Research to Policy: Management of acute respiratory infections and diarrhoea

1. Research to Policy: Management of acute respiratory infections and diarrhoea ICIUM 2004, Thailand Dr. Shamim Qazi CAH/WHO Switzerland

2. Outline Examples from ARI and diarrhoea case management • Research • Translation of research in policy • Translation of policies into programmes

3. Translation of research to policyExamples:- ARI case management- Duration of therapy

4. Problem: High pneumonia mortality • In 1980s an estimated 4.3 million deaths occurred in under 5 year old children/year in the world • ARI case management guidelines • Based on simple signs like fast breathing and lower chest indrawing were developed

5. Meta analysis of 7 community based trials in Bangladesh, India (2), Pakistan, Nepal, The Philippines >8000 < I month old >7500 < 1 year old >43500 1-4 year old Published in 2003 Reduction in total mortality < I month old - 27% < 1 year old - 20% 1-4 year old - 24% Reduction in pneumonia mortality < I month old - 42% < 1 year old - 36% 1-4 year old - 36% Research Findings ARI case management Results

6. Translation of research into policies and programmes

7. Translation of Research Findings into Policies and Programmes • Development of WHO Standard ARI case management guidelines • ARI Control Programmes for low resource settings

8. Continuing research

9. Continuing Research • Studies to assess the effectiveness of ARI case management guidelines when used in high antimicrobial settings • Improving case management for severe and very severe pneumonia • Studies to assess appropriate duration of therapy for non-severe pneumonia

10. Research findings: 3 vs. 5 days oral amoxicillin for pneumonia • Two multicentre, double blind, RCTs: • 7 centres in Pakistan (n=2000) • 8 centres in India (n=2218) • Patients: Age 2-59 months with WHO defined non - severe pneumonia • Oral amoxicillin 15 mg/kg/dose thrice daily • Outcome: 3 days was as efficacious as 5 days

11. Research findings: 3 vs. 5 days oral cotrimoxazole for pneumonia • One multicentre, double blind, RCT: • 1 centre in Bangladesh and 3 centres in Indonesia • 1014 randomized to 5-day and 1008 to 3-day group • Patients: Age 2-59 months with WHO defined non - severe pneumonia • Oral trimethoprim 4 mg/kg/dose twice daily • Outcome: 3 days was as efficacious as 5 days

12. Research FindingsConclusions - Recommendations • Meeting of experts held in Geneva to review the results of studies on pneumonia management (Oct 2003) • Recommendations: • WHO defined Non-severe Pneumonia to be treated for 3 days • In areas of high cotrimoxazole AMR oral amoxicillin to be used

13. Translation of Research Findings into Policies • Incorporation of the revised case management policy into existing documents (Ongoing) • Development of an official policy WHO-UNICEF document on community management of pneumonia

14. Examples of research to policyDiarrhoea management

15. Meta-analysis of 15 studies including 2397 randomized children published in 2001 Low osmolarity ORS reduces stool output, duration of diarrhoea and need for unscheduled IV therapy Meta-analysis of 12 studies including 8490 randomized children published in 2001 Zinc supplementation reduces the duration and severity of diarrhoea and lowers the incidence of diarrhoea in the following 4 to 6 months Research Findings Reduced Osmolarity ORS Zinc supplementation

16. A single ORS solution be used and that this ORS solution contain 75 mEq/l of sodium and 75 mmol/l of glucose, and have a total osmolarity of 245 mOsmol/l Enough evidence demonstrates the efficacy of zinc supplementation (10 to 20 mg per day for 14 days) on the clinical course of diarrhoea Research FindingsConclusions Recommendations Reduced Osmolarity ORS New York, July 2001 Zinc supplementation New Delhi, May 2001

17. Translation of Research Findings into Policies • Endorsement of the conclusions & recommendations by International and Development Agencies in May 2002, New York

18. Translation of Research Findings into Policies • Inclusion of the reduced osmolarity ORS solution in the WHO model EDL • Development of an official WHO-UNICEF policy document describing case management of diarrhoea including the new developments • Incorporation of the revised case management policy into existing documents • Inclusion of zinc in the WHO model Essential Drug List ?

19. Translation of Research Findings into Policies • Packets of Reduced Osmolarity ORS available commercially through UNICEF- Copenhagen (January 2004) • Adoption and Launch of the new ORS solution in India (March/April 2004)

20. Translation of policies into programmes

21. Translation of Policies into Programmes • For reduced osmolarity ORS, no new actions required as new ORS replaces the old formulation in existing Programmes • For zinc, a new product, programmes need to be developed with new messages, training and logistics

22. Continuing research

23. Continuing Research • Phase IV studies to assess the safety of the reduced osmolarity ORS solution when used on a large scale, especially with regard to hyponatremia (one study almost completed in Bangladesh and one study ready to start in India) • Safety studies on the use of zinc supplementation in infants below 6 months of age

24. Conclusions