Nutrition in Emergencies

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EHN Capacity Building Training

• Nutrition in Emergencies

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• The Impact of Malnutrition

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The Impact of MalnutritionWhat is malnutrition?

• A state in which the physical function of an
  individual is impaired to the point where he or
  she can no longer maintain an adequate bodily
  performance processes such as growth, pregnancy,
  lactation, physical work, and resisting and
  recovering from disease

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The Impact of MalnutritionThe Malnutrition-Infect
ion Cycle
Inadequate dietary intake
Weight loss Growth faltering Lowered
immunity Mucosal damage
Appetite loss Nutrient loss Mal-absorption Altered
metabolism
Disease
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The Impact of MalnutritionMalnutrition Child
Mortality
Source Lancet Child Survival Series
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• Nutrition Indices A Review

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Nutrition Indices - Review
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Nutrition Indices - Review Developmental Contexts
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Nutrition Indices ReviewEmergency Contexts
Cut off points for MUAC differ from agency to
agency these cut offs are consistent with MSF
guidance
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Nutrition Indices ReviewEmergency Contexts
Moderate Acute Malnutrition
Cut off points for MUAC differ from agency to
agency these cut offs are consistent with MSF
guidance
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Nutrition Indices ReviewEmergency Contexts
Severe Acute Malnutrition (SAM)
Cut off points for MUAC differ from agency to
agency these cut offs are consistent with MSF
guidance
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Nutrition Indices ReviewEmergency Contexts
Global Acute Malnutrition (GAM)
Cut off points for MUAC differ from agency to
agency these cut offs are consistent with MSF
guidance
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Nutrition Indices ReviewClinical Malnutrition
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Nutrition Indices ReviewMalnutrition Child
Mortality

• 54 associated
• with Underweight
• ? associated
• with Acute malnutrition
• Proportion associated
• with Acute grows
• dramatically in
• emergency contexts

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• Assessing the Severity of Crisis

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Severity of CrisisDefinition of an Emergency

• Abnormally high rates of acute malnutrition
  resulting from a crisis event

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Severity of a CrisisThree Criteria

• 1. Prevalence of malnutrition in relation to
  internationally defined benchmarks and thresholds
• 2. Trends in rates of malnutrition over time
  pre-crisis including seasonality
• 3. The relationship between malnutrition and
  mortality

Adapted from HPN Network Paper 56, Helen Young
and Susanne Jaspars, November 2006
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Severity of CrisisBenchmarks and Thresholds
WHO, Management of Malnutrition in Major
Emergencies, 2000
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Severity of CrisisBenchmarks and Thresholds
Emergency Threshold
WHO, Management of Malnutrition in Major
Emergencies, 2000
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Severity of CrisisBenchmarks and Thresholds
Static rates exceed emergency thresholds
Rainer Gross, Patrick Webb Lancet 2006 367
120911
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Severity of CrisisMalnutrition Over Time
Seasonal annual Variation in rates
K. Brown Et al., 1982, The American Journal of
Clinical Nutrition 36 pp. 303-313.
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Severity of CrisisMalnutrition and Mortality
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• Responding to Crisis

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Responding to CrisisNutrition Causal Framework
Malnutrition
Inadequate Food Intake
Disease
Household Food Security
Social and Care Environment
Access to Health Care the Health Environment
Adapted from Unicef
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Responding to Crisis Prevention Before Cure
Higher Priority
Lower Priority
Food security/General Distribution
Supplementary feeding
Therapeutic feeding
Cost/Benefit
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Responding to Crisis Prevention Before Cure
Higher Priority
Lower Priority
Food security/General Distribution
Supplementary feeding
Therapeutic feeding
Cost/Benefit
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Responding to CrisisPrevention before Cure
Rates of malnutrition begin to climb
April 07
June 07
September 07
December 07
Rates of acute malnutrition (lt5)
ENDF engagement increases
Cross-border trade disrupted
Cattle prices down food prices up
CRISIS!
Food supplies diminishing
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Responding to Crisis Prevention Before Cure

• Ensure the population has adequate access to
  appropriate quantities of quality food
• Market-based interventions
• Cash transfers
• General food distribution or blanket
  supplementary feeding
• Nutritional Surveillance

Food Security Colleagues
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Responding to CrisisPrevention before Cure
Rates of malnutrition begin to climb
April 07
June 07
September 07
December 07
Rates of acute malnutrition (lt5)
ENDF engagement increases
Cross-border trade disrupted
Cattle prices down food prices up
CRISIS!
Food supplies diminishing
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Responding to Crisis Selective Feeding
Higher Priority
Lower Priority
Food security/General Distribution
Supplementary feeding
Therapeutic feeding
Cost/Benefit
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Responding to Crisis Screening
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Responding to CrisisScreening
Acute Malnutrition
With Complications
Without Complications
Oedema () OR Marasmic-Kwashiorker OR WHM lt80
OR MUAC lt125mm OR oedema AND illness
80 WHM, MUAC lt125mm
70 WHM, MUAC lt110mm OR oedema
Supplementary Feeding
Outpatient Therapeutic Care
Stabilization Care
Anorexia, LRI, High fever, Severe dehydration,
anemia, not alert, hypolglycaemia, or hypothermia
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Responding to CrisisSupplementary Feeding
Acute Malnutrition
With Complications
Without Complications
Oedema () OR Marasmic-Kwashiorker OR WHM lt80
OR MUAC lt125mm OR oedema AND illness
80 WHM, MUAC lt125mm
70 WHM, MUAC lt110mm OR oedema
Supplementary Feeding
Outpatient Therapeutic Care
Stabilization Care
Anorexia, LRI, High fever, Severe dehydration,
anemia, not alert, hypolglycaemia, or hypothermia
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Responding to CrisisSupplementary Feeding

• Blanket
• Prevent malnutrition by providing a food
  supplement to all members of vulnerable groups
  such as children lt5 and pregnant and lactating
  women (alluded to earlier)
• Targeted
• Prevent moderately malnourished women and
  children from becoming severely malnourished by
  providing a food supplement to malnourished
  individuals

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Responding to Crisis Supplementary Feeding
should be based on dry take-home rations unless
there is a clear rationale for on-site feeding -
SPHERE

• Wet Rations
• Food is prepared and consumed on-site (ration is
  determined according to childs nutritional
  requirements)
• Dry Rations
• Food is taken home and consumed with family
  (ration often increased to account for
  intra-household allocation)

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Responding to Crisis Supplementary Feeding
Recommended Quantities

• Rations
• Blend CSB, WSB, Unimix
• Oil and/or Sugar
• High Energy Biscuits
• BP5

WHO, 2000
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Responding to CrisisOutpatient Care
90 of severes can be treated as outpatients
Acute Malnutrition
With Complications
Without Complications
Oedema () OR Marasmic-Kwashiorker OR WHM lt80
OR MUAC lt125mm OR oedema AND illness
80 WHM, MUAC lt125mm
70 WHM, MUAC lt110mm OR oedema
Supplementary Feeding
Outpatient Therapeutic Care
Stabilization Care
Anorexia, LRI, High fever, Severe dehydration,
anemia, not alert, hypolglycaemia, or hypothermia
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Responding to CrisisOTP - Screening
Uncomplicated
Complicated
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Responding to CrisisOTP First Contact

• Medical Assessment
• Appetite Assessment
• Presumptive treatment Amoxicillin,
  Anti-malarial, and Vitamin A (except in edema
  cases)
• Ready to Use Therapeutic Food (RUTF)

Uncomplicated
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Responding to CrisisOTP - Weekly Follow Up

• Medical exam
• RUTF
• Week 2 antihelminths
• Week 4 Measles immunization

Uncomplicated
Complicated
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Responding to CrisisStabilization Care (SC)
Acute Malnutrition
With Complications
Without Complications
Oedema () OR Marasmic-Kwashiorker OR WHM lt80
OR MUAC lt125mm OR oedema AND illness
80 WHM, MUAC lt125mm
70 WHM, MUAC lt110mm OR oedema
Supplementary Feeding
Outpatient Therapeutic Care
Stabilization Care
Anorexia, LRI, High fever, Severe dehydration,
anemia, not alert, hypolglycaemia, or hypothermia
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Responding to CrisisStabilization Centers

• 24 hour specialized care (NRU, Pediatric wards,
  TFC)
• 1 feeding assistant for every 10 patients
• 1 nurse and 2 health workers for every 50
  patients (TFC)

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Responding to CrisisStabilization Care
Outpatient Care
See WHO, Management of Severe Malnutrition,
1999, and CTC Field Manual for further detail.
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Responding to CrisisCommunity Therapeutic Care

• Comprehensive approach to addressing severe acute
  malnutrition, including four primary components
• Supplementary Feeding Program (SFP)
• Outpatient Therapeutic Program (OTP)
• Stabilization Center (SC)
• Community Mobilization Active Case Finding

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MicronutrientsThe Silent Killer

• Over 2 billion people affected
• Increases the general risk of infectious disease
  and of dying from diarrhoea, measles, malaria and
  pneumonia
• Emergency affected populations are at increased
  risk of deficiency

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Micronutrients Deficiency Diseases
Adapted from ENN
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Micronutrients Deficiency Diseases
Adapted from ENN
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Micronutrients Deficiency Diseases
Adapted from ENN
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MicronutrientsPrevention Before Cure

• Ensure the population has access to key
  micronutrients
• Local foods
• Fortified foods
• On-site fortification
• Supplements
• Multiple Micronutrient Powders

This is YOUR job
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• Thank You!