Philip Malish- VEDO National NGO - South Sudan

Dr Aisha Fatima, Jhpiego Pakistan

Good morning everyone. Rashed Shah from Save the Children US, Washington DC

Dr. Patricia Paredes Jodrey, USAID Washington, Child Health Team Lead

Alison Wittcoff, FHI 360

Welcome everyone! Feel free to introduce yourself in the chat box.

Please share the links here. thanks

Elena Pantjushenko, PATH - hello all!

Good morning/afternoon. John Borrazzo, Save the Children US and Child Health Director, MOMENTUM Country and Global Leadership project, based in Washington DC.

Dr Ankur Sooden, JSI India

Dr. Vikas Kaushal, Head Health, Save the Children, India

Hi Everyone - Eric Swedberg, Managing Director, Child Health, Save the Children

Hi everyone - Jane Briggs MNCH lead USAID MTaPS program implemented by MSH and partners

Good morning all. Diaa Hammamy

Good morning/afternoon. Daniel Lopez de Romana, Nutrition International

Good afternoon from Nigeria, I am Osemwekha Ekenakema, iCCM Technical Advisor, US President Malaria Initiative for States Project, Nigeria

Feel free to put your questions in the chat!

What are the numbers for children dying from diarrhoea in India, in Telangana state, in Hyderabad city, please tell me.

Bangladesh has reduced child diarrhea deaths by 97% since 1990 - from ~63,000 to ~1,700 in 2019 according to the GBD. An extraordinary achievement other LMICs can learn from. Diarrhea went from #2 killer of children to #11 over the period.

@Shobha Mocherla - you can read the latest coverage results for Telangana here: https://dhsprogram.com/pubs/pdf/OF43/OF43.TG.pdf

Is the impact of rotavirus vaccine studied globally?

How important is the inclusion of co-packaged ORS-zinc products on the national essential medicines lists? Is that a key lever for high-burden countries to prioritize the co-packaged approach?

Amsalu this is a good study of rotavirus vaccine impact globally but a little out of date now (2017) - https://pubmed.ncbi.nlm.nih.gov/28430997/. Other sources also listed that will be helpful. Global rotavirus vaccine coverage is 46% - too low!

Hello everyone, Dyness Kasungami from the Task Force Secretariat, JSI/DC. The presentations will be translated into French. If you have audiences in Francophone countries or organizations, let us know so that we can specifically target the sharing of the resources from this meeting and also support engagement with our Francophone colleagues.

Hi Everyone,Joseph Monehin, Senior Child Health Advisor, USAID Washington.

Thank you @Leith Greenslade for sharing the study document.

To Speakers. Since 2004 we have seen very slow incremental improvement in the use of Zinc. Step-change is needed. Step-change normally requires system change - a change in the way we do things - do you think co-packaging is that system change?

Thanks for the great context setting so far. I struggle with the stagnation of just ORS treatment, which really is the first line in preventing mortality. Shouldn't this be a first focus? And then we can worry about the co-pack with zinc. But there is an effective counter-argument to this. ORS will help prevent mortality. But as has been noted, mortality from diarrheal disease has been dramatically reduced already. Perhaps we need to focus more on the morbidity impacts, such as the shortened severity and duration of disease, with combined ORS and zinc. This will have both short- and long-term effects on the formation of human capital (e.g. nutritional status, caregivers loss of time). This may have particular relevance to those in a position to mobilize appropriate domestic financing to support the scale-up.

To Dr Singh- It seems the product was not procured copackaged, seeing the printing instructions. Where did the co packaging happen? At the stores or at the dispensing point?

have any pharmaceutical companies been involved in co packaging efforts would UNITAID market development approaches be useful

Dear Jane, Copack done at stores located at PHC/CHCs

Diarrhea is easy to prevent and treat. Yet it is the leading killer of children in South Sudan because diarrhea is a real burden and it is a very sad situation where a lot of resources are spent to manage the condition and people did not have the right information of how to use ORS/Zinc.In South Sudan, there is need for mass awareness raising on use of ORS/Zinc to prevent diarrhea vs the traditional treatment of the diseases, training of health workers on use of the ORS/Zinc, and ensure the availability of ORS/Zinc all health facilities.To best of my knowledge, when it comes to diarrhea, oral rehydration salts (ORS) and zinc sulphate are the most effective treatments. Zinc strengthens the gut lining and reduces the severity and duration of episodes as well as prevents future ones. ORS can be a life-saver. It replenishes electrolytes and quickly rehydrates a dehydrated child.

Dr O P Singh: did your team also study pneumonia prevalence in geographies where ORS-ZINC copacks were distributed?

@Alison can you share the link to the review from Toronto you mentioned in your remarks.

here you go https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249638

@Philip- thank you for your reflection on what is needed in South Sudan. Increased awareness and demand by caregivers is key to high coverage of ORS/zinc. Do you have specific ideas about how the ORSZCA and the Task Force can support the Ministry of Health and your organization to raise awareness and increase demand for ORS/zinc in South Sudan? How has South Sudan addressed availability and access to ORS/zinc?

@Prudence Hamade - yes, a number of private sector companies have been involved in the packaging of ORS/Zinc, including companies that are domestically manufacturing these products in places like Kenya, Nigeria, and Uganda. As part of our work at CHAI, it was critical that we worked closely with the private sector on these efforts and demonstrated the business potential of the co-packaged products.

Yes Ankur. In our SDI program we did case control studies on prevalence.

@AudreyBattu - A vital insight - Simon and I found similarly that the harnessing of the interest in the private sector in Zambia, proving the business case whilst linking in the leadership of government and an enabling regulatory environment, were all key.

ICDDR’B also pioneered the food based ORS.Does the co-packaging still possible with food based ORS?

@Malia Boggs - what elements are essential to having supportive policy environment for ORS-zinc uptake in countries? Is it about having both products on national EMLs? What regulatory aspects need to be addressed? Thank you.

You can read more about the work that CHAI has done on Zinc/ORS scale up here: http://jogha.org/col-scaling-up-ORS-and-Zinc.htm

@Elena - I do think a critical piece of the regulatory process is the over the counter prescription of zinc, as well as the inclusion of both zinc and ORS on the essential medicines list.

I agree - EML inclusion is essential as well as OTC for zinc and ORS but also registration of the products including the copack, to be on the market in countries is important

@Elena, I'm happy to chat offline but yes a supportive policy environment would entail having zinc as a OTC product that's registered available everywhere where ORS is sold or available. It would entail ensuring the co-pack and all products are on the EML. Have you seen the report by CHAI on Progress Over a Decade of Zinc and ORS Scale up?

To what is the consistent decrease mortality attributed despite low coverage of ORS/Zn and rotavirus vaccine?

At national level I would include domestic funds allocation for ORS/Zn procurement. In several countries still very dependent on donor procurement.

*advocacy for..

@Montse this is what “mobilize governments” refers to - last dot point under national, but we can make this clearer.

I had just sent message and it clicked in my slow brain 😂. But maybe it would not hurt to be more explicit…

Madu Ezioma MrsFMOH Abuja

@Montse no problem - we will clarify!

Thanks @Leith, see answer above

Please what is the plan for continuity and sustainability for these countries after the end of 2025?

This will help in preventing nose-diving od success after this period probably due to non-support from host countries or other factors

Echoing Dr Black’s answer: our learning in Zambia indicated that convening a government/private sector/NGO/Health worker partnership around a new exciting local *product*, was perhaps more attractive as a vision than convening around a regulatory or policy change. This points to potential for behaviour change among key institutions? I’m not sure if this is an area of study we could be considering?

while the co-packaging/bundling is an excellent innovation let say 2 sachet of ORS and 10 or 14 zinc tablets, sometimes the child may need more ORS sachets as the diarrhea continues, therefore procuring additional separate ORS will be needed.

To join ORSZCA https://orszco-pack.org/join/

One hopeful point in response to this question -- we have not seen decreases in coverage once the market has been catalyzed, the government has strongly committed, and the demand has been generated. In fact, we have continued to see modest increases in coverage in countries that have addressed these supply and demand barriers. We found that interventions we implemented, despite having stopped as of 2016 in these countries, yet through monitoring of independent DHS surveys, we continue to see zinc/ORS coverage increase Nigeria (8 program states combined): 1% to 18% during program period (2013-16) and reaching 23% in the most recent DHS 2018 India• Gujarat: 1% to 17% during program period and reaching 35% in DHS 2019-21• MP: 1% to 27% during program period and now 36%• UP: 1% to 13% during program and now 29%

Is there a specific plan to engage the alliance member organizations on supporting the national/global strategy?

Join ORSZCA here! https://orszco-pack.org/sign-up-here/