A Half Century of Oral Rehydration Therapy in Childhood Gastroenteritis: Toward Increasing Uptake and Improving Coverage

  • Amira M. Khan
  • James E. Wright
  • Zulfiqar A. BhuttaEmail author


Termed by the Lancet, as “potentially the most important medical advance of the twentieth century,” therapy with oral rehydration solutions (ORSs) has been essential to reducing mortality in children less than 5 years (under five) with infectious gastroenteritis and diarrhea. The target of the diarrhea-control programs in the 1990s was to achieve ORS use in 80% of diarrhea cases by the year 2000. Nevertheless, nearly 20 years later, global uptake remains limited to only a third of the cases. Our analysis shows that from 1990 to 2017, mean ORS coverage in Countdown countries [the 81 Countdown-to-2030 priority countries, which together account for 95% of maternal deaths and 90% of under-five deaths] increased from ~ 30% to nearly 40%. Flawed government policies, inadequate supplies, and lack of awareness among health workers and communities all contributed to this shortfall in coverage. Moreover, imperfect measurement methodology is implicated in questionable coverage data. A multipronged approach focusing on the manufacture, supply, training, and behavioral change is essential to ensure that ORS is used in all epidemic diarrhea cases globally, especially in the under-five population.


Oral rehydration solution ORS ORT Diarrhea Coverage Rehydration Child health 


Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    GBD 2016 Diarrhoeal Disease Collaborators. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis. 2019;18:1211–1228.Google Scholar
  2. 2.
    Nalin D, Cash R. 50 years of oral rehydration therapy: the solution is still simple. The Lancet. 2018;392:536–538.CrossRefGoogle Scholar
  3. 3.
    Editorial. Water with sugar and salt. The Lancet. 1978;312:300–301.CrossRefGoogle Scholar
  4. 4.
    Claeson M, Merson M. Global progress in the control of diarrheal diseases. Pediatr Infect Dis J. 1990;9:345–355.CrossRefGoogle Scholar
  5. 5.
    Santosham M, Chandran A, Fitzwater S, Fischer-Walker C, Baqui A, Black R. Progress and barriers for the control of diarrhoeal disease. The Lancet. 2010;376:63–67.CrossRefGoogle Scholar
  6. 6.
    World Health Organization. Diarrhoeal Disease Control Programme. Programme for Control of Diarrhoeal Diseases: ninth programme report, 1992–1993 [Internet]. World Health Organization; 1994. Available from:
  7. 7.
    Black R. Progress in the use of ORS and zinc for the treatment of childhood diarrhea. J Glob Health. 2019;9:010101.CrossRefGoogle Scholar
  8. 8.
    Munos M, Walker C, Black R. The effect of ORS and recommended home fluids on diarrhoea mortality. Int J Epidemiol. 2010;39:i75–i87.CrossRefGoogle Scholar
  9. 9.
    World Health Organization/The United Nations Children’s Fund (UNICEF). End preventable deaths: Global Action Plan for Prevention and Control of Pneumonia and Diarrhoea. World Health Organization/The United Nations Children’s Fund (UNICEF); 2013.Google Scholar
  10. 10.
    Victora C, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ. 2000;38:1246–1255.Google Scholar
  11. 11.
    Fischer Walker C, Fontaine O, Black R. Measuring coverage in MNCH: current indicators for measuring coverage of diarrhea treatment interventions and opportunities for improvement. PLoS Med. 2013;10:e1001385.CrossRefGoogle Scholar
  12. 12.
    United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO). Tracking Progress towards Universal Coverage for Reproductive, Newborn and Child Health: The 2017 Report. Washington, DC: United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO); 2017.Google Scholar
  13. 13.
    Sreeramareddy C, Low Y, Forsberg B. Slow progress in diarrhea case management in low and middle income countries: evidence from cross-sectional national surveys, 1985–2012. BMC Pediatr. 2017;17:83.CrossRefGoogle Scholar
  14. 14.
    United Nations Children’s Fund (UNICEF). Pneumonia and diarrhoea—Tackling the deadliest diseases for the world’s poorest children. United Nations Children’s Fund (UNICEF); 2012.Google Scholar
  15. 15.
    Gill C, Young M, Schroder K, et al. Bottlenecks, barriers, and solutions: results from multicountry consultations focused on reduction of childhood pneumonia and diarrhoea deaths. The Lancet. 2013;381:1487–1498.CrossRefGoogle Scholar
  16. 16.
    United Nations Children’s Fund/World Health Organization. Clinical Management of Acute Diarrhoea. United Nations Children’s Fund/World Health Organization; 2004.Google Scholar
  17. 17.
    Sanders D, Doherty T, Mason J, Coovadia H, Costello A. Excellent can be the enemy of good: the case of diarrhoea management. The Lancet. 2013;382:307–308.CrossRefGoogle Scholar
  18. 18.
    Bhutta Z, Black R, Chopra M, Morris S. Excellent can be the enemy of good: the case of diarrhoea management—authors’ reply. The Lancet. 2013;382:308.CrossRefGoogle Scholar
  19. 19.
    Keusch G, Walker C, Das J, Horton S, Habte D. Diarrheal diseases. In: Black R, Laxminarayan R, Temmerman M, Walker N, eds. Disease Control Priorities—Reproductive, Maternal, Newborn, and Child Health. 3rd ed. Washington, DC: 6 International Bank for Reconstruction and Development/The World Bank; 2016.Google Scholar
  20. 20.
    Pathak D, Pathak A, Marrone G, Diwan V, Lundborg C. Adherence to treatment guidelines for acute diarrhoea in children up to 12 years in Ujjain, India—a crosssectional prescription analysis. BMC Infect Dis. 2011;11:32.CrossRefGoogle Scholar
  21. 21.
    Wagner Z, Shah M, Sood N. Barriers to use of oral rehydration salts for child diarrhea in the private sector: evidence from India. J Trop Pediatr. 2014;61:37–43.CrossRefGoogle Scholar
  22. 22.
    Bhutta Z, Das J, Walker N, et al. Interventions to address deaths from childhood pneumonia and diarrhoea equitably: what works and at what cost? The Lancet. 2013;381:1417–1429.CrossRefGoogle Scholar
  23. 23.
    Wagner Z, Asiimwe J, Dow W, Levine D. The role of price and convenience in use of oral rehydration salts to treat child diarrhea: a cluster randomized trial in Uganda. PLoS Med. 2019;16:e1002734.CrossRefGoogle Scholar
  24. 24.
    Freedman S, Pasichnyk D, Black K, et al. Gastroenteritis therapies in developed countries: systematic review and meta-analysis. PLoS ONE. 2015;10:e0128754.CrossRefGoogle Scholar
  25. 25.
    Freedman S, Soofi S, Willan A, et al. Oral ondansetron administration to nondehydrated children with diarrhea and associated vomiting in emergency departments in Pakistan: a randomized controlled trial. Ann Emerg Med. 2019;73:255–265.CrossRefGoogle Scholar
  26. 26.
    Danewa AS, Shah D, Batra P, Bhattacharya SK, Gupta P. Oral ondansetron in management of dehydrating diarrhea with vomiting in children aged 3 months to 5 years: a randomized controlled trial. J Pediatr. 2016;169:105–109.e3.CrossRefGoogle Scholar
  27. 27.
    International Vaccine Access Center at Johns Hopkins Bloomberg School of Public Health. Pneumonia and Diarrhea Progress Report 2018. International Vaccine Access Center at Johns Hopkins Bloomberg School of Public Health; 2018.Google Scholar
  28. 28.
    Roche M, Garcia R, MacLean A, Solomons N. Designing co-packaging for zinc & oral rehydration salts (ORS) to influence caregiver and provider behaviours for treating childhood diarrhea in guatemala. Eur J Nutr Food Saf. 2015;5:528–529.CrossRefGoogle Scholar
  29. 29.
    Gebremedhin S, Mamo G, Gezahign H, Kung’u J, Adish A. The effectiveness bundling of zinc with Oral Rehydration Salts (ORS) for improving adherence to acute watery diarrhea treatment in Ethiopia: cluster randomised controlled trial. BMC Public Health. 2016;16.Google Scholar
  30. 30.
    Diarrhea Innovations Group (DIG). Proposal to include an additional listing of copackaged ORS and zinc for management of diarrhea in children on the WHO Model List of Essential Medicines for Children—Application for submission to the 22nd Expert Committee on the Selection and Use of Essential Medicines. PATH; 2018.Google Scholar
  31. 31.
    UNICEF Supply Division. Oral Rehydration Salts and Zinc: UNICEF Suppliers and Product Range. United Nations Children’s Fund (UNICEF); 2016.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Amira M. Khan
    • 1
  • James E. Wright
    • 1
  • Zulfiqar A. Bhutta
    • 1
    • 2
    Email author
  1. 1.Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
  2. 2.Center of Excellence in Women and Child HealthThe Aga Khan UniversityKarachiPakistan

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