Interim GL_Nutr Care of EVD Px_Version 0.4
DRAFT version 0.4
WHO/UNICEF Interim guideline
Nutritional Care in Adults and Children infected with Ebola
Virus Disease in Treatment Centres.
Acknowledgements (To be added)
Glossary
CSB
EVD
HEB
ORS
RUSF
RUTF
Corn-Soy Blend
Ebola Virus Disease
High Energy Biscuit
Oral Rehydration Salts
Ready-to-Use-Supplementary Food
Ready-to-Use-Therapeutic Food
Table of Contents
1. SCOPE AND PURPOSE .................................................................................................................... 2
2. PROCESS FOR DEVELOPMENT OF INTERIM GUIDELINE (TO BE COMPLETED)..................... 2
3. BACKGROUND .................................................................................................................................. 3
3.1 Brief description of Ebola Virus Disease ....................................................................................... 3
3.2 Treatment priorities for patients with Ebola Virus Disease .......................................................... 3
3.3 EVD symptoms which effect nutritional care and status .............................................................. 4
4. SPECIFIC NUTRITIONAL AND FOOD REQUIREMENTS FOR PATIENTS WITH EBOLA VIRUS
DISEASE................................................................................................................................................. 4
4.1 Nutritional requirements .............................................................................................................. 4
4.2 Provision of food ........................................................................................................................... 5
5. CATEGORIES OF PATIENTS WITH EBOLA VIRUS DISEASE IN RELATION TO NUTRITION .... 6
6. FOOD COMMODITIES THAT ARE CONSIDERED IN EBOLA VIRUS DISEASE TREATMENT .... 6
7. NUTRITIONAL CARE PROTOCOLS FOR PATIENTS WITH EBOLA VIRUS DISEASE IN
CURRENT TREATMENT CENTRES ..................................................................................................... 8
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8. SPECIAL PROVISIONS TO BE CONSIDERED WHEN DISCHARGING A PATIENT CURED
FROM EBOLA VIRUS DISEASE ......................................................................................................... 10
8.1 Screening on acute malnutrition ................................................................................................ 10
8.2 Discharge provisions ................................................................................................................... 11
9. OUTSTANDING ISSUES THAT NEED FURTHER CONSIDERATIONS ........................................ 11
1. Scope and purpose
This interim guideline provides recommendations on nutritional support to adults and children
infected with the Ebola virus. It highlights the key clinical problems in patients affected by Ebola
Virus Disease (EVD) that would interfere with nutritional status and support of patients; what the
nutritional needs are; and what nutritional support should be given in the context of the current
Ebola crisis.
The guideline focuses on nutritional support in all EVD patients during treatment and convalescence
whilst ensuring safety of health staff and caretakers. It is not a clinical guideline but aims to be
practical on nutrition. It also does not focus specifically on malnutrition. It is intended for relevant
health staff of organisations that implement or contribute to EVD treatment programmes as well as
Ministries of Health.
Though the recommendations provided are to some extent universal, the application may vary
according to contexts and capacities. Treatment centres for EVD vary from having only a few
patients to hundreds, from having resource limitations to being fully equipped, from having a few to
sufficient numbers of staff, etc. Therefore the implementation of these guidelines need to be
adapted accordingly. This guideline lays out some basic principles of nutritional care assuming that
the treatment centre is not optimally equipped and human resources are limited. Through increased
field experience on application of suggested protocols this document will need revision within 3
months.
2. Process for development of interim guideline (to be completed)
Review process: references found – direct and indirect evidence
Guideline development group: List names of people and organisations (e.g. MSF, ICRC ) who
contributed
WHO Steering committee: WHO (NHD, PED, FOS, ERM) and UNICEF
Guideline meetings: e.g. Telecon 12th September 2014
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3. Background
3.1 Brief description of Ebola Virus Disease
EVD is an acute infection caused by the Ebola virus that starts with a flu-like syndrome, fever and
profound weakness (ref1). Table 1 provides an overview of the main symptoms. Most of the
symptoms have a direct or indirect impact on nutrition. The pathogenesis of the disease is not
completely understood, but the diarrhoea experienced with EVD can be profound and in addition to
electrolyte loss, protein loss may occur. Symptoms may appear anywhere from 2 to 21 days after
exposure to Ebola virus though onset in the first two weeks following exposure is considered to be
most common (ref1). The mortality of EVD is high and no licensed specific anti-viral treatment or
vaccine is available for use in humans (ref3). The majority of patients are adults. Patients may have
short or long hospitalized courses. It is estimated once the patient is hospitalised, the mean time to
death is approximately 4 days and to discharge, 12 days (ref4).
Table 1. Symptoms in patients with EVD (ref1, ref2, ref4)*.
Most patients suffer from (approximate %):
- Fever (90)
- Fatigue (>75)
- Vomiting (65-70)
- Loss of appetite (65)
- Diarrhoea (65)
- Headache (55)
- Nausea
Some patients suffer from (approximate %):
- Stomach pain (45)
- Muscle and/or joint pains (40)
- Difficulties in swallowing (appears to be
present in third of patients)
- Cough (30)
- Breathing difficulty (25)
- Sore throat (20)
- Conjunctivitis (20)
- Bleeding (external, internal)
(note: bleeding in ≈20% of confirmed
cases; mostly in later stage of diseases)1
- Impaired kidney and liver function
- Confusion (<15)
- Hiccups (11)
- Jaundice (10)
*Other signs and symptoms which have been reported at a frequency of less than 10% of confirmed and probable EVD patients with a
definitive clinical outcome in Guinea, Liberia, Nigeria, and Sierra Leone are reported in ref4.
3.2 Treatment priorities for patients with Ebola Virus Disease
1
Despite a common belief that haemorrhage is a defining feature, visible bleeding is not universal. When present, bleeding
is not a typical early presenting feature though it can present early, most often it appears late in severely ill patients (ref1).
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The management of EVD patients is similar to other diseases with severe sepsis or shock (ref5, ref2).
The standard practice when diarrhoea is present aims particularly at strategies dealing with volume
and electrolyte repletion. Ideally, this is done with oral rehydration salts (ORS) solution and then
parenteral repletion when need and resources are appropriate. Additionally, treatment of
complicating infections and palliative care are important (ref2). Like other critically ill patients,
especially in areas where malnutrition also may be common, EVD patients may have varied
nutritional needs.
3.3 EVD symptoms which effect
nutritional care and status
Naso-gastric tubes are not recommended in most
field settings in the treatment of EVD*

A lack of appetite, a sore throat, difficulty
swallowing and breathing difficulties
interfere with nutritional care. However,
encouragement by health staff seems to
have an effect, enabling patients to eat and
drink.

Vomiting also interferes with nutritional care
and along with diarrhoea causes additional
nutritional stress through rapid loss of
electrolytes, protein and fluid.

4. Specific nutritional and food
requirements for patients with
Ebola Virus Disease
4.1 Nutritional requirements



Because their position in the gastro-intestinal tract is
difficult to locate without proper use of a
stethoscope (most personal protective equipment
employed in this outbreak interferes with use of a
stethoscope);
Because they are difficult to monitor as health staff
have limited time;
Because patients with sore throat complain about
the pain they cause (there is a risk that patients
remove them, creating an infection risk);
Because some patients oppose insertion and
retention of the naso-gastric tube (or are confused),
this decreases the likelihood of benefit versus risk to
staff, increases the risk of tearing staff protective
gear as well as the risk of spray during removal;
Because severely ill patients who are bleeding may
experience harm from placement of the tube;
Because many treatment centres have insufficient
trained staff to insert and maintain them.
* When patients support naso-gastric tube placement,
exceptions can be made for treatment centres that are fully
equipped with sufficient and appropriate staff and materiel,
good infection-prevention-control practice and good waste
disposal management.
The nutritional needs and approach to
nutritional care in any individual will be
determined by:
o
o
o
Preceding nutritional status
Severity of illness
Age
EVD patients need sufficient energy (kcal), proteins and especially a great deal of fluid and
electrolytes to compensate for losses through diarrhoea, vomiting and fever. In many patients
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diarrhoea and vomiting are not constant, but occur as intermittent episodes. It is unclear whether
preceding nutritional status contributes directly to the outcome of the disease. Currently, it is
unknown which nutritional support contributes to the survival of the patients. Therefore this
guideline suggests, until further evidence is available, to provide the recommended daily allowance
(RDA) for each nutrient to the patients. If patients can eat more, especially during convalescence,
this should not be discouraged.
In the acute phase nutritional support should not interfere with the strategies for volume and
electrolyte repletion as nutrition requirements will be of a lower priority during the acute phase of
EVD. The intake of high energy/high protein foods may be important, especially in patients who are
acutely ill for longer time periods (e.g.: up to 3 weeks), but promoted in a way which supports the
patients and avoids adding stress.
4.2 Provision of food
Anti-emetic medications may provide some relief and facilitate oral rehydration if nausea and
vomiting are common (ref1). If swallowing is difficult including in settings when the patient has a
decreased level of consciousness or is confused, the risk of aspiration may be high. When feeding
occurs the patient should be positioned upright or if necessary in a semi-supine (‘half sitting’)
position. Offering liquid food via a straw may facilitate intake.
Patients should be provided with food if they are conscious and can swallow. As most patients lose
their appetite, soft foods and fluids are easier to tolerate (ref1). Small frequent meals are often
better tolerated. It is important to offer food the patient likes to eat. While ideally electrolyte
repletion occurs through ORS intake, sometimes patients will be eating small amounts but not
tolerate substantive ORS volume. Consequently, potassium in particular as well as other electrolytes
should be elements considered in food selection.
The nature of the treatment of EVD (patients are put in isolated wards) does not allow family or
friends to assist in physically feeding the patients unless they are trained to work under appropriate
infection-prevention-control practice (including the wearing of personal protective equipment). Due
to the work load, health care staff have no or limited time to assist the patients with eating or
drinking. The food that is offered to the patient should ideally:






Be palatable and attractive
Be relatively nutrient dense
Be liquid, semi-solid or solid (depending on the patient’s condition)
Be easy to ingest and not require assistance from health care staff when the patients eat (as
they have limited time to help)
Carry limited risk of bacterial contamination when kept at bedside for 1-2 hours
Not demand many eating utensils as they are a source of contamination
Note on eating utensils - Food could be offered: in a) bowls and with cutlery that is kept on the
patient’s ward and allocated to a single patient (at bedside) with chlorination procedures in place to
clean utensils; and/or b) in disposable materials (for single use only) that should be burned after use
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(plastic, polystyrene, straws, wooden/paper/plastic spoons, foil). This is only possible in conjunction
with the facility’s strict waste disposal management for contaminated materials.
Nutritional support to a patient with EVD in a treatment centre is likely to be not more than 2 - 3
weeks. These figures could be useful for planning the logistics and quantities needed of food
commodities (ref4).
5. Categories of patients with Ebola Virus Disease in relation to
nutrition
Currently, field experience with patients with EVD in treatment centres show differences in their
capacity to eat and drink. This guideline recognises three categories of EVD patients (see Table 2).
Table 2. Categories of patients with EVD in relation to nutrition.
Category of
patients with
EVD
Description
Category 1
Patients with no specific nutritional features. They have normal to increased
appetite and can ingest normal food and eat without need of assistance. This
category concerns confirmed or unconfirmed patients at the beginning of the
disease. They can also be convalescing.
Category 2
Patients with symptoms of EVD but who are alert, can eat and swallow semisolid/solid food and have a reduced appetite.
Category 3
Patients with EVD who are very weak, have no appetite and who can hardly
eat or drink*.
*some patients are not able to eat at all and therefore the only option would be IV or naso-gastric tube (the
difficulties of which have been discussed elsewhere in this document).
6. Food commodities that are considered in Ebola Virus Disease
treatment
Table 3 shows an overview of potential commodities that could be considered during treatment and
convalescence of patients with EVD taking into account the nutritional requirements, patients’
limitations as well as operational constraints in treatment centres.
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Table 3. Food commodities to be considered for patients with EVD in treatment centres.
Food commodity
Advantages
Comments
Category
of
patients
SPREADS
- Ready-to-Use
Therapeutic Food
(RUTF) in paste form
- Ready-to-Use
Supplementary Food
(RUSF) in paste form
Hygienic, individual portions,
easy to eat.
Do not need preparation and
can be positioned at bedside
with relatively low risk of
bacterial contamination.
Rather dry and plenty of liquid
should be offered separately.
Problematic in patients with some
swallowing difficulties.
RUSF is cheaper than RUTF.
1 and 2
Hygienic, individual portions,
easy to eat.
Do not need preparation if used
as dry biscuit and can be
positioned at bedside. Can be
made into a porridge by adding
water.
If offered as biscuit, plenty of water
should be offered separately as it
can be dry.
RUSF is cheaper than RUTF.
1 and 2
(and
maybe 3
if offered
as
porridge)
Offered as porridge
Requires preparation in a kitchen
and regular distribution
1 and 2
(and
maybe 3)
in individual packaging
BISCUITS
- Ready-to-Use
Therapeutic Food in
biscuit form
- Ready-to-Use
Supplementary Food in
biscuit form
- Other: High Energy
Biscuits (HEB)
SUPERCEREALS
i.e. Corn-Soy-Blend: CSB+
or CSB++
(CSB+ = without milk
powder for adults)
MILK BASED FORTIFIED
DIET (F100)
ENTERAL FEEDING
PRODUCTS
e.g. powders to which
water is added or readyto-use drinks in cans or
cartons
SUGARY DRINKS
Juices, drinks with
glucose/fructose or sugar,
sugary carbonated soft
drinks
Offered as liquid drink (through
straw), easy to ingest and
contributes to fluid intake
Requires preparation in a kitchen
and regular distribution
Theoretical risk of lactose
intolerance in adult patients taking
large amounts. Risk of bacterial
contamination if kept at ward >2
hrs
2 and 3
Individual package, easy to
ingest with straw and
contributes to fluid intake
Often low or free in lactose and
gluten
Expensive
Risk of bacterial contamination if
kept at ward >2 hrs
3
Easy to ingest and contributes
to maintaining blood glucose
levels
From field experience these
seemed to be liked by patients.
Some juices might be rich in
potassium (see below)
Low in many micronutrients
3
And if
desirable
also in 1
and 2
CEREAL BASED-ORS FOOD
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(see Annex 1)
DILUTED RUTF
It has been suggested to
dilute RUTF spreads with
water, bananas and/or
with prepared F100 in
blenders
POTASSIUM RICH FOOD
e.g. juices, mashed fruits.
Based on field experience
potassium rich foods
might be of particular
importance as ORS might
be insufficiently consumed
(see Annex 4)
COMMON FAMILY FOOD
(mashed or solid)
Based on preference of
the individual patients
This was used in Bangladesh in
case of diarrheal epidemic like
shigella (to treat dehydration
and bring nutrients
simultaneously)
Requires preparation in a kitchen
and regular distribution; risk of
bacterial contamination.
Very low in energy (20 kcal/100
ml). Option needs to be tested for
results.
2 and 3
This will make. RUTF spreads
easier to ingest, ensures fluid
intake and avoid it to be stuck
in the mouth (potentially useful
for the very sick)
This option is only possible when
electrical blenders are available
and in small centres. Risk of
bacterial contamination possibly <2
hrs if kept at ward.
Option needs to be tested for
results, safety and feasibility.
3
This food is relatively easy to
ingest and particularly
attractive for children. From
field experience it is known that
this can compensate partially
for the potassium losses due to
diarrhoea and vomiting
E.g. rice-gruel or rice porridge,
fufu, mashed carrots, millet,
okra, palava sauce, etc
2 and 3
Not suitable for those that have
eating difficulties. This might be
nutritionally insufficient if this is
the only food offered.
Micronutrient powders or pastes
might need to be added.
1 and 2
7. Nutritional care protocols for patients with Ebola Virus Disease in
current treatment centres
Whenever possible an assessment should be done on patients, to indicate what they can and prefer
to eat, in order to bridge what is nutritionally needed to what the patient wants to eat. Ideally, a
‘menu’ of 4-5 choices should be presented to each patient (e.g. CSB+/Supercereal porridge, ricegruel or rice porridge, fufu, RUSF, F100, mashed carrots, porridge from RUTF biscuits) every day. This
increases the likelihood that the patients eat, but is logistically likely only manageable in smaller
treatment centres that are well resourced. It is recommended to offer at least a menu with solid
food, a menu with semi-solid food and one with liquids only.
Anthropometry is not a standard procedure when patients enter the treatment centres: weight-for
height or BMI measurements are difficult as tools are not everywhere available and for risk of
contamination of materials. Additionally, anthropometry for adults is not implemented as the
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nutritional protocol will not differ if adult patients are malnourished at the onset of the disease2. For
children3 >6 up to 59 months MUAC could be used to screen for malnutrition and treatment should
be done according to the national protocol for severe acute malnutrition whilst simultaneously
taking into account the treatment principles for EVD4.
However, at discharge anthropometry could be used to screen for all malnourished patients (both
adults and children) to provide adequate commodities to treat at home (see chapter 8).
The nutritional care protocols for patients with EVD are similar for adults and children >6 months in
choice of commodities, however the quantities provided differ as well as the form food might be
offered (children 6 – 24 months might need more mashed food). For children <6 months specific
guidance has been developed (see below).
Table 4 lists the nutritional care protocol that the consulted experts have identified as currently the
best option taking into account nutritional needs, operational constraints and the various categories
of patients. More detailed menus with indicated quantities and time tables are included as Annexes
2, 3 and 6. Note: The menus in the annexes take into account a limited number of commodities (e.g.
availability of only one type of CSB/Supercereal and one type of ‘therapeutic’ milk because of
operational constraints).
Table 4. Nutritional care protocols for adults and children >6 months.
Category of
patients with
EVD
Category 1
Patients with
normal to
increased
appetite and can
ingest normal
food and eat
without need of
assistance.
Category 2
Suggestion
 Common family meal
 And/or 1-2 porridges of CSB+/Supercereal (adults) or CSB++/Supercereal+
(children)
 And/or snacks : drinks, HEB
Convalescent patients usually need (and want) more food: do not limit the
quantity of the food and provide extra RUSF.
 1-2 porridges per day of CSB+/Supercereal (adults) or CSB++/Supercereal+
(children)
2
In the current contexts not many adults come in treatment centres as malnourished. If this situation changes
and substantial numbers of patients with EVD enter the treatment as severely acute malnourished (SAM), a
new nutritional protocol could be envisaged taking into account both EVD and SAM for adults.
3
For adolescents screening for malnutrition at entry in the treatment centre would ideally be done through
BMI-for-age, but this is difficult under the current circumstances in most centres as it requires tables, weighing
scale and height boards as well as calculators. These are all materials that are potential sources of further
contamination.
4
ORS might need to be replaced by ReSoMal.
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Patients with
symptoms of EVD
(and confirmed
with the disease)
but who are
alert, can eat and
swallow semisolid/solid food
and have a
reduced
appetite.
 Common family meal (solid or as soups)
 RUSF as snacks or RUTF in biscuit form (as biscuit or porridge)
 Anything the patient likes can be added, e.g. cookies, local juices, sugary
drinks, HEB, soups, mashed foods.
Category 3
 Milk based fortified diet (F100)5
 Anything the patient likes can be added, especially for category 2 and 3
(cookies, local juices, sugary drinks, HEB, soups, mashed foods)
Patients with
EVD (confirmed)
who are very
weak, have no
appetite and who
can hardly eat or
drink.
Other options to consider (to be tested for acceptability and/or feasibility
for this category):
 And/or RUSF or RUTF as snacks or made into liquids with water or F100
 And/or cereal-based ORS porridge
 And/or enteral feeding products
Additional to this protocol special dietary measures can be considered if potassium levels need to be
corrected with food (see Annex 4).
Normal meals for category 1 patients can be catered for by treatment centres as well as families that
have expressed willingness and capacity to provide prepared meals. Guidance for those families can
include recommendations on energy-dense, potassium-rich and digestible foods and snacks (see
Annex 5 for lists of foods that can be suggested for the family to prepare).
For children <6 months specific guidance has been developed and available on
http://www.ennonline.net/infantfeedinginthecontextofebola2014. Note that the document on
infant feeding refers to conditions not necessarily within treatment centres.
8. Special provisions to be considered when discharging a patient
cured from Ebola Virus Disease
8.1 Screening on acute malnutrition
5
Suitable for any patient (even adults) but particularly for children. F100 can be prepared according to its
normal recipe or diluted.
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When patients have recovered from EVD it is important to screen for acute malnutrition, especially
amongst children 6 to 59 months. This can be done with MUAC for adults and children 6 to 59
months. For children 5 to 19 years BMI-for-age can be used. As treatment centres are likely
overloaded with patients, it is recommended to discharge the malnourished patient with
commodities as suggested in the nutritional treatment protocols for acute malnutrition from the
Ministry of Health. If such a protocol does not exist it is recommended to discharge the patient with
RUTF (for severe acute malnutrition) and CSB/Supercereal (for moderate acute malnutrition). The
amount of commodities should be sufficient for 1 month. If there are operational centres that treat
acutely malnourished individuals, referral to existing treatment facilities is recommended when the
patient is no longer contagious.
8.2 Discharge provisions
Regardless of the presence or absence of acute malnutrition in the discharged patient, he/she
should receive a means6 in order to ensure he/she can cover the food needs for the whole family for
one month. This is particularly important as family members and patients are stigmatised and
struggle with household food security.
In addition, it is recommended that each discharged patient is provided with a supply of at least 2
RUSF sachets/bars per day for two weeks.
9. Outstanding issues that need further considerations
To date no research is available on the efficacy and effectiveness of nutritional care to patients with
EVD. In order to optimise the patients’ survival as well as relieving some of the symptoms and
suffering such research is recommended.
A group of experts will need to be consulted on specific recommendations for pregnant and lactating
women, and on relevance of providing anti-oxidants as well as the specific needs concerning, for
example, zinc, iodine, magnesium, selenium, and thiamine.
It is also envisaged that more specific treatment protocols for various age groups will be drafted in
the near future (for age categories such as 6-23 months and 24-59 months) and possibly treatment
protocols for severely malnourished patients with EVD. Additionally, a list of DOs and DON’Ts for
the field might be drafted.
6
Depending on the context the recovered patient and his/her family should receive cash, vouchers and/or
food rations (nutritionally adequate and sufficient for the whole household for one month).
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Ref 1. Clinical Management of Patients with Viral Haemorrhagic Fever: A Pocket Guide for the Frontline Health Worker 13 April 2014 Interim emergency guidance-generic draft for West African
adaptation. World Health Organization.
Ref 2. Ebola hemorrhagic Fever. Fact Sheet, Centers of Disease Control CDC, (2014). National Center
for Emerging and Zoonotic Infectious Diseases Division of High-Consequence Pathogens and
Pathology (DHCPP)
Ref 3. http://www.who.int/mediacentre/factsheets/fs103/en/ consulted 19 September 2014.
Ref 4. WHO Ebola Response Team (2014) “Ebola Virus Disease in West Africa - The First 9 Months of
the Epidemic and Forward Projections.” N Engl J Med. 2014 Sep 22. [Epub ahead of print]
Ref 5. Fowler RA, Fletcher T, Fischer Ii WA, Lamontagne F, Jacob S, Brett-Major D, Lawler JV,
Jacquerioz FA, Houlihan C, O'Dempsey T, Ferri M, Adachi T, Lamah MC, Bah EI, Mayet T, Schieffelin J,
McLellan SL, Senga M, Kato Y, Clement C, Mardel S, Vallenas Bejar De Villar RC, Shindo N, Bausch D.
(2014) “Caring for Critically Ill Patients with Ebola Virus Disease: Perspectives from West Africa.” Am
J Respir Crit Care Med. 2014 Aug 28. [Epub ahead of print]
http://www.atsjournals.org/doi/pdf/10.1164/rccm.201408-1514CP
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Annex 1. Cereal based ORS studied in ICDDR, Bangladesh
Type of Cereal ORS
Quantity/ Water
Rice flour
50g/litre7
Maize flour
60g/litre
Millet flour
60g/litre
Sorghum Flour
60g/litre
Wheat flour
60g/litre
Mashed Potatoes
200g/litre
Mashed GN Plantain
250g/litre
Recipe
1 one litre water to be taken in a clean saucepan
2 Then to add 50ml more water for cooking loss
3 Now to add two pinch of salt and the cereals
4 Then to mix thoroughly and cook to make it even solution, it needs one minute boiling when bubbles come out
5 It needs continuous stirring when cooking
6 Now the solution is ready to serve
7 Solution can be kept for limited number of hours in room temperature
7
Low in energy (in kcal)
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Annex 2. Menu for ADULTS with EVD
Category 1:

2 porridges per day (CSB+/Supercereal), each porridge should contain:
150 g CSB+/Supercereal
10 g oil
10 g sugar

Common family meal:
130 g cereal (e.g. rice)
60 g pulses8 (or meat9/chicken/fish)
50 g vegetables
10 g oil
1 g salt
Convalescent patients usually need (and want) more food: do not limit the quantity of the
food and provide extra RUSF. Also other nutritional products (HEB, RUSF, etc) and/or
desirable foods can be added.
Provides ± 2100 kcal and 13 % protein
Category 2:
Ideally, the fortified food (as CSB+/Supercereal, RUSF etc) should be given in priority. If the
patient can eat more, then the normal meal should be added. If the patient wants, the
quantity of CSB+/Supercereal and/ or RUSF can be increased.

1-2 porridges per day (CSB+/Supercereal):
150 g CSB+/Supercereal
10 g oil
10 g sugar

Common family meal (mashed or solid):
130 g cereal (e.g. rice)
60 g pulses10 (or meat11/chicken/fish)
50 g vegetables
10 g oil
1 g salt

Ready-to-Use Supplementary Food:
8
Well cooked and soaked night before
No bush meat
10
Well cooked and soaked night before
11
No bush meat
9
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2 sachets RUSF spreads12 OR
4 bars of RUSF biscuits or 3 bars of RUTF biscuits13 + water (if porridge is preferred)
Other food: anything the patient likes (cookies, HEB, mashed meals, etc) and plenty of
tasty drinks14 (an assessment is needed).
Provides ± 2500 kcal and 12 % protein (including 1 porridge, 2x RUSF and 1 normal meal)
Category 3:

F100 (someone must help the patient to sit to drink the milk (straws can facilitate drinking; do
not keep the milk more than 2 hrs)
300 ml per meal x 6 per day (= 1 sachet for 2 people per meal).
Note: this menu takes into account the operational constraints during the preparation of
therapeutic milk and absence of night feeding possibilities (1 cup per patient/time). Every two
hours therapeutic milk left at patient’s bedside should be discarded

Any other fortified food that patients can eat (porridges made of CSB+/Supercereal, RUSF,
RUTF) and/or enteral products

Other food: anything the patient likes (cookies, HEB, mashed meals, etc) and plenty of tasty
drinks15 (an assessment is needed). This category is particularly important for those that have
limited chance of survival.
12
If RUSF not available, this can be replaced by RUTF spreads
If RUTF biscuits are not available, HEB can be used temporarily.
14
Juices in tetra/carton package
15
Juices in tetra/carton package
13
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Annex 3. Menu for CHILDREN > 6 MONTHS with EVD
Category 1: the range of quantity are depending of the age and appetite of the child

1 or 2 porridges per day (CSB+/Supercereal)16:
100 g CSB+/Supercereal
10 g oil
10 g sugar

Ready-to-Use Supplementary Food:
1 or 2 sachets of RUSF spreads17
OR
2 to 4 bars of RUSF biscuits or 1 to 3 bars of RUTF biscuits18 + water (if porridge is
preferred)

Common family meal (mashed or solid) (in 1-2 portions): see adults but smaller portions (half
for example), and/or mashed fruits
Convalescent patients usually need (and want) more food: do not limit the quantity of the
food and provide extra RUSF. Also other nutritional products (HEB, RUSF, etc) and/or
desirable foods can be added.
Provides ± 1400 to kcal and 12 % protein(including 1 porridge + 1x RUSF + 1 normal meal)
– corresponds to the need of 6 to 59 months children
Category 2:
The range of quantity are depending of the age and appetite of the child.
Ideally, the fortified food (as CSB+/Supercereal, RUSF etc) should be given in priority. If the
patient can eat more, then the normal meal should be added. If the patient wants, the
quantity of CSB+/Supercereal and/ or RUSF can be increased.

1 or 2 porridges per day (CSB+/Supercereal)19:
100 g CSB+/Supercereal
10 g oil
10 g sugar

Ready-to-Use Supplementary Food:
1 or 2 sachets of RUSF spreads20
OR
2 to 4 bars of RUSF biscuits or 1 to 3 bars of RUTF biscuits + water (if porridge is preferred)
16
CSB++/Supercereal+ can also be used, but in this menu operational constraints are taken into account
limiting the commodities for one type of CSB that is suitable for both adults and children > 6 months
17
If RUSF not available, this can be replaced by RUTF spreads
18
If RUTF biscuits ares not available, HEB can be used temporarily.
1919
CSB++/Supercereal+ can also be used, but in this menu operational constraints are taken into account
limiting the commodities for one type of CSB that is suitable for both adults and children > 6 months
20
If RUSF not available, this can be replaced by RUTF spreads
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If the child desires:

Common family meal (mashed or solid) (in 1-2 portions): see adults but smaller
portions (half for example), and/or mashed fruits
Other food: anything the patient likes (cookies, HEB, mashed meals, etc) and plenty of
tasty drinks21 (an assessment is needed).
Provides ± 1500 to kcal and 11 % protein (including 1 porridge + 2x RUSF or 2 porridges
and 1 RUSF) – corresponds to the need of 6 to 59 months children
Category 3:
The range of quantity are depending of the age and appetite of the child – Quantities can be
increased.

F100 (someone must help the patient to sit to drink the milk (straws can facilitate drinking; do
not keep the milk more than 2 hrs); Give as much as much as the child wants
150 - 300 ml per meal x 6 per day (= 1 sachet for 2 people per meal).
Note: this menu takes into account the operational constraints during the preparation of
therapeutic milk and absence of night feeding possibilities (1 cup per patient/time). Every two
hours therapeutic milk left at patient’s bedside should be discarded

Any other fortified food that patients can eat (porridges made of CSB+/Supercereal, RUSF,
RUTF) and/or enteral products

Other food: anything the patient likes (cookies, HEB, mashed meals, etc) and plenty of tasty
drinks22 (an assessment is needed). This category is particularly important for those that have
limited chance of survival.
Provides ± 900 to 1800 kcal and 11 % protein (with F100 only)
21
22
Juices in tetra/carton package
Juices in tetra/carton package
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Annex 4. Provision of extra potassium through food
Dietary measures for extra provision of potassium include
 Additional snacks (ready to eat), such as fruits and nuts (see Table) or fruit juices.
 Family meal including one or more of the following foods:
o Starchy roots
o Beans, peas, lentils
o Green leaves, tomato paste
o Fish
o Goat, pork, rabbit meat
Some principles for food processing

Cereals may be rich in potassium when raw, but they lose a lot during processing => starchy
roots maybe preferred over cereals as staple food.

If food is boiled, an important part of the potassium is lost in the water (unless it is used for soup
and the patient consumes also the water in which the vegetables have boiled) => fish will be
preferably grilled than boiled and green leaves cooked shortly in a saucepan and then added to
the sauce or the meal.
The table below can help selecting the type of foods according to availability and cultural habits and
to advise families on which food they could offer to their family members.
Food
West African Foods rich in Potassium23
Potassium (mg /100g
edible portion)
Starchy roots, tubers
Cassava tuber dried
Cassava flour
Cocoyam Tuber, raw /boiled
Potato, boiled
Sweet potato, boiled
Yam tuber, boiled
609
587
457/384
440
369
687
Legumes
African yam bean, boiled
Bambara groundnut, dried, raw / boiled
Beans, white, boiled
Peas, boiled
Soya beans, boiled
357
1190 / 330
429
284 - 387*
569
Vegetables
Green leaves (Amarante, Baobab, Cassava, Roselle, Spinach,
Vernonia), raw
23
Source: Adapted from FAO. West African Food Composition Table 2012.
www.fao.org/docrep/015/i2698b/i2698b00.pdf
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391 - 605 *
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Green leaves (Amarante, Baobab, Cassava, Roselle, Spinach,
Vernonia), boiled**
Garlic, raw
Parsley, fresh
Tomato paste, concentrated
206 - 318 *
533
600
1010
Fruits
Avocado, pulp
Banana
Baobab fruit /Monkey bread (pulp)
Coconut milk/water
Dattock pulp, raw
Dattock dried pulp
Dates (dry)
Figs (dry)
Mango deep orange/pale orange
Melon
Papaya
Orange
Plantain, ripe, raw / boiled
Tamarind fruit, ripe, raw
492
369-376*
1020
234/270
345
807
669
887
157/180
228-248
206
166
500 / 381
648
Nuts, Seeds
Cashew nuts, raw
Coconut, mature kernel, fresh, raw
Coconut, kernel, dried, raw
Groundnut, shelled, dried, raw
Melon seeds
Sesame seeds
641
415
617
727
648
468
Meat & poultry & their products
Goat meat, grilled / boiled
Pork meat, grilled
Rabbit meat, grilled
474 / 316
365
432
Fishs & their products
Most of the fishes, especially Anchovy, Carp, Mackerel &
375 - 615
Sardine, preferably grilled than boiled.
* according to species
** Around 50% lost in boiling (unless cooked as soup and patient eats also cooking liquid).
Preferably cook shortly in a saucepan.
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Annex 5. Food families can prepare for weak patients with EVD that do not have much appetite.
Families are welcome to bring soft foods or soups and energy-dense and potassium rich snacks to
their sick family members with EVD. Below some suggestions:
1) Snacks:
Bananas / plantains, Avocado, Mango, dry dates and figs, baobab fruit, nuts...
2) Soft food:
Puree from potatoes, sweet potatoes, cassava, yam tubers, pumpkins,
These starchy foods can be mixed with vegetables: zucchini, eggplant, carrots, green leaves, etc.
or with legumes (beans, peas, lentils soaked 1 night and well cooked), eggs, mashed fish, etc.
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Porridges from rice, maize, millet (well cooked) mixed with sugar, milk or the above vegetables.
Porridges, purees and soups can be enriched with 1 table spoon of vegetable oil / meal.
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Annex 6. Examples of meal schedules in a treatment centre
Note: This schedule is based on the possibility of day-time feeding only.
8:00 AM
10:00 AM
12:00 AM
2:00 PM
4:00 PM
6:00 PM
8:00 PM
ALL DAY
N.B.
Breakfast
Patients Cat. 1 and 2 - Porridge or HEB
Patients Cat. 3 - Therapeutic milk
Snack
Patients Cat.1 and 2 - Fruits + nuts, biscuits, RUSF/RUTF
Patients Cat.3 - Therapeutic milk or enteral product (or RUTF, diluted
or not if they can swallow well)
Family Meal
Patients Cat.1 and 2 - Family food (solid, soft, or mashed)
Patients Cat.3 - Therapeutic milk or enteral product or soup
Snack
Patients Cat.1 and 2: Fruits + nuts, biscuits
Patients Cat.3 - Therapeutic milk or enteral product (or RUTF, diluted
or not if they can swallow well)
Patients Cat.3 - Therapeutic milk or enteral product (or RUTF, diluted
or not if they can swallow well)
Dinner
Patients Cat.1 and 2 - Porridge or HEB
Patients Cat.3 - Therapeutic milk
Snack for the night
Patients Cat.1 and 2 - RUSF/RUTF
Patients Cat.3 - RUSF/RUTF (diluted or not if they can swallow well)
Water, Sweet drinks ad libidum, ORS according to prescription.
1) This schedule is a "template" example and should be adapted according to
centre and human resources as well as patient load. Rationale behind this example
is:
- Need of small and frequent meals
- For Cat.3: Therapeutic milk is given every 2 hours to ensure someone is
collecting the remains and milk is not staying more than 2 hours at patient’s
bedside. If different staff is responsible for hygiene, they can collect remains of milk
and meals can be given every 3 hours.
2) Keep 1 RUSF/RUTF for the night at patient’s bedside (easy to be handled by
patient and limited risk of bacterial contamination.
3) For patients who do not need feeding assistance or if staff is overloaded, the
snacks can be given at the same time as the main meals and patients should be
instructed to eat these later.
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