Zinc Supplementation in Cholera Patients
Zinc Supplementation in Cholera Patients
Cholera is one of the leading causes of morbidity and mortality among children and adult in
 developing countries. We will evaluate the effect of supplementation of zinc on reduction of
 duration and severity of cholera. Since cholera is primarily a disease of older children and
 adults, we intend to study the effects of zinc supplementation among children of 3 to 14
 years of age, whose initial stool weight will be >4ml/kg/hour in 1st 6 hours and dark field
 examination is positive. 90 subjects in each group hospitalized with cholera with diarrhea
 for less than 24 hours will be selected. After inclusion in the study, informed consent will
 be obtained from guardian explaining the full procedure in the hospital. The subjects will be
 randomized to receive either zinc or placebo until diarrhea resolves. History of illness and
 baseline information will be collected in the hospital through interview, which may take
 duration of 10 minutes.After 6 hours of initial rehydration, fluid balance study will be
 carried out on all subjects until diarrhea resolves. 1 ml (1/4 teaspoonful) of blood sample
 will be taken to assess serum zinc level on admission after initial hydration and will be
 repeated on the day of recovery. This procedure carries a small risk of infection if not done
 under sanitary conditions; however, we will maintain proper sanitation, so there is no risk
 in the procedures. There is no potential risk in this study.20mg elemental Zinc will be given
 daily in 2 divided doses till cholera resolves. Both groups will receive syrup or tablet
 Erythromycin 50mg/kg/24 in 4 divided doses for 3 days. Oral rehydration solution/intravenous
 acetate fluid will be used for rehydration. Daily body weight will be taken and stool will be
 sent for C/S until the day of recovery or 5 days. Zinc loss in stool will be seen in 20% of
 random stool samples. Information obtained from history and the laboratory investigations of
 subject will be kept strictly confidential and no one other than the investigators of this
 study and the Ethics Committee of this Centre will/ has access to the information. The study
 will benefit the patients as study physician will do close observation, examination and will
 take care frequently, as research staff will monitor systematic progress and take necessary
 action. Study micronutrient (zinc) is shown to have benefit in children in acute diarrhea. If
 the results of the study is positive, it will benefit the patients in their treatment during
 this study and thereafter. The data will be analyzed for clinical effects of zinc on
 diarrhea.The study will help to improve the treatment strategy of cholera in children. The
 study will use hospital records, which will be returned after completion of the study. Stool,
 urine and 1 ml (1/4 teaspoonful) of venous blood will be taken to assess serum zinc level.
Study design:

 A double blind randomized clinical trial using zinc and placebo.

 Randomization:

 Patients will be randomized to one of two groups, A or B. Block randomization will be done
 using block length of 6. Group A will receive Zinc+ Erythromycin and Group B: will receive
 Placebo+Erythromycin

 Dose of Erythromycin

 Syrup/tab Erythromycin 50mg/kg/24 hours in 4 divided doses for 3 days.

 Dose of zinc:

 Zinc acetate will be given at 10mg twice daily (10mgx2=20mg elemental zinc) until cholera
 resolves (the time of passage of last unformed stool or first formed stool followed by 24
 hours without any diarrheal stool).

 Composition of the syrup:

 For both groups, the bulk of the base syrup will be consist of the same chemicals; in
 addition to this, group A will have the treatment substance (i.e. elemental zinc 20 mg/day)

 Syrup A: Quantity per 5 ml

 Zinc Acetate 10 mg elemental zinc

 Syrup B: Base substance

 Base Substance:

 Ascorbic acid 30 mg Glycerin USP 1.2 ml Propylene glycol USP 0.75 ml Sorbitol 70% BP 2.0 ml
 Methyl Paraben USFN 3.5 mg Polysorate-80 50 mg (Tween -80) BPC Lemon oil PH grade 0.0125 ml
 Caramel Brown colour 1 mg Purified water 0.75 ml

 Clinical procedure in the hospital:

 Patients who meet the selection criteria will be observed for initial six hours, while their
 urine and stool specimen will be collected separately. Patient whose initial stool-output
 >4ml/kg/hour during this period and dark field examination of stool is positive will be
 enrolled in the study. Patients will be kept in study ward. After complete hydration,
 patients will be randomised in blocks of 6 to one of two groups A and B. Group A will receive
 syrup zinc and group B will receive placebo till cholera resolves. Both the groups will
 receive the identical bottles containing syrup with same flavor and only single unique serial
 number will be written on the bottles. The number will indicate an exact subject of study.
 Both the groups will receive Syrup/Tab Erythromycin. 1ml blood will be collected for serum
 zinc on admission after complete dehydration and this test will be repeated at the time of
 discharge. Stool culture and sensitivity (C/S) will be sent daily until the day of recovery
 or 5 days. Balance will be performed on all the patients till cholera resolves. If any
 complication develops after enrollment, study will be discontinued and patient will be
 treated accordingly.

 Assessment of dehydration:

 To reduce observational variation, especially regarding the assessment of dehydration, a
 standardized form is developed for the assessment of dehydration.

 CONDITION* (1=normal, 2=irritable/lessactive, 3=lethargic/comatose) MUCOSA (1=normal, 2=dry)

 EYES (1=normal, 2=sunken) THIRST* (1=normal, 2=thirsty, 3=unable to drink) SKIN TURGOR*
 (1=normal, 2=reduced) PULSE* (1=normal, 3=feeble/absent)

 DEHYDRATION STATUS:

 1. no sign of dehydration

 2. some dehydration (two signs coded 2 with at least one key sign*)

 3. severe dehydration (some dehydration, plus one key sign* coded 3)

 (* This method was recently validated by a group of international experts in oral rehydration
 therapy who were invited to ICDDR, B and is currently being used in a large WHO sponsored
 multi-centre trial for the evaluation of low osmolarity ORS. The investigators have been
 trained in this method).

 Rehydration phase:

 All the patients recruited in this study, will have either, some dehydration or severe
 dehydration. Therefore, before being randomized into study, during initial 6 hours all the
 patients will be rehydrated either by ORS or intravenous fluid. Patients with signs of some
 dehydration will be rehydrated by ORS and patients with severe dehydration will be rehydrated
 intravenously as described below. The following IV fluids will be used:

 Sodium Potassium Chloride Acetate Dhaka Solution (mmol/L) (mmol/L) (mmol/L) (mmol/L) 133 13
 98 48 Rate of administration will be 100 ml/kg over 4 hours, plus volume-for-volume
 replacement for ongoing losses hourly.

 If, at the end of four hours:

 1. The patient is fully rehydrated, he/she will be randomized to one of the treatment
 groups;

 2. Some dehydration persist, IV infusion will continue at the rate of 50 ml /kg over 2
 hours, plus replacement volume for volume of ongoing losses;

 3. Severe dehydration persists, IV infusion will continue for an additional 2 hours at the
 rate of 100 ml/kg, plus replacement of ongoing losses. This is very unusual, however,
 occurring only in very few patients who pass large watery stools frequently.

 If at the end of six hours, the patient is fully rehydrated patient will be randomized to one
 of the treatment group. If signs of dehydration persist after 6 hours, the patient will be
 excluded from study. All intake and output during this initial rehydration phase will be
 recorded.

 Maintenance phase:

 After completion of rehydration, subjects will be randomized to one of the two groups Group A
 and Group B. Group A will be given zinc acetate and group B will be given placebo. The
 supplementation of zinc or placebo will be continued till diarrhea resolves. Ongoing stool
 losses will be replaced with equal volume of Rice-ORS.

 Dietary management:

 Standardize hospital diet will be given to all patients which includes milk suji, rice,
 vegetable, daal, bread banana and chicken or fish.

 Intake and output measurement:

 All oral and intravenous fluid will be measured and recorded until cholera resolves. Stool
 weight will be measured separately from urine every 8 hours until cholera resolves. Urine
 will be separated and measured 8 hourly, weight of vomitus will also be taken 8 hourly. Daily
 clinical examination will be done by the investigators and study physician with observation
 on stool consistency and character.

 Clinical recovery:

 Clinical recovery will be defined as the time of passage of last unformed stool or first
 formed stool followed by 24 hours without any diarrheal stool.

 Sample size calculation:

 We assume that zinc will reduce 20% of mean duration of illness compared to erythromycin
 group18 at 90% power and 5% level of confidence. Therefore the sample size will be:

 n=2 (SD)2 aß/(D)2 n=2 (5)2 10.5/(2.6)2 n=77.66=78 per treatment group So the total number of
 samples will be 78 x 2 =156. Considering 15% drop out the total number of samples will be
 156+24=180

 Assessment of weight gain:

 Weight will be taken on admission and daily until cholera resolves.

 Laboratory tests:

 1. Microscopic examination

 1. Dark field examination will be done on stool samples on admission.

 2. Microbiological assays:

 1 Daily stool C/S will be done till cholera resolves or 5 days.

 3. Micronutrient assay:

 1. Serum zinc level will be obtained on day 1 and on the day of recovery

 2. Randomly zinc loss in cholera will be seen in 20% samples.
Inclusion Criteria:

 -  Children aged between 3-14 years hospitalized at ICDDR, B presenting with cholera
 within 24 hours of onset.

 -  Stool output more than 4ml/kg/hour within the first 6 hours of observation period.

 -  Positive dark field examination

 Exclusion Criteria:

 -  Unable to rehydrate within 6 hours

 -  Negative dark field examination

 -  Systemic illness requiring immediate administration of antibiotics.

 -  Received antibiotics in the 24 hours prior to hospitalization

 -  Patients presenting with bloody mucoid diarrhea

 -  Unconscious or medical emergencies