Ramona Sunderwirth, MD
Global Health Fellowship
Lecture Series
St Lukes/Roosevelt Hospital Center

 Objectives
 Assessment
 Interventions
 Nutrient Deficiencies
 Surveillance & Monitoring

 1- Initial Assessment
 6- Health Care in EM phase
 2- Measles Immunization
 7Control of communicable diseases & epidemics
 3- Water & Sanitation
 4- Food & Nutrition
 8- Public health surveillance
 5- Shelter & Site Planning
 9- Human resources & training
 10- Coordination

(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 .

 Food & nutritional security threatened
 Malnutrition, disease & death
 Refugees need partial/full food support (acute phase), +/- nutritional rehabilitation

 Objectives of food intervention programmes
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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

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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 involved
Nutrition education
Aim of food programs:
 Restoration & maintenance of sound nutritional status
 Food ration that meets
 Assessed requirements
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Nutritionally balanced
Palatable & culturally acceptable

 Phase I
 Early, quick evaluation → severity of global picture
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Need for rapid intervention
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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

n
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Numbers & demographics
Current nutritional status
Milling possibilities
Food preferences
 Family capacity to prepare, store, process food
 Access to fuel, utensils, containers
 Local food availability
 Present/over time
 Local food for purchase
 Ease of access
 Groups at risk
 Who/ how many
 Self reliance & coping strategies

 Health status & services
 Availability of human resources
 Environmental health risks
 Storage capacity & quality
 Community structure
 Delivery schedule of food & non food commodities
 Food distribution systems
 Social-economic status
 Logistics constraints
 Security constraints
 Other agencies activities & assistance provided:
 Quantity, items, frequency
 Selective feeding programs

 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

 How to measure malnutrition
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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
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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

 U5 Moderate Severe
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W/H % of median value 70-79%
W/H in Z scores
< 70%
-3 to -2 Z < -3 Z (edema)
 MUAC 115 - <125 mm < 115 mm (edema)
 Adults
 BMI (wt in kg)/(ht in m)2 16-17 < 16
 MUAC (pregnant women)

 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

 Essential indicators
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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
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Very hi MR among most vulnerable: under estimates malnutrition
Timing & season of the year
 Distribution of malnutrition in population
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Age grp, date of arrival, ethnic grp, camp section, etc
Helps target programs
 Three main contextual factors
 Mortality figures
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General food rations & food accessibility
Major outbreaks of disease

 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

 General food distribution
 Ensure adequate food rations for all
 Selective feeding programs
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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)
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<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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General food ration available
 2,100Kcal/person/day for all refugees
 Malnutrition rate
 Indicates level of intervention required
 Aggravating factors: requiring ↑ level intervention
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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

Finding
Food availability at household level
< 2100 kcal/person/day
Malnutrition rate (GAM) under 10
% with no aggravating factors
Action required
Improve general rations until local food availability and access can be made adequate
- Attention to malnourished individuals through regular community services [2] .
Malnutrition rate (GAM) 10 – 14
% or 5 – 9 % plus aggravating factors
Malnutrition rate (GAM) ≥ 15 % or 10 – 14 % with aggravating factors [1]
Supplementary feeding targeted to individuals identified as malnourished in vulnerable groups
Therapeutic feeding for SAM individuals
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).

 WFP
 UNHCR
 UNICEF
 Food aid agencies
 Health agencies

 Minimum 2,100Kcal/per/d
 10-12% protein energy, 10-17% fat energy
 Classic food basket : 6 ingredients
 Cereal
 Pulse
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Oil/fat
Fortified cereal blend
 Sugar & salt
 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
 UNHCR & WFP
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Banned distribution dried milk powder (except in TFP) bottle- feeding to be avoided 
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Sometime fish/meat
Grinding facilities if whole grain  Culturally Acceptable & Familiar food

 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

 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

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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
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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

 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

 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

 Active 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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Wet rations
 500-700Kcal
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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
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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

 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

 Vit A (xerophthalmia)
 Low content in GFR
 Poor health/nutritional status
 Measles
 Vit B1 (beriberi - thiamin)
 Ration based on polished rice
 Vit 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

 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)

 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
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Few cases indicate Vit A reserves of most pop depleted
Treat all clinical cases immediately
 Prevention
 Emergency Phase
 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

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Vit B1 (beriberi): RDA 1.1 mg/per/d
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Assessment/surveillance of GFR: rice based (milling/polishing)
Cases recorded/reported, Rx PO/IM
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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
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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

 Clear case definition for scurvy, routine surveillance
 Preventive measures
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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

 Most prevalent nutrient deficiency
 Associated w/ folate deficiency
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Malaria & hookworm exacerbate nutritional anemia
A/S of GFR if ↑ cases reported to health services
Prevention intervention
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Supplementation (iron + folate) to hi risk grps: pregnant/lactating women, and moderately malnourished
 Fortification: blended food( CSB, CSM)
 Diversification: provision of meat to GFR

 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
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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
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Iodized oil administered periodically to vulnerable grps
Iodization of salt: safest/cheapest solution
Iodine PO to goitres

 Food availability & accessibility
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Actual amount & quality that reaches families
Data gathered at different levels of food chain
Information from distributing agencies, beneficiaries
 Health & nutritional status
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Nutritional surveys repeated regularly (q 3mos)
Monitor trends malnutrition
Morbidity (outbreaks) & mortality (CMR, U5MR )
 Feeding programs
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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

 Food availability & accessibility
 GF distribution (agencies & at distributions points)
 Other sources of food (farming, income-generating activities)
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Market availability & prices
Information from refugees
Household availability survey
 Health & nutritional status
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Nutritional survey (q 6 mos)
Malnutrition cases
 Food & nutritional situation of local population
 Feeding programs

 Refugee Health, an approach to emergency situations
Medecins sans Frontieres 1997
 UNHCR Handbook for emergencies, 2 nd ed. 2000, 3 rd ed. 2007