they can be sold in general stores along with other consumer goods. The seller is simply a seller of goods and does not provide information on the OTC product. That is done through promotion in the media and the information on the package. This means that OTC as a specifi c group will have a clear and level “playing fi eld”; which will obviously attract players, in this case the pharmaceutical manufacturers. In India, the term OTC has no legal recognition. All drugs which are not “prescription-only” are by default considered OTC. Even the so-called OTC drugs like paracetamol (which come under schedule K) have to be sold by licensed drug stores.[12] Non-drug-licensed stores or shops can sell drugs which are under schedule K of the Drugs Control Rules (1945) which are known as “household remedies.”[12] These medicines can be sold without a license in villages with a population less than.

Published in Journal of Pharmacology and Pharmacotherapeutics