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Transcript of Ramona Sunderwirth, MD Global Health Fellowship Lecture Series St Lukes/Roosevelt Hospital Center.
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Ramona Sunderwirth, MDGlobal Health FellowshipLecture SeriesSt Lukes/Roosevelt Hospital Center
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Emergency Food & Nutrition in Refugee Situations
ObjectivesAssessmentInterventionsNutrient Deficiencies Surveillance & Monitoring
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Refugee CrisesEmergency 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
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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 .
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REFUGEE SITUATIONFood & nutritional security threatened
Malnutrition, disease & death
Refugees need partial/full food support (acute phase), +/- nutritional rehabilitation
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Complex Causes of Malnutrition
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OBJECTIVESObjectives 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 programmesMonitor regularity & adequacy of food rationsMay take charge of general food distribution
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Organization of Food SupportWorld Food Program & UN High Commissioner for Refugees
MOU (WFP & UNHCR) establishes responsibilities & 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 involvedNutrition education Aim of food programs:
Restoration & maintenance of sound nutritional statusFood ration that meets
Assessed requirementsNutritionally balancedPalatable & culturally acceptable
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ASSESSMENT of Food & Nutritional Situation(part of Initial Health Assessment)
Phase IEarly, quick evaluation → severity of global picture
Need for rapid intervention Facilitate planning necessary resources Based on observation, interviews/discussions key informants
Phase IIQuantified data gathered on nutritional situationDecides type & size of nutritional programs Prevalence of malnutrition, food available/accessible,
factors affecting nutritional statusExpensive, time consuming, not always feasible
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Assessment : Basic Information
Numbers & demographics
Current nutritional status
Milling possibilities
Food preferences
Family capacity to prepare, store, process food
Access to fuel, utensils, containers
Local food availabilityPresent/over timeLocal food for purchaseEase of access
Groups at riskWho/ how many
Self reliance & coping strategies
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Assessment: Other Important InformationHealth status & services
Environmental health risks
Community structure
Food distribution systems
Social-economic status
Logistics constraintsSecurity constraints
Availability of human resources
Storage capacity & quality
Delivery schedule of food & non food commodities
Other agencies activities & assistance provided:Quantity, items, frequencySelective feeding programs
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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 marketFood basket of individual households (by sample survey)Food sources often diverse: food aid, shared w/ locals,
food purchased/bartered for/ gathered
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Nutritional status of refugee population:prevalence of acute malnutrition in U5 yrs age
How to measure malnutritionW/H index most reliable: reflects present situation, most
sensitive to rapid changeOedema → severe malnutrition (Kwashiorkor)MUAC: quick, high variability, rapid assessment tool
Implementation of nutritional surveySample of children 6mo-5yrs w/ W/H index
How to express malnutrition rates: Z scoresGlobal malnutrition: % children <-2 Z scores and/or oedemaModerate malnutrition: % children < -2 Z scores > 3 Z scoresSevere malnutrition: % children < -3 Z scores and /or oedema
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Key Nutritional IndicatorsU5 Moderate Severe
W/H % of median value 70-79% < 70%W/H in Z scores -3 to -2 Z < -3 Z
(edema)MUAC 115 - <125 mm <
115 mm (edema)
AdultsBMI (wt in kg)/(ht in m)2 16-17 < 16MUAC (pregnant women)
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Other informationContextual factors
Mortality figuresMajors disease outbreaks (measles, cholera,
diarrhea, etc)Micronutrient deficienciesHousing conditionsWater supply & sanitationClimate & geographyCustomary diet of populationSecurity situationProvisions of local health services
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Interpretation of resultsEssential indicators
Global acute malnutrition rate : 5% common in Africa/Asia, 5-10% should act as warning, > 10% serious
Severe acute malnutrition rateBias in estimating severity
Very hi MR among most vulnerable: under estimates malnutrition
Timing & season of the yearDistribution of malnutrition in population
Age grp, date of arrival, ethnic grp, camp section, etcHelps target programs
Three main contextual factorsMortality figuresGeneral food rations & food accessibilityMajor outbreaks of disease
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Planning quantity of food Based on demographic information & prevalence
of malnutrition from nutritional surveyIf presumption of major nutritional emergency,
assume:U5: 15-20% of total popPregnant: 1.5-3% of total popLactating: 3-5% of total pop
15-20% moderate malnutrition2-3% severe malnutrition
Quantity of Commodity Required= Ration/person/day X no. benef. X no. days
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Selective feeding programmes
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Classical Emergency Food Interventions General food distribution
Ensure adequate food rations for all
Selective feeding programsTargeted 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 groupsTherapeutic feeding programs (TFP)
<5yrs severely malnourished, idem other age grps LBW infants Unaccompanied minors/orphans <1yr age Mothers of <1yr infants w/ breastfeeding failure
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How to decide on the InterventionGeneral food ration available
2,100Kcal/person/day for all refugeesMalnutrition rate
Indicates level of intervention requiredAggravating factors: requiring ↑ level intervention
CMR > 1/10,000 day, ↑ level malnutrition Inadequate food ration < 2,100Kcal/person/dayEpidemics: measles, cholera, shigella , pertussis, etcSevere cold & inadequate shelter, ↑ level activity/malesUnstable situation: new influx of refugeesWastage (grinding, poor storage), losses, ↑ barter for non food
items
Other considerationsVulnerabilities of specific grps, logistical constraints, agencies
capacity, security, food basket unfamiliar to refugees, local nutritional status, etc
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Responding To CrisisSimplified Decision Tool
Finding Action requiredFood 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).
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Responsibilities & Coordination
WFPUNHCRUNICEFFood aid agenciesHealth agencies
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Quality of GFRMinimum 2,100Kcal/per/d
10-12% protein energy, 10-17% fat energy
Classic food basket: 6 ingredients Cereal Pulse Oil/fat Fortified cereal blend Sugar & salt
Sometime fish/meat Grinding facilities if
whole grain
Complementary food itemsFortified blended foods or
staple foods to vulnerable grps
Essential vitamins & minerals: fresh foods, vegetables, fruits, fortified cereals, blended foods, condiments, tablets
UNHCR & WFPBanned distribution dried
milk powder (except in TFP)bottle- feeding to be
avoided
Culturally Acceptable & Familiar food
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Feeding programme foodsFortification
Adding micronutrients to foods Iodized salt Fortified blended food
Fortified blended foods A flour composed of pre-cooked cereals + a
protein source, mostly legumesFortified with vitamins + mineralsE.g.: corn soya blend (CSB) wheat soya blend (WSB) plumpynut
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Implementation of GFR distributionMain 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 rationClear definition of the agreed responsibilities
of partners w/ effective coordination
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Problems Gaps in food supply/delivery
Lack of funds, insufficient supplies, poor managementFood losses
During transport, warehousing, distribution, storage of large amounts food → security problems
Inadequate nutrient content of ration (long term programs)
Food diversionBy households in exchange for non food items/complementary
food items: positive effectsBy powerful grps → inequities in access: security problem,
detrimental effectsPoor organization of distribution & logistical problems:
↓security Lack of coordination among partners supplying all items
regularlyProblems w/ food preparation
Lack cooking utensils/fuelLack of knowledge to prepare items distributed
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Alternative to General Food Distribution
Opportunities for refugees to acquire food by themselvesCash distributionsDistributions of food items w/ hi economic value &
local demandIncome-generating programs & support for
individual efforts to grow foodstuffsFood-for-work programsMass preparation of cooked meals
Rare situations of great insecurity, temporary solution
Heavy logistical requirements, negative psychosocial consequences for population
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Supplementary Feeding ProgramsNot 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 factorsHigh MRHigh prevalence of infectionGeneral ration below minimum requirements
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Identifying those EligibleActive identification and F/U those at risk
House to house visits Children U5, elderly, malnourished, ill
Mass screening of all children
Screening on arrival w/ registration
Referrals by community /health services
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Supplementary (selective) Programs
Wet rations500-700Kcal Prepared in feeding centre kitchen, consumed on site
twice/dayBeneficiary has to come for meals to feeding center, every
dayMay substitute for a regular meal at home
Dry rations1,000-1,200KcalHi protein source & hi energy source (oil)Premixed cereal or blended food as base/PlumpynutTake home for preparation & consumptionRations distributed once weeklyPreferred
Easier to organize, less staff, lower risk transmission infection Less time consuming for mother, family life preserved, food shared
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Therapeutic Feeding ProgramsOn site wet feeding (therapeutic milk F75 & F100)
Intensive medical careInfection & dehydration
Psychological stimulation during rehabilitation phase
150Kcal/kg/day3-4g protein/kg/d
Frequent mealsPhase I: 8-10 meals/24h (usually lasts 1 week)Phase II (rehabilitation): 4-6 meals/24h
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Selective Feeding Programsexit criteria
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NUTRIENT DEFICIENCIESpredictable & preventable
Vit A (xerophthalmia)Low content in GFRPoor health/nutritional
statusMeasles
Vit B1 (beriberi - thiamin)Ration based on polished
riceVit B2 (ariboflavinosis)
Ration based on cereal flour unfortified w/ B2
Vit B3 (pellagra –niacin )Ration based on maize w/
limited amounts of groundnuts /fish/meat
Vita C (scurvy)Semi-desert area w/ limited
provision of animal products (milk), fresh fruits & vegetables
Iron (anemia)Ration limited in meat
content
Iodine (goitre, cretinism)Pop living in area w/ low
iodine soil content & w/ no iodine salt fortification of food
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Prevention Good surveillance system
GFR quality monitoringEarly detection of cases in refugee pop, clear case
definitionsPrompt implementation of Rx & preventive
measuresEnsure food diversification
Varied items & fresh foodFood fortificationProvision of fortified blended food
CSB, WSBVit/mineral supplementation ( Vit A, F, Folate,
Iodine)
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Vit AEstimate of Vit A content in GFR Food items w/ hi Vit A content in local marketRecord cases of xerophtalmia, report to health
agencyFew cases indicate Vit A reserves of most pop depletedTreat all clinical cases immediately
PreventionEmergency Phase
Supplementation: mass distribution ages 6mo-15 yrs (measles immunization) Breastfeeding best source of Vit A for infants < 6 mos age
Post Emergency Phase 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
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Vit Bs: water solubleavoid well refined/polished cereal
Vit B1 (beriberi): RDA 1.1 mg/per/dAssessment/surveillance of GFR: rice based (milling/polishing)Cases recorded/reported, Rx PO/IMFood diversification (groundnuts/beans) best strategyFood 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/dA/S of GFR: maize basedCases definition, record, report, Rx PO Vit B3 + B complexFood fortification(blended cereals, maize flour) best strategyFood 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 &
proteinsRx cases, mass supplementation
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Vit C: RDA > 15mg/per/dClear case definition for scurvy, routine
surveillance
Preventive measuresDrug supplementation to vulnerable grpsFood fortification: (Vit C destroyed by heat) blended foodsFood diversification: fresh fruit/vegetables/milk
Outbreak Daily mass Vit C drug distribution, weekly/bi-weekly
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Minerals: Iron deficiencyAnemia
Most prevalent nutrient deficiencyAssociated w/ folate deficiencyMalaria & hookworm exacerbate nutritional
anemiaA/S of GFR if ↑ cases reported to health servicesPrevention 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
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Minerals: Iodine (IDD)30% world’s pop live in I-deficient environmentsGoitrogens in local diet: thiocyanate in cassavaIDD under reported (goitre,↓ psycho-motor development,
cretinism)
A/S in post emergency phaseNational control programmesIDD prevalence in pop
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
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SURVEILLANCE & MONITORINGEmergency 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 statusNutritional surveys repeated regularly (q 3mos)Monitor trends malnutritionMorbidity (outbreaks) & mortality (CMR, U5MR)
Feeding programsMonitoring feeding centers
Proper registration Proportion of recoveries, deaths Attendance rates, coverage of target grp Average Wt gain in TFP
Monitoring program effectiveness : Health Status
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Surveillance & MonitoringPost Emergency Phase
Food availability & accessibilityGF distribution (agencies & at distributions points)Other sources of food (farming, income-generating activities)
Market availability & prices Information from refugees Household availability survey
Health & nutritional statusNutritional survey (q 6 mos)Malnutrition cases
Food & nutritional situation of local population
Feeding programs
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BibliographyRefugee Health, an approach to emergency
situations Medecins sans Frontieres 1997UNHCR Handbook for emergencies, 2nd ed.
2000, 3rd ed. 2007