Download Food & Nutrition in Emergencies

Ramona Sunderwirth, MD
Global Health Fellowship
Lecture Series
St Lukes/Roosevelt Hospital Center
Emergency Food & Nutrition in
Refugee Situations
 Objectives
 Assessment
 Interventions
 Nutrient Deficiencies
 Surveillance & Monitoring
Refugee Crises
Emergency Phase Top 10 Priorities
 1- Initial Assessment
 2- Measles Immunization
 3- Water & Sanitation
 4- Food & Nutrition
 5- Shelter & Site Planning
 6- Health Care in EM
phase
 7- Control of communicable
diseases & epidemics
 8- Public health
surveillance
 9- Human resources &
training
 10- Coordination
Definitions (Wikipedia)
 Food security refers to the availability of food & one's access
to it. A household is considered food secure when its
occupants do not live in hunger or fear of starvation.
 Hunger is a feeling experienced when one has a desire to eat.
 Malnutrition is the insufficient, excessive or imbalanced
consumption of nutrients .
REFUGEE SITUATION
 Food & nutritional security threatened

Malnutrition, disease & death
 Refugees need partial/full food support (acute
phase), +/- nutritional rehabilitation
Complex Causes of Malnutrition
OBJECTIVES
 Objectives of food intervention programmes
 Ensure adequate nutritional general food ration (GFR)
 2,100Kcal/person/day → Prevent malnutrition/mortality
 ↓ Prevalence/mortality from malnutrition
 Role of health agencies: Rx of malnutrition/nutritional deficits
 Selective feeding programmes
 Monitor regularity & adequacy of food rations
 May take charge of general food distribution
Organization of Food Support
World Food Program & UN High Commissioner for Refugees
 MOU (WFP & UNHCR) establishes responsibilities &
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coordination mechanisms for meeting food & nutritional
needs of refugees
UNHCR food & nutritional coordinator - responsibility for
coordination of all aspects of the program
Refugees (women) must be involved
Nutrition education
Aim of food programs:
 Restoration & maintenance of sound nutritional status
 Food ration that meets
 Assessed requirements
 Nutritionally balanced
 Palatable & culturally acceptable
ASSESSMENT of Food & Nutritional Situation
(part of Initial Health Assessment)
 Phase I
 Early, quick evaluation → severity of global picture
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Need for rapid intervention
Facilitate planning necessary resources
Based on observation, interviews/discussions key informants
 Phase II
 Quantified data gathered on nutritional situation
 Decides type & size of nutritional programs
 Prevalence of malnutrition, food available/accessible, factors
affecting nutritional status
 Expensive, time consuming, not always feasible
Assessment : Basic Information
 Numbers & demographics
 Access to fuel, utensils,
 Current nutritional status
containers
 Local food availability
 Present/over time
 Milling possibilities
 Food preferences
 Family capacity to prepare,
store, process food
 Local food for purchase
 Ease of access
 Groups at risk
 Who/ how many
 Self reliance & coping
strategies
Assessment: Other Important Information
 Health status & services
 Environmental health risks
 Community structure
 Food distribution systems
 Social-economic status
 Availability of human
resources
 Storage capacity & quality
 Delivery schedule of food &
non food commodities
 Other agencies activities &
assistance provided:
 Quantity, items, frequency
 Logistics constraints
 Security constraints
 Selective feeding programs
Food availability & accessibility
 Quantity/quality food (usually insufficient w/out distribution)
 Initial data:
 Food distribution already taking place

Food ration, frequency of distribution, distribution agency, target
group
 Assessment of local market
 Food basket of individual households (by sample survey)
 Food sources often diverse: food aid, shared w/ locals, food
purchased/bartered for/ gathered
Nutritional status of refugee population:
prevalence of acute malnutrition in U5 yrs age
 How to measure malnutrition
 W/H index most reliable: reflects present situation, most sensitive to
rapid change
 Oedema → severe malnutrition (Kwashiorkor)
 MUAC: quick, high variability, rapid assessment tool
 Implementation of nutritional survey
 Sample of children 6mo-5yrs w/ W/H index
 How to express malnutrition rates: Z scores
 Global malnutrition: % children <-2 Z scores and/or oedema
 Moderate malnutrition: % children < -2 Z scores > 3 Z scores
 Severe malnutrition: % children < -3 Z scores and /or oedema
Key Nutritional Indicators
 U5
 W/H % of median value
 W/H in Z scores
 MUAC
Moderate
Severe
70-79%
< 70%
-3 to -2 Z
< -3 Z (edema)
115 - <125 mm < 115 mm (edema)
 Adults
 BMI (wt in kg)/(ht in m)2 16-17
 MUAC (pregnant women)
< 16
Other information
 Contextual factors
 Mortality figures
 Majors disease outbreaks (measles, cholera, diarrhea, etc)
 Micronutrient deficiencies
 Housing conditions
 Water supply & sanitation
 Climate & geography
 Customary diet of population
 Security situation
 Provisions of local health services
Interpretation of results
 Essential indicators
 Global acute malnutrition rate : 5% common in Africa/Asia, 5-10%
should act as warning, > 10% serious
 Severe acute malnutrition rate
 Bias in estimating severity
 Very hi MR among most vulnerable: under estimates malnutrition
 Timing & season of the year
 Distribution of malnutrition in population
 Age grp, date of arrival, ethnic grp, camp section, etc
 Helps target programs
 Three main contextual factors
 Mortality figures
 General food rations & food accessibility
 Major outbreaks of disease
Planning quantity of food
 Based on demographic information & prevalence of
malnutrition from nutritional survey
 If presumption of major nutritional emergency, assume:
 U5: 15-20% of total pop
 Pregnant: 1.5-3% of total pop
 Lactating: 3-5% of total pop
 15-20% moderate malnutrition
 2-3% severe malnutrition
Quantity of Commodity Required=
Ration/person/day X no. benef. X no. days
Selective feeding programmes
Classical Emergency Food Interventions
 General food distribution
 Ensure adequate food rations for all
 Selective feeding programs
 Targeted Supplementary feeding programs (SFP)

Moderately malnourished U5, selected pregnant /nursing women,
referrals from TFP, other malnourished people & medically referred
 Blanket SFP
 Children <3 or 5 yrs age, all pregnant/nursing women, other at risk groups
 Therapeutic feeding programs (TFP)
 <5yrs severely malnourished, idem other age grps
 LBW infants
 Unaccompanied minors/orphans <1yr age
 Mothers of <1yr infants w/ breastfeeding failure
How to decide on the Intervention
 General food ration available
 2,100Kcal/person/day for all refugees
 Malnutrition rate
 Indicates level of intervention required
 Aggravating factors: requiring ↑ level intervention
 CMR > 1/10,000 day, ↑ level malnutrition
 Inadequate food ration < 2,100Kcal/person/day
 Epidemics: measles, cholera, shigella , pertussis, etc
 Severe cold & inadequate shelter, ↑ level activity/males
 Unstable situation: new influx of refugees
 Wastage (grinding, poor storage), losses, ↑ barter for non food items
 Other considerations
 Vulnerabilities of specific grps, logistical constraints, agencies capacity,
security, food basket unfamiliar to refugees, local nutritional status, etc
Responding To Crisis
Simplified Decision Tool
Finding
Action required
Food availability at household level
< 2100 kcal/person/day
Improve general rations until local food availability and access can be
made adequate
Malnutrition rate (GAM) under 10 %
with no aggravating factors
- Attention to malnourished individuals through regular community
services[2].
Malnutrition rate (GAM) 10 – 14 % or 5
– 9 % plus aggravating factors
- Supplementary feeding targeted to individuals identified as
malnourished in vulnerable groups
- Therapeutic feeding for SAM individuals
Malnutrition rate (GAM) ≥ 15 % or 10 –
14 % with aggravating factors[1]
- General rations; plus
- Supplementary feeding for all members of vulnerable groups.
- Therapeutic feeding for SAM individuals
[1] Aggravating factors are: i) General food ration below the mean energy requirement (<2100 kcal/kg/person), ii) Crude Death Rate greater
than 1/10 000/day and iii) Epidemic of measles or whooping cough.
[2] This may include therapeutic care integrated into primary health system (hospitals and health centres).
Responsibilities & Coordination
 WFP
 UNHCR
 UNICEF
 Food aid agencies
 Health agencies
Quality of GFR
 Minimum 2,100Kcal/per/d
 10-12% protein energy, 10-17%
fat energy
 Classic food basket: 6 ingredients
 Cereal
 Pulse
 Complementary food items
 Fortified blended foods or
staple foods to vulnerable grps
 Essential vitamins &
minerals: fresh foods,
vegetables, fruits, fortified
cereals, blended foods,
condiments, tablets
 Oil/fat
 Fortified cereal blend
 UNHCR & WFP
 Sugar & salt
 Banned distribution dried milk
 Sometime fish/meat
powder (except in TFP)
 bottle- feeding to be avoided
 Grinding facilities if whole
grain
 Culturally Acceptable & Familiar
food
Feeding programme foods
 Fortification
 Adding micronutrients to foods
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Iodized salt
Fortified blended food
 Fortified blended foods
 A flour composed of pre-cooked cereals + a protein source,
mostly legumes
 Fortified with vitamins + minerals
 E.g.: corn soya blend (CSB)
wheat soya blend (WSB)
plumpynut
Implementation of GFR distribution
Main Factors for success
 Political willingness (donors)
 Adequate planning & good logistical organization
 Registration of refugees, ration cards (UNHCR)
 Distribution system: equity, representative, head of family
(natural unit targeted for distribution) registered
 Good organization: regular distributions, well- planned
site (1/20,000-30,000 refugees)
 Regular monitoring of ration
 Clear definition of the agreed responsibilities of
partners w/ effective coordination
Problems
 Gaps in food supply/delivery
 Lack of funds, insufficient supplies, poor management
 Food losses
 During transport, warehousing, distribution, storage of large amounts food
→ security problems
 Inadequate nutrient content of ration (long term programs)
 Food diversion
 By households in exchange for non food items/complementary food items:
positive effects
 By powerful grps → inequities in access: security problem, detrimental
effects
 Poor organization of distribution & logistical problems: ↓security
 Lack of coordination among partners supplying all items regularly
 Problems w/ food preparation
 Lack cooking utensils/fuel
 Lack of knowledge to prepare items distributed
Alternative to General Food
Distribution
 Opportunities for refugees to acquire food by
themselves
 Cash distributions
 Distributions of food items w/ hi economic value & local
demand
 Income-generating programs & support for individual efforts to
grow foodstuffs
 Food-for-work programs
 Mass preparation of cooked meals
 Rare situations of great insecurity, temporary solution
 Heavy logistical requirements, negative psychosocial
consequences for population
Supplementary Feeding Programs
 Not a substitute for inadequate general ration
 Extra ration provided must be additional to, not a substitute for
the general ration
 Based on prevalence of malnutrition & aggravation factors
 High MR
 High prevalence of infection
 General ration below minimum requirements
Identifying those Eligible
 Active identification and F/U those at risk
 House to house visits
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Children U5, elderly, malnourished, ill
 Mass screening of all children
 Screening on arrival w/ registration
 Referrals by community /health services
Supplementary (selective)
Programs
 Wet rations
 500-700Kcal
 Prepared in feeding centre kitchen, consumed on site twice/day
 Beneficiary has to come for meals to feeding center, every day
 May substitute for a regular meal at home
 Dry rations
 1,000-1,200Kcal
 Hi protein source & hi energy source (oil)
 Premixed cereal or blended food as base/Plumpynut
 Take home for preparation & consumption
 Rations distributed once weekly
 Preferred
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Easier to organize, less staff, lower risk transmission infection
Less time consuming for mother, family life preserved, food shared
Therapeutic Feeding Programs
 On site wet feeding (therapeutic milk F75 & F100)
 Intensive medical care
 Infection & dehydration
 Psychological stimulation during rehabilitation phase
 150Kcal/kg/day
 3-4g protein/kg/d
 Frequent meals
 Phase I: 8-10 meals/24h (usually lasts 1 week)
 Phase II (rehabilitation): 4-6 meals/24h
Selective Feeding Programs
exit criteria
NUTRIENT DEFICIENCIES
predictable & preventable
 Vita C (scurvy)
 Vit A (xerophthalmia)
 Semi-desert area w/ limited
 Low content in GFR
provision of animal products
 Poor health/nutritional status
(milk), fresh fruits & vegetables
 Measles
 Vit B1 (beriberi - thiamin)
 Iron (anemia)
 Ration based on polished rice
 Ration limited in meat content
 Vit B2 (ariboflavinosis)
 Ration based on cereal flour
 Iodine (goitre, cretinism)
unfortified w/ B2
 Pop living in area w/ low iodine
 Vit B3 (pellagra –niacin )
soil content & w/ no iodine salt
 Ration based on maize w/
fortification of food
limited amounts of
groundnuts /fish/meat
Prevention
 Good surveillance system
 GFR quality monitoring
 Early detection of cases in refugee pop, clear case definitions
 Prompt implementation of Rx & preventive measures
 Ensure food diversification
 Varied items & fresh food
 Food fortification
 Provision of fortified blended food
 CSB, WSB
 Vit/mineral supplementation ( Vit A, F, Folate, Iodine)
Vit A
 Estimate of Vit A content in GFR
 Food items w/ hi Vit A content in local market
 Record cases of xerophtalmia, report to health agency
 Few cases indicate Vit A reserves of most pop depleted
 Treat all clinical cases immediately
 Prevention
 Emergency Phase
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Supplementation: mass distribution ages 6mo-15 yrs (measles immunization)
Breastfeeding best source of Vit A for infants < 6 mos age
 Post Emergency Phase
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Mass distribution Vit A (every 4-6 mos if < 50% RDA in ration)
Drug supplementation (none for pregnant women, infants < 6 mos age)
Food fortification + food diversification (best solution: red palm oil, fresh
fruits/vegetables)
Care: Vit A quickly destroyed by heat
Vit Bs: water soluble
avoid well refined/polished cereal
 Vit B1 (beriberi): RDA 1.1 mg/per/d
 Assessment/surveillance of GFR: rice based (milling/polishing)
 Cases recorded/reported, Rx PO/IM
 Food diversification (groundnuts/beans) best strategy
 Food fortification: blended food fortified w/ thiamin (60g/per/d of CSB)
 Outbreak: weekly mass drug supplements
 Vit 3 (PP or niacin-pellagra): RDA 15mg/per/d
 A/S of GFR: maize based
 Cases definition, record, report, Rx PO Vit B3 + B complex
 Food fortification(blended cereals, maize flour) best strategy
 Food diversification (groundnuts, dried fish/meat)
 Outbreak: weekly mass drug supplementation
 Vit B2 (ariboflavinosis- neuropathy, glossitis, conjunctivitis, stomatitis)
 A/S of GFR: refined/unfortified cereal w/ ↑ proportion carb/fat & proteins
 Rx cases, mass supplementation
Vit C: RDA > 15mg/per/d
 Clear case definition for scurvy, routine surveillance
 Preventive measures
 Drug supplementation to vulnerable grps
 Food fortification: (Vit C destroyed by heat) blended foods
 Food diversification: fresh fruit/vegetables/milk
 Outbreak
 Daily mass Vit C drug distribution, weekly/bi-weekly
Minerals: Iron deficiency
Anemia
 Most prevalent nutrient deficiency
 Associated w/ folate deficiency
 Malaria & hookworm exacerbate nutritional anemia
 A/S of GFR if ↑ cases reported to health services
 Prevention intervention
 Supplementation (iron + folate) to hi risk grps: pregnant/lactating
women, and moderately malnourished
 Fortification: blended food( CSB, CSM)
 Diversification: provision of meat to GFR
Minerals: Iodine (IDD)
 30% world’s pop live in I-deficient environments
 Goitrogens in local diet: thiocyanate in cassava
 IDD under reported (goitre,↓ psycho-motor development, cretinism)
 A/S in post emergency phase
 National control programmes
 IDD prevalence in pop
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Goitre by clinical examination of school children (<5%)
Urinary I
 Availability of iodine (seafood/ I salt)
 Presence of goitrogens in local food basket
 Intervention
 Iodized oil administered periodically to vulnerable grps
 Iodization of salt: safest/cheapest solution
 Iodine PO to goitres
SURVEILLANCE & MONITORING
Emergency Phase
 Food availability & accessibility
 Actual amount & quality that reaches families
 Data gathered at different levels of food chain
 Information from distributing agencies, beneficiaries
 Health & nutritional status
 Nutritional surveys repeated regularly (q 3mos)
 Monitor trends malnutrition
 Morbidity (outbreaks) & mortality (CMR, U5MR)
 Feeding programs
 Monitoring feeding centers
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Proper registration
Proportion of recoveries, deaths
Attendance rates, coverage of target grp
Average Wt gain in TFP
 Monitoring program effectiveness : Health Status
Surveillance & Monitoring
Post Emergency Phase
 Food availability & accessibility
 GF distribution (agencies & at distributions points)
 Other sources of food (farming, income-generating activities)
 Market availability & prices
 Information from refugees
 Household availability survey
 Health & nutritional status
 Nutritional survey (q 6 mos)
 Malnutrition cases
 Food & nutritional situation of local population
 Feeding programs
Bibliography
 Refugee Health, an approach to emergency situations
Medecins sans Frontieres 1997
 UNHCR Handbook for emergencies, 2nd ed. 2000, 3rd
ed. 2007