NUTRITION IN EMERGENCIES WORKING GROUP

REPORT OF DISCUSSIONS AND QUESTIONS AND ANSWERS MARCH 2006

Discussion on Prevention and control of micronutrient deficiencies in populations affected by emergency

Andrew Seal (ICH): How do the new WHO/WFP/UNICEF guidelines on multiple-micronutrient supplementation fit with the research from Pemba, which recorded a 12% increase in morbidity with iron supplementation? Why are the agencies recommending 5.8mg rather than 12.5mg iron?

WHO: There have been many discussions since the Pemba study but the agencies have decided, so far, to keep the iron in because so many children are iron deficient. Note that in Pemba the iron was provided in tablet form but the new guidelines suggest that the supplement should be added to food. It is possible that the interaction between iron and zinc may not be as strong if mixed with food. The results of future programmes/studies will be closely monitored and if there are further problems the formulation may be changed.

Micro-nutrient Initiative: Recall that Pemba is highly malarial area – the increase in morbidity is not found in other non-malarial areas.

MSF-H: Some confusion about the results of the Zinc supplementation. Isn’t Zinc supplementation supposed to improve recovery rates of diarrhoea? Why no impact in Pemba?

WHO: Indeed, there is evidence that Zinc can do this but we do not yet have the results of the Zinc analyses from Pemba (the iron studies were stopped but not the Zinc ones). We hope that the results will be positive.

Kate Dewey: In meta-analyses zinc has been shown to reduce the incidence of both diarrhoea and pneumonia.

Lida Lhotska: How were the recommendations about changing the dose of supplementation if a fortified ration is given formulated? Is it practically possible in the field to control compliance to either requirement?

UNICEF: In Pakistan, we used to separate lists of beneficiaries – those with and those without SFP. Households receiving SFP were given less packages of the multiple-micronutrient powders and different education.

UNHCR: In our experience, generally feeding is inadequate for children aged 6-36 months even if blended food is given with the ration. There is a need to assess not only what the household receives as a whole but also intra-household food distribution. We need to think carefully about how we are assessing what is required in each separate situation. Also, for training it would be useful to have clear guidelines on what different age groups require (??).

UNICEF: We will be completing the final draft on guidelines of how to use the multiple-micronutrient powders within a month. Agencies (including UNCHR) will be asked to review these and any suggestions for training would be welcomed.

Caroline (ACF): How were the 15 micronutrients chosen?

UNICEF/Dewey: Based on the results of trials that demonstrated which were the most important for this age group. Also, some micronutrients cannot be combined together easily so had to be left out of the sprinkles formulation.

SC(UK): Need to be careful not to use the term “Sprinkles” because these particular products are somehow funded by Heinz which violates the code. Would be better to use the term multiple-micronutrient powders if possible.

Some confusion about which product should be used for pregnant and lactating women and which for children. UNIMAP is still the tablet of choice for pregnant women. New formulation is for children.

If the current recommendation is that these products be used during an emergency, what happens after funding for an emergency runs out?

UNICEF: Agree that this may be a problem - clearly some mothers will want to continue using the supplement. This issue was discussed at Panama. Need to think carefully about how to define an emergency – is it in terms of a natural rapid onset disaster (e.g. tsunami) or in terms of high levels of malnutrition? Need to think about this at the next meeting. On the other hand, starting off the supplementation in emergencies can be a method of introducing a broader fortification policy. For example, in Pakistan the emergency actually helped to get the issue of MMP supplementation onto the national agenda when for many years it had been lagging behind. Scientists in the country were able to see the impact very quickly and this triggered the start of a national programme.

ICH: How applicable are child development tools used by ACH across different cultures? What do the results of the ACH studies mean for agencies working in the field?

There are always problems with using certain types of development tools which have been developed for one culture in other places. However, the motor scales are applicable everywhere and the WIPSI and other scales that we used had been used elsewhere in Argentina before so we there were some standards already available.

Agencies in the field have a powerful tool in epidemiology to help us predict which children will have problems. We know, for example, that we must focus our work on the most vulnerable children. We are currently providing weekly iron supplementation to children and encouraging the Government to extend this programme and use mass media to promote it. Also, need to promote access of all people to health services – something we have known for 30 years but seemed to have forgotten this.

Did the study look at relationship between growth/development and feeding habits? Only 20% of the children were exclusively breastfed at month 4 – sample size too small. There is a need to consider looking at the relationship between the mother and child.

Dewey: Useful methods to measure motor development were published last year in the Food and Nutrition Bulletin. These “motor development milestone assessment methods” were used by WHO in the new multi-country growth standards. Important to measure motor development because in some places see bigger results in terms of motor development than growth.

Carlos: Can the change in the development indicators be measured in the short term, e.g.: in emergencies? Probably not – takes more than a few months to effect a change in these indicators but could look at changes in the motor indicators, breastfeeding rates etc.

Discussion on Infant Feeding in Emergencies (including HIV/AIDS)

Funding: Bruce… We should be Opportunistic trying to link funds to

  • HIV funding
  • The possibility of human to human transmission of Avian influenza may be funding opportunity.
  • USAID is looking to refund Linkages… new procurement will start in October.

There was a question about whether UNICEF were dropping Infant feeding from their core Core commitments.

  • Pakistan experience: within 7 days, a rapid assessment showed 20% of mothers stopped BF. There was no trained group on IFE in country. Modules were ordered from ENN who shipped them out in one working day and within 3 days whole infant feeding guidelines… developed from global guidelines and circulated to all camps..
  • There were difficulties in finding people to train and a suggestion to overcome this is in having an international group of trainers. There was some opposition toi this proposition as the materials are developed for field workers to be adapted in field… should be adapted…
  • Maaike Arts from UNICEF Vietnam… started the training. Article that come in Field Exchange should be considered her article. She has now left UNICEF …
  • Infant Feeding is still part of UNICEF’s core commitment.
  • Debated a lot in core group about training: In the case of Pakistan… 40 hour and 80 hour had taken place in Pakistan. Through WHO and UNICEF training efforts… Are the lack of training a reflection on WHO training? Can we actually start drawing on resources we have trained in a few years? Political decision to ask Pakistani government to gather 10s of people who have supposedly been trained.
  • In Pakistan, for the last 10 years all BF activities planning ministry. 11/2 to 2 years ago moved to MOH. 3,000 physicians all within camps and no one available to work on BF because already working on other issues. Also Planning ministry wasn’t handling over the list which is why they needed outside help.
  • This was an Emergency of scale country not related to Tsunami…
  • UNICEF response from Sri Lanka quite different from Indonesia: Government took charge and made sure that BMS weren’t used in field.
  • In Indonesia midwives give child bottle first, industry now targeting midwives rather than doctors, midwives are helping mothers to receive infant formula. Having to look at retraining midwives. Now looking at 40 hours training for midwives.

Fathia (UNHCR): IFE: Recently experience with CARE… In Kenya, Mary Lung’aho did a good job and helped Somali health workers. The training can be used in non-Emergencies as well. UNHCR High Commisioner has included IYCF in 2006-9 plan. There is a paper that will include infant feeding.

Gay… got to tackle the universal ignorance about infant feeding probably why donors don’t give… unless they are “educated”… don’t believe that women can breastfeed… need to do infant feeding in emergencies training… for donors… until we can educate them…

Audrey : Medical and nursing education is related to skills and knowledge and one element pre-service education. If we could indeed really carry out pre-service ed of midwives, nurses and medical students, there are 1600 medical schools in the world and it ought not to be impossible to develop a pre-service curriculum so that core practitioners in the world know what to do every day and in emergencies? It would cost some money but it is sustainable? “Question is how can we “invade” core curriculum of all health care schools.”

Indonesian midwives were trainined in a one-day seminar of Ministry of Women’s Affairs. There was a Midwives Association, yet the reason for Midwives propoting BMS was “what can we do when mothers have “no food”…”

Flora… met with MOH… revised version of international code… please make mechanism for ensuring that it is applied.

Caroline Abla: Point that donors need to be educated. At USAID’s OFDA, not seeing one NGO discussing infant feeding in Emergencies. NGOs don’t focus on IFE. Process of reviewing guidelines: the minimum technical requirements we could require and details about infant feeding in Emergencies may be an option to include.

ACF has developed an e learning CD on breastfeeding for field workers before they leave to the field… Cecile from ACF has copies of this E learning package.

Discussion on Innocenti 2005

WHO and WABA reminded the group that “key messages” had been agreed upon prior to the celebration and were made available on the Innocenti + 15 website. In response to a question about having the 2005 Innocenti Declaration endorsed by the World Health Assembly, it was explained that this would be difficult in 2006 since it had not been submitted to the Executive Board. A campaign for endorsement of the Declaration by organizations such as midwives and other medical associations.

Afternoon Session

Discussion on Nutrition Assessments

Q1: IFRC – Has there been any advancement of tools for the analysis and assessment of the underlying causes of malnutrition?

A1: various organisations have developed tools to assess the underlying causes of malnutrition, following the UNICEF conceptual framework of malnutrition from 1991. IFRC themselves have just finished the food security assessment guidelines which should complement the nutrition assessment. WFP has conducted an integrated food security and nutrition assessment in Dafur, where information was collected from the same households. Data is currently being analysed. Oxfam will share its emergency food security and nutrition guidelines.

Q2: How are organisations planning to use the new WHO growth charts as reference set?

A2: a need was expressed, that the old sets would need to be used to ensure comparison with the new data set for the population. Confusion and un-comparability were feared by various representatives. Therefore, recommendations was formulated, to use both datasets for presentation of nutrition data. Both data sets shall be integrated into any analysis software. For a prevalence assessment, data should be analysed following both charts, as a parallel system. This would probably be needed for the coming years.

Q3: Are organisations using the mean weight for height as indicators?

SCUK is currently doing a review on cost saving and trend monitoring using the mean w/h, but now findings are yet available. This would enable a lighter methodology than 30x30 cluster. Quoting the mean would still be of reference as compared to fixed GAM %age. Results form the Golden paper suggest better sot efficiency, especially when considering surveys and surveillance (e.g. with sentinel sites). It was recognised that oedema would is difficult to consider with mean w/h.

Discussion on Smart

There is need to document further challenges and use of the SMART methodology.

Testing of the SMART methodology has been conducted in different settings and countries and feedback prided to SMART facilitators specifically on the nutrition and mortality components.

Food Security module has not been tested yet and more work on this module is underway.

The future of SMART seemed unclear.

Discussion on LQAS

  1. In the LQAS designs, the confidence intervals of the point estimates are large. What to do to improve and reduce the CI?

The CI of the LQAS design results are similar to what we accept in the 30x30 design. There is room for improving these. Improvement of precision (CI) is aimed at through improved data quality obtained through training, supervision and support during data collection.

  1. LQAS designs are suggesting (identified through statistical simulations) a design effect equal to 1. Would results be different when analysed by CSample.

CSample was used for all results except GAM and SAM. The findings on these tests are not included in this report, but will be reported on later (results suggested no difference).

  1. LQAS designs would definitely reduce the actual workload of the 30x30 surveys and any developments to reduce this workload were encouraged.
  1. It would be interesting to apply the methodology in a wider geographical area and look at time-saving results.

Tuesday Session Q & A session

Clusters

Q. Is OCHA co-ordinating / leading all of the clusters?

A. ??

Q. How will the clusters be co-ordinated?

A1.Formally there is none at the moment.

A2.There is encouragement for each of the clusters to work together, but no formal co-ordination mechanism between them for the moment.

Q.How is measurable accountability within the cluster mechanism envisaged?

A.The lead agency is accountable. Co-ordination is therefore extremely important to make sure that things are done and achieved. Capacity development is thus needed within the agencies. Preparation for this is on going in the pilot countries (Liberia, DRC and Uganda(?)) to address these capacity issues.

Q. How will capacity building within the cluster mechanism be managed in an emergency situation?

A. More than training is needed in this case. The value of the cluster approach is to bring national counterparts on board and to transfer the capacity and give opportunities to understand the cluster co-ordination (this was done in Pakistan). If systems are already in place when an emergency strikes, these systems will be used.

Comment

The FAO is involved in the early recovery cluster, together with ILO in livelihoods in the early recovery group.

Humanitarian Tracking System

Q.The majority of nutrition and mortality data available comes from NGOs & there should be more reflection of this within the clusters.

A.There is agreement from Alessandro on this point and it is one of the aims of the clusters to have more NGO participation.

Q.The tracking system does not track causes but rather measures outcomes.

A.One of the issues of the tracking service is also to look at the determinants of malnutrition and mortality.

Sarahawi

Q.In the Sarahawi experience, have the causes been analysed or the food rations changed as a consequence of these findings?

A1.Cultural practices including the excessive consumption of tea with lots of sugar, cultural aspects of beauty (big is beautiful) and low physical activity levels surely play a role in the obesity levels observed.

A2.The cost of the prevention of obesity through the provision of fresh foods is prohibitive and this type of programme cannot be carried out.

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Summary of Discussions and Q & A session from the Nutrition in Emergencies Working group March 2006