Zinc Sulfate Acceptability
Zinc Sulfate Acceptability
Introduction:

 Zinc (Zn) is an essential mineral widely distributed within the human body with
 metalloproteins, Zinc-binding proteins, etc. It is necessary for signal transduction and also
 cell growth and proliferation via respective metallo- and zinc-dependent enzymes. Zinc
 supplementation can significantly reduce diarrheal severity and duration as well as prevents
 future incidences and reduces use of other medications in diarrhoea. For this reason WHO,
 UNICEF, USAID and experts worldwide jointly recommended zinc supplementation (10 mg for
 infants less than 6 months old and 20 mg in 6 - 59 months old) combined with reduced
 osmolarity ORS for clinical management of acute diarrhoea. But due to strong metallic taste
 zinc products are less palatable to children even after using masking flavours as recommended
 by WHO. Several companies have formulated the product since WHO recommendations came but
 still transient side effects like vomiting and regurgitation remain evident. Despite careful
 counselling to the caregivers expected adherence rate to 10 days regimen of zinc supplement
 is yet to be reached.

 With the aim to increase zinc supplement coverage during acute diarrheal illness, it is
 necessary to conduct a study to introduce new formulation Zinc tablet which is more
 palatable, more dispersible and more acceptable.

 Intervention:

 Zinc sulfate [Zinc Dispersible Tablet, 20 mg; (Elemental Zinc 20 mg as Zinc Sulfate
 Monohydrate / Tablet)]

 Methods: Prospective, open label, interventional study

 Hypothesis:

 Improved formulation of Zinc Sulfate will have good acceptability.

 Study population:

 Stratum 1: 3 months - <18 months = 175 children Stratum 2: 18 months - 59 months = 175
 children

 Objectives:

 1. Primary Objective:

 Acceptability of the zinc product in the management of childhood diarrhea will be
 assessed by observing:

 i) Incidence of vomiting or regurgitation among enrolled children receiving the
 improvised zinc formulation.

 ii) The adherence: The number of days (out of the total 10 days) the child took the
 protocol-prescribed dose of the medicine. The treatment will be considered to have good
 acceptability if at least 80% of the prescribed treatment is taken by at least 70% of
 the children over the duration of 10 days, as per WHO guidelines.

 2. Secondary objective :

 To assess palatability Secondary end point evaluation (Palatability): The statistical
 analysis will comprise the calculation of the percentage of patients out of 350 who found the
 investigational product to have "very well-tolerated, well-tolerated or tolerated" scores
 (i.e. any of the upper 3 possible scores). A 95% confidence interval, using the normal
 approximation of the binomial distribution, will be calculated for the percentage.
Background:

 Zinc is a metalloprotein. The two important function of zinc are- first, unlike other metals
 zinc is virtually non-toxic (1). The homeostatic mechanisms that regulate its entrance,
 allocation, and excretion from cells and tissues are so well-organized that no disorders are
 known to be associated with its excessive accumulation, in contrast to iron, copper, mercury,
 and other metals. Second, its physical and chemical properties, including its generally
 stable relationship with macromolecules and its co-ordination flexibility, make it extremely
 adaptable in meeting the needs of proteins and enzymes that take diverse biological functions
 (2-4). Zinc is one of the most common metal ion distributed widely in cytoplasm as well as
 building blocks for keratin like structures and intracellular organelles like chromosomes(5).
 Importance of zinc as an essential trace element is well established for its role on growth
 and development, protection against free radical damage, endocrine, reproductive and
 cognitive functions(6). Globally, zinc deficiency is associated with 16% of lower respiratory
 tract infections and 10% of diarrheal diseases respectively with higher attributable
 fractions in sub-regions(7). Severe zinc deficiency is a rare entity whereas mild to moderate
 zinc deficiency is quite evident mostly in children living in poverty and associated with
 approximately 453,000 deaths each year(8, 9). Simultaneously, diarrhoea as the second most
 prevalent cause of under five deaths and is responsible for 800,000 deaths each year (10). A
 meta-analysis of 12 studies observed the impact of zinc supplements on the management of
 acute diarrhea, 11 studies showed a reduction in the duration of the diarrheal episode. In
 eight of these reported that the reduction of diarrheal episode was statistically
 significant. Five of these studies also found that zinc supplements reduced stool output and
 frequency. The data revealed that zinc supplementation had a significant effect on the
 clinical course of acute diarrhea, reducing its duration as well as severity (11). Another
 meta-analysis of 18 trials with 6165 enrolled participants observed that in acute diarrhea,
 zinc reduced duration of diarrhea (MD -- 12.27 hours, 95% CI -23.02 to -1.52 hours; 2741
 children, nine trials), and a reduced amount of diarrhea by day three (RR 0.69, 95% CI 0.59
 to 0.81; 1073 children, two trials), day five (RR 0.55, 95% CI 0.32 to 0.95; 346 children,
 two trials), and day seven (RR 0.71, 95% CI 0.52 to 0.98; 4087 children, seven trials). Zinc
 also reduced the period of persistent diarrhea (MD -15.84 hours, 95% CI -25.43 to - 6.24
 hours; 529 children, five trials). In few trials there was report on the severity, but the
 results were not consistent (12).

 Zinc supplementation can significantly reduce diarrheal severity and duration as well as
 prevents future incidences and reduces use of other medications in diarrhea (13-16). Several
 studies evaluated the effect of zinc supplementation on diarrhea and found a preventive and
 long-lasting impact. These showed that 10 mg to 20 mg of zinc per day, for 10 - 14 days,
 reduced the number of diarrheal episodes in 2 - 3 months after the supplementation (12). For
 this reason WHO, UNICEF, USAID and experts worldwide jointly recommended zinc supplementation
 (10 mg for infants less than 6 months old and 20 mg in 6 - 59 months old) combined with
 reduced osmolarity ORS for clinical management of acute diarrhoea (17).

 The physiological effect of zinc on intestinal ion transport has not yet been established
 thoroughly. In in-vitro studies with rat ileum recently established that zinc inhibits
 cAMP-induced, chloride-dependent fluid secretion by inhibiting basolateral potassium (K)
 channels. This study has also observed the specificity of Zn to cAMP-activated K channels,
 because zinc did not block the calcium (Ca)-mediated pottasium channels. As this study was
 not done in Zn-deficient animals, it provides support that Zn is probably effective in the
 absence of Zn deficiency (18, 19). Zinc also improves the absorption of water and
 electrolytes, improves regeneration of the intestinal epithelium, increases the levels of
 brush border enzymes, and enhances the immune response, allowing for a better clearance of
 the pathogens. Another report has recently shown evidence that zinc inhibits toxin-induced
 cholera, but not Escherichia coli heat-stable, enterotoxin-induced, ion secretion in cultured
 Caco-2 cells (20). In this way, Zinc plays an important role in modulating the host
 resistance to infectious agents and decreases the risk, severity, and duration of diarrheal
 diseases. It also plays an important role in metallo-enzymes, polyribosomes, and the cell
 membrane and cellular function, giving belief that it plays a central role in cellular growth
 and in the function of the immune system (21).

 The primary site of absorption of exogenous zinc in the human is in the proximal small bowel,
 either the distal duodenum or proximal jejunum ((22). Factors known to control absorption
 include the amount of zinc present in the intestinal lumen, the presence of dietary promoters
 (e.g., human milk, animal proteins) or inhibitors (e.g., phytate, other minerals), zinc
 "status" especially in relation to chronic zinc intake, and physiologic states (23).

 After absorption zinc is bound to protein metallothionein in the intestines. Zinc is widely
 distributed throughout the body. It is primarily stored in RBCs, WBCs, muscles, bones, Skin,
 Kidneys, Liver, Pancreas, retina, and prostate. The extent of Zinc binding is 60 - 70% to
 plasma albumin, 30 - 40% to alpha 2 macroglobulins or transferring, and 1% to amino acids
 like histidine and cysteine. Peak plasma concentration of Zinc occurs in approximately two
 hours. The processes of secretion and reabsorption or excretion of intestinal endogenous zinc
 have not been well characterized in humans. There are several potential sources of the
 endogenous zinc: pancreatic and biliary secretions, gastroduodenal secretions,
 transepithelial flux from the enterocytes or other intestinal cell types and sloughing of
 mucosal cells.(23) Zinc sulfate, acetate, and gluconate are all acceptable zinc salt
 formulations, of which zinc sulfate is low-cost, efficacious, safe, and therefore, optimal
 for the national program. Zinc sulfate tablets may be dispersed in breast milk, in oral
 rehydration solutions, or in water on a small spoon. Zinc sulfate dispersible tablet is also
 available in the market, containing 20 mg of elemental zinc. Pediatric zinc sulfate tablets
 are also available(24) It has been anticipated that the successful scaling up of zinc
 supplementation for childhood diarrhea could potentially save 400,000 under-five deaths per
 year (25). The Scaling Up of Zinc for Young Children (SUZY) Project was established in 2003
 with the aim of setting Bangladesh on the path to covering all under-five children with zinc
 supplementation in any diarrheal illness episode. In December, 2006 a national mass media
 campaign to promote a dispersible tablet zinc formulation, "Baby Zinc," for management of
 childhood diarrhea was launched. All media messages linked zinc treatment to the continued
 use of oral rehydration salts (ORS)(26). However, by 2012, zinc coverage was below 5%
 globally though in some countries such as Bangladesh, coverage was as high as 41% (27).
 According to WHO, Bangladesh was the only country to achieve high treatment rates nationally:
 as of 2014 nearly 80% of children with diarrhea received ORS, and 34% received both ORS and
 zinc (28). This was achieved through decades of investment by the government, icddr,b, the
 international development organizations, BRAC, and other key stakeholders (29, 30). This
 endeavor included the large-scale Scaling Up Zinc for Young Children (SUZY) Project which was
 initiated in 2003 and included partnerships with the government, non-governmental
 organizations (NGOs), the private sector to improve provider dispensing, caregiver demand and
 availability of optimal, affordable products (26, 31).

 But combined data collected from five RCTs (n = 3156) observed that zinc significantly
 increased the chance of vomiting compared to the control agent (RR1.2, 95% CI 1.05-1.4)(32).
 Due to strong metallic taste zinc products are less palatable to children even after using
 masking flavours as recommended by WHO. Several companies have formulated the product since
 WHO recommendations came but still transient side effects like vomiting and regurgitation
 remain evident (33-36). Despite careful counselling to the caregivers expected adherence rate
 to 10 days regimen of zinc supplement is yet to be reached (33, 35, 37, 38).

 A clinical trial with new formulation Zinc Sulfate for use in acute diarrheal illness will be
 conducted to achieve good adherence rate. New improvised Zinc preparation will be palatable,
 more dispersible and thereby acceptable to young children with diarrhea.

 Study design: Prospective, open label, interventional study

 Study Site: The study will be conducted at the Dhaka Hospital of the International Centre for
 Diarrhoeal Disease Research, Bangladesh (icddr,b).

 Study population:

 Stratum- I : 3 months - <18 months Stratum- II : 18 months - 59 months

 Sample size:

 Sample size is estimated considering the primary outcome variables:

 For one component of the primary objective we have considered the study-report done by Khan
 et al (34), where they found incidence of vomiting or regurgitation in 22% of enrolled
 children. We assume that the incidence of vomiting or regurgitation on receiving the
 improvised zinc formula would not be greater than 10 % cases in this study, thus a total 300
 children will be needed that would accommodate up to 19% attrition. Sample size is calculated
 using the formula [ 2(Zα + Zβ)2 * p * q] / d2

 Where:

 P = (p1+p2)/2 p1 = 22% incidence of vomiting or regurgitation according to study report done
 by Khan et al p2 = 10% incidence of vomiting or regurgitation with the improvised zinc
 formula that we are assuming Zα = 5% significance level Zβ = (1 -β) = 80% power p = [p1 (22%)
 + p2 (10% )]/2 = 16%; q = 100% -16% = 84%; Zα = 1.96 and Zβ = 1.64 Sample size is further
 estimated for the other component of the primary objective, i.e. adherence. A total of 350
 children will be enrolled (175 patients from 3 months to below 18 months age group, and 175
 children from 18 months to 59 months age group). To identify a ± 7.5% minimal difference in
 acceptability between children aged over and below 18 months with an anticipated 70%
 acceptability (p), setting the level of confidence at 95% (z = 1.96) using the formula: pqz2/
 d2 the estimated sample size is 175 children per group allowing 18% dropout.

 Intervention:

 Investigational product: Zinc Sulfate [Zinc Dispersible Tablet, 20 mg; (Elemental Zinc 20 mg
 as Zinc Sulfate Monohydrate / Tablet)]

 Dosage:

 Half the tablet (10 mg) for 3 to 6 months old children and 20 mg daily for > 6 to 59 months
 old children. The tablet will be dissolved in a teaspoon of safe water or breast milk and
 administered once daily for 10 days.

 Packaging and labeling: Investigational product will be dispensed in a blister pack
 containing 10 tablets.

 The caregivers will bring the blister packs (even if all tablets are used) on day 11 (after
 enrollment) for a follow up visit to the outpatient department (OPD) of the Dhaka Hospital of
 icddr,b, and they will be evaluated about the adherence with the supplied drug intake during
 the follow up visit. Study investigator will update accountability records of the
 investigational product according to ICH E6, GCP guideline. If caregiver failed to have the
 follow up visit at hospital, the study staff will visit children's house after 12 days of
 enrollment. Investigational product will not be provided to any third party.

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Inclusion Criteria:

 -  Children of age 3 - 59 months with an acute diarrhea episode who will be prescribed
 oral re-hydration salts (ORS) per WHO guidelines

 -  Residence: within 10 km of the Dhaka Hospital of icddr,b

 -  Signed informed consent by the guardians/caregivers

 Exclusion Criteria:

 -  Some or severe dehydration

 -  Already in the middle of a course of zinc sulfate due a recent previous episode

 -  Severe acute malnutrition (weight for height < - 3 z score or bi-pedal edema)

 -  Congenital anomalies

 -  Fever or invasive diarrhea or any other medical illness (other than acute diarrhea)

 -  Having any known medical condition that may interfere with the subject's ability to
 sense or discriminate between different tastes