Nutrition in Emergencies

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Nutrition in Emergencies

• Marie McGrath,
• Emergency Nutrition Network

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Emergency Nutrition Network (ENN)

• Set up in 1996 by humanitarian agencies
• To develop sectoral memory and learn from
  experiences in emergency nutrition and food
  security
• Field Exchange
• www.ennonline.net

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Terminology

• Underweight Stunting Marasmus
  
• Micronutrient deficiencies
• Wasting Kwashiorkor
  
• Under-nutrition Over-nutrition
• Micronutrients Macronutrients

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Importance of nutrition in emergencies

• Biafran war (1967-1970)
• 1 million civilians died
• Ethiopian famines 1980s
• Mobilised aid

Tumultuous scenes at food distribution sites in
Ethiopia. Ken Bailey, Field Exchange 12, 2001
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Why is nutrition in emergencies important?

• Protection of nutritional status in emergencies
  humanitarian right (international law)
• Acutely malnourished - more sick
• Sick more likely to get malnourished
• Emergencies impact on range of factors increase
  risk of malnutrition, illness (morbidity) and
  death (mortality)

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Malnutrition and risk of illness and death

• Not infectious disease. implicated in half
  child deaths in the world
• Some emergencies result in very high levels of
  severe malnutrition
• Cut-offs for severe malnutrition is threshold
  where mortality risk rises sharply
• Risk of death of malnourished associated with
  disease patterns malaria, diarrhoea, measles,
  ARI, HIV and AIDS
• Nutritional status also affected by reduced food
  intake due to worsening food security
• Relationship between malnutrition and mortality
  is complicated
• Other factors affect mortality
• Important to interpret mortality data with
  nutrition and health information
• Crude Mortality Rate (CMR) lt1.0/10,000
  individuals/day
• Under-five Mortality Rate (U5MR) lt2.0/10,000
  U5s/day

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South Sudan, 1998

• U5MR rose faster than CMR.
• July, outbreak of dysentery and CMR caught up
  with U5MR.
• July nutrition survey 80 acute malnutrition (WH
  lt-2 zscores).
• October nutrition survey 48 acute malnutrition,
  partially explaining continued high mortality
  despite dysentery under control.

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What are the causes of malnutrition?

• Immediate causes.individual
• Underlying..households/communities
• Basic.society
• UNICEF conceptual framework to determine causes
  of malnutrition

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UNICEF Conceptual framework of Malnutrition
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Broad-based approaches to tackle malnutrition

• Not just lack of food complex mix of factors
• Interventions to cure individuals and prevent
  death
• Interventions to prevent malnutrition rates
  rising
• Heath, healthy environment
• Ensuring food security (ability of household to
  access food)
• Public nutrition approach

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What is an emergency?

• MSF top ten under-reported
• Violence in Central Africa Republic
• TB deaths on increase
• Conflict in Chechnya
• Conflict in Sri Lanka
• .
• In 2006, the top ten accounted for 7.2 minutes
  out of 14,512 minutes on three major US TV
  network nightly newscasts.
• Five of the countries never mentioned at all.

• Extraordinary-urgent-sudden
• Emergency disaster crisis
• An unforseen and often sudden event that causes
  great damage, destruction and human suffering,
  CRED, 2007
• Complex major humanitarian crisis,
  multi-causal, essentially political nature,
  system wide response needed
• Loud v silent
• Impartiality - basis of and in proportion to
  need?????

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What is a nutrition emergency?

• Classification systems
• Severity using acute MN as an indicator of
  distress
• UN-SCN thresholds (1995)
• ODI (2003)
• FSAU/FAO Integrated food security phase
  classification (2006)
• Howe and Devereux Famine Magnitude Scale 2004 (6
  stages)
• Food security (CMElt0.2/10,000/d and wasting
  lt2.3)
• Food crisis conditions (CMRgt0.5 butlt1/10,000/d
  and/or wasting gt10 but lt20 and/or oedema)
• Extreme famine conditions (CMRgt15/10,000/d)
• When to respond?
• Thresholds for emergency interventions ODI and
  FSAU
• SMART reliable and consistent data and
  reporting

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Where do emergencies occur?

• Largest famines (excess deaths) in Asia
• China 1958-1962, 30 million people died
• North Korea, 3.5 million people
• Most nutritional emergencies chronic and
  invisible
• Allocation of food aid not just wasting
• 2000-2004 emergency food aid went to just 6
  countries Ethiopia, Sudan, Afghanistan, Angola,
  Iraq, North Korea

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What are the causes?

• Emergencies where acute malnutrition rates rise
  are usually directly caused by severe shortages
  of food combined with disease epidemics.
• Vulnerability
• Poverty, chronic food insecurity, poor
  infrastructure..developing countries
• HIV and AIDS
• Majority of humanitarian crisis in countries
  where rates already high
• Emergencies can increase the risk of infection,
  eg rape and sexual explotation in conflict areas
• Affects agricultural production (labour loss),
  intensifies poverty (assets stripped)
• No clear associations between malnutrition rates
  and HIV and AIDS at population level
• Climate change
• Average global temperatures rising, other
  ecological changesincrease nutrition emergencies
  and famine?
• Climate vulnerability analysis into frameworks

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Triggers for nutrition emergencies

• Natural disasters
• floods, hurricanes
• Droughts develop more slowly
• Earthquakes large mortality, less dramatic effect
  on food security
• Conflict
• War tactics can block access to food/health
  services
• Destroy infrastructure, food production
• Political crisis and economic shocks
• Zimbabwe
• Drought, floods, disruption of farming activities
  due to political strife, national mismanagement
  of grain reserves.vulnerability
• Individual vulnerability may be linked to social
  or political status

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Who most nutritionally vulnerable in emergencies?

• Physiological
• U2s, pregnant and lactating, elderly
• Geographical
• Political
• Internal displacement and refugees
• Around 9.2 million refugees and 25 million IDPs
  worldwide

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Increased deaths (mortality) Daily deaths per
10,000 people in selected refugee situations 1998
and 1999
IFE 1/1
AND because infants and children are the most
vulnerable...
people of all ages children under 5
years
Deaths/10,000/Day
Camp location
Refugee Nutrition Information System, ACC/SCN at
WHO, Geneva
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Risks of death highest for the youngest at
therapeutic feeding centres in Afghanistan, 1999
IFE 1/2
Deaths as of admissions
Age (months)
Golden M. Comment on including infants in
nutrition surveys experiences of ACF in Kabul
City. Field Exchange 2000916-17
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Risk of death higher for malnourished
children Distribution of 12.2 million deaths
among children under 5 years old in all
developing countries, 1995 WHO
Geneva, 1995
IFE 1/3
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What types of malnutrition occur in emergencies?

• Acute malnutrition (wasting), especially in young
  children
• Measured as weight-for-height/presence of
  bilateral oedema
• Moderate acute (MAM) WHgt70-lt80 WH or gt-3 -
  lt-2 z score
• Severe acute (SAM) WHlt70 or lt-3 z score
• U5 acute MN as proxy
• Micronutrient deficiencies
• Clinical, sub-clinical
• Dietary diversity
• Chronic malnutrition (stunting)
• Inhibits full mental and physical potential
• Small mothers have small babies

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Marasmus(wasting malnutrition)

• Severe form acute malnutrition
• Generally wasted
• Thin arms
• Thin face, old man
• Ribs visible
• Sunken eyes
• Lack of skin turgor
• May be alert but irritable

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Source Unknown
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Kwashiorkor(oedematous malnutrition)
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• Kwashiorkor
• Severe form of acute MN
• Clinical signs include oedema (bilateral foot
  oedema, can spread to other parts of body)
• Cracked and peeling skin, changes in hair colour
  and texture, lethargy and misery

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Micronutrient deficiencies

• Iron deficiency (anaemia)
• Vitamin A deficiency (xeropthalmia)
• Iodine deficiency
• Vitamin C deficiency
• Niacin deficiency (pellagra)
• Thiamine deficiency (beri-beri)
• Riboflavin deficiency (ariboflavinosis)

Haemacue survey in Tanzania, Field Exchange,
Issue 28, July 2006
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Source UNHCR Source A Seal, Field
Exchange 32, Ethiopia, 2004
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Micronutrient deficiencies
Signs of scurvy blackness of the legs indicative
of haemorrhage. Northern Afghanistan, Field
Exchange 13, 2001
Pellagra (niacin deficiency), Angola Field
Exchange 30, Angola, 2007
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Nutrition Assessment

• Establish prevalence of malnutrition
• 30x30 cluster
• Identify potential causes
• Decide on appropriate interventions
• Rapid assessment
• Nutrition surveys
• Nutritional surveillance

ACF coverage survey, Uganda, Field Exchange 34,
2008
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ACF, Uganda, Field Exchange 34, 2008
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Nutrition Response in emergencies

• Curative, eg therapeutic care
• Preventative, eg improving water supply and
  sanitation to prevent disease epidemics
• Food and non-food interventions