Ramona Sunderwirth, MDGlobal Health FellowshipLecture SeriesSt Lukes/Roosevelt Hospital Center

Emergency Food & Nutrition in Refugee Situations

ObjectivesAssessmentInterventionsNutrient Deficiencies Surveillance & Monitoring

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

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 SITUATIONFood & nutritional security threatened

Malnutrition, disease & death

Refugees need partial/full food support (acute phase), +/- nutritional rehabilitation

Complex Causes of Malnutrition

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

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

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

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

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

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

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

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)

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

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

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

Selective feeding programmes

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

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

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).

Responsibilities & Coordination

WFPUNHCRUNICEFFood aid agenciesHealth agencies

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

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

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

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

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

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

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

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

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

Selective Feeding Programsexit criteria

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

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)

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

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

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

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

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

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

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

BibliographyRefugee Health, an approach to emergency

situations Medecins sans Frontieres 1997UNHCR Handbook for emergencies, 2nd ed.

2000, 3rd ed. 2007