Emergency Nutrition

Hassen M Jerar (MSc)

Department of Human Nutrition

Human Nutrition
Department
 Introduction
• What is an emergency?
– Serious, unexpected and often dangerous
situation requiring immediate action
– Situation that poses an immediate risk to health,
life, property or environment
– A condition that require an urgent intervention to
prevent worsening of the situation
• Although in some situations, mitigation may not be
possible and agencies may only be able to offer
palliative care for the aftermath

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 Emergency Nutrition…
• What is a nutrition emergency?
– Deals with the scientific and conceptual advances
in understanding the causes ,prevention,
mitigation and treatment of malnutrition in
emergencies.
– Any situation where there is an exceptional and
widespread threat to life, nutrition, food security,
health and basic subsistence, which is beyond the
coping capacity of individuals and the community

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 Emergency Nutrition…
• Nutrition emergencies differ in terms of:
– Length (short term, chronic)
– Cause (natural, conflict related, economic-political,
complex)
– Impact (destruction of infrastructure, agricultural,
health and social systems)
– Affected groups (internally displaced persons,
refugees, stable populations)
– Humanitarian response (huge response, no
response at all)
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Causes of nutrition emergencies
– A natural disaster due to climatic or other environmental conditions
such as drought, flooding, major storms, or insects infestation such as
locusts and global warming.
– Armed conflict, war or political upheaval
– Disruption or collapse of the food distribution network and/or the
marketing system of a population. This might be the result of an
environmental, political or economic crisis
– Lack or disruption of the provision of emergency food distribution to
a population experiencing food shortage
– Severe shortages of food combined with disease
pandemics/outbreaks/epidemics such as COVID-19
– Extreme poverty of marginalized populations e.g. the elderly and
urban slum populations who have poor access to water, health care
and livelihoods

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 Famines of the 20th century from East Africa
(Source: Devereux, 2002)
Location Date Causal trigger Excess mortality
Ethiopia (Tigray) 1957-58 Drought and locusts 100,000 – 397,000
Ethiopia (Wollo) 1966 Drought 45,000-60,000
Ethiopia (Wollo and Tigray) 1972-75 Drought 200,000 – 500,000
Somalia 1974-75 Drought 20,000
Ethiopia 1983-85 Conflict and drought 590,000-1,000,000
Sudan (Darfur, Kordofan) 1984-85 Drought 250,000
Sudan (South) 1988 Conflict 250,000
Somalia 1991-93 Conflict and drought 300,000 – 500,000
Sudan (Bahr el Ghazal) 1998 Conflict and drought 70,000

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Nutritional vulnerabilities in emergencies
– Physiological vulnerability
• Young children, pregnant and lactating women, older
people, the disabled and people living with chronic
illness such as HIV/AIDS, TB and COVID19
– Geographical vulnerability
• People living in drought or flood-prone areas or in areas
of conflict
– Political vulnerability
• Oppressed populations
– Social status (Internally displaced and refugees)
• Those who have fled with few resources

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Main nutritional problems of concern in
emergencies
– Acute malnutrition (wasting) especially in
young children
• The clinical forms of this are kwashiorkor
characterised by oedema (swelling due to fluid
retention) and marasmus
– Micronutrient deficiencies
• Especially iron, vitamin A, iodine, folate and
zinc deficiencies (common in disadvantaged
populations)

Department of Human Nutrition

Nutrition assessment in emergencies
• Commonly conducted at the outset and
throughout an emergency
– These include
• Rapid assessments
• Surveys and
• Nutrition surveillance

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 Types of emergency nutrition assessment

Types of Objectives Data collection methods

assessment
Rapid •To verify the existence or threat of an •Direct observations of
assessment nutritional emergency population and environment
•To estimate the number of people •Interviews with key informants
affected •Focus group discussions
•To establish immediate needs •Review of records from
•To identify local resources available available feeding centres
•To identify the external resources and/or health facilities
needed •Rapid surveys
Surveys •To establish the prevalence of •Cluster sample surveys of
malnutrition (including micronutrient under-fives (sometimes women
deficiencies) or older children)
•To identify likely causes of
malnutrition
Nutrition •To identify trends in nutritional •Repeated surveys
surveillance status. •Growth monitoring
Department of Human Nutrition •Sentinel site surveillance 10
Nutrition responses in emergencies
• Include
– Food responses
• General food distribution, emergency school feeding,
food for work, supplementary feeding, micronutrient
fortification and supplementation, and therapeutic care
– Non-food responses
• Support for livelihoods, infant and young child feeding
and health
• Food aid remains the dominant form of response to
nutrition-related problems in emergencies

Department of Human Nutrition

 Typical FOOD responses to nutritional
emergencies
Type of Objectives Description
assessment
General ration •To meet immediate food needs •Free distribution of a
distribution •To protect or recover livelihoods combination of food
•To prevent distress migration and social commodities to the
disruption affected population as a
whole.
Emergency •To contribute to improved scholastic •Food provided either as
school feeding performance a cooked meal or
•To reduce short-term hunger and supplement in school or
nutritional deficiencies as a take-home ration.
•To improve attendance, enrolment and
concentration
•To reduce gender or geographical
disparities
•To contribute to household food
security
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 Typical FOOD responses to nutritional
emergencies…
Type of Objectives Description
assessment
Food for work •To improve the •Wages are paid not with money but
household food security of with food rations to build vital new
participants infrastructure that will increase the
•To create community food security of households or
assets communities.
Supplementary •To reduce prevalence of •Blended foods targeted at children
feeding mild and moderate with mild and moderate malnutrition
malnutrition and pregnant and lactating women as
take home rations or on site-feeding.
Where rates of malnutrition are very
high, food is targeted to all under fives.
Basic medical care is sometimes
provided (e.g. de-worming,
immunisation, vitamin A
supplementation)
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 Typical FOOD responses to nutritional
emergencies…
Type of Objectives Description
assessment
Micronutrient •To prevent •Food aid rations can be improved through
fortification and epidemics of the inclusion of nutrient rich foods,
supplementation micronutrient complementary fresh food items, fortified
deficiency diseases foods or by increasing the size of the general
food ration to facilitate diet diversification
by exchange or trade. Food supplementation
products for home fortification or nutrient
supplements can also be distributed.
Therapeutic care •To treat and •Therapeutic foods such as F75, F100 and
reduce the RUTF are provided to the severely
prevalence of malnourished. Those without medical
severe acute complications treated in the community
malnutrition and while those with medical complications
prevent mortality receive specialised medical care at health
care units or stabilisation centres
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Typical NON-FOOD responses to nutritional
emergencies…
Type of Objectives Description
assessment
Livelihood •To improve household income A variety of interventions are
support for food and non-food needs introduced:
(income & •To support livelihoods including •Cash for work
employment, agriculture •Cash grants
market and •To stimulate local economies •Micro-finance
agricultural •To rebuild community assets •Commodity vouchers
support) •To control prices •Cash vouchers
•Monetization and
subsidised sales
•Market infra-structure
•De-stocking
•Agriculture, livestock &
fishing support

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 Typical FOOD responses to nutritional
emergencies…
Type of Objectives Description
assessment
Infant and To promote exclusive breastfeeding for Breast feeding is
young child the first six months of life promoted through
feeding To promote timely and appropriate counselling and ensuring
support complementary feeding from 6 months that refugees and
and continued breastfeeding until 2 displaced populations
years of age and beyond. have secluded areas for
To ensure that The Code is adhered to in breastfeeding. Caregivers
all emergencies as a minimum should be provided with
requirement and violations are reported. easy and secure access to
The International Code of Marketing of water and sanitation
Breastmilk Substitutes was adopted in facilities, and to the
1981 by the World Health Assembly and appropriate foods to
calls upon breastmilk substitute prepare nutrient-dense
manufacturers and distributors not to food to older infants and
provide free or low-cost supplies to any young children.
part of the health care system.
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 Typical FOOD responses to nutritional
emergencies…
Type of Objectives Description
assessment
Health support •To ensure people have Nutrition-related health interventions
access to services that include:
prevent, diagnose and •Provision of essential health
manage communicable services
diseases •Provision of adequate and safe
•To ensure that all children water supplies and sanitation.
aged 6 months to 15 years •Prevention of overcrowding in
have immunity against refugee and displaced camps
measles. •Immunisation
•To ensure people have •De-worming
access to reproductive •Prevention and management of
health services including communicable diseases (e.g. HIV
clean and safe deliveries and sexually transmitted infections,
diarrhoea, pneumonia)

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Coordination of nutrition in emergencies

• Coordination is a priority
– Huge expansion in the number of organisations
working in nutrition-related areas during
emergencies
– All agencies working in a particular area should
coordinate their activities
– The coordination aims to improve nutrition co-
ordination, capacity building, emergency
preparedness, assessment, monitoring and
surveillance
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Standards, monitoring and evaluation

• Monitoring and evaluation of nutrition

programmes are conducted to ensure
that standards are met during
emergencies
– The standards include the development of Sphere
nutrition, food security and food aid standards

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Advances in nutrition in emergencies
• Include
– Standardisation of nutrition assessments particularly
nutrition surveys
– Understanding of the underlying causes of malnutrition
– Development of more sophisticated early warning systems
to predict famine
– Standardisation of rations provided through food aid
– Greater emphasis on community-based targeting of food
rations
– Development of ready-to-use-therapeutic-foods for
severely malnourished children

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Advances in nutrition in emergencies…
– Greater understanding of the importance of
micronutrients (vitamins and minerals) and the
development of blended foods that can be
fortified with micronutrients
– Active promotion of breastfeeding during
emergencies
– Expansion of non-food interventions
– Introduction of Sphere standards
– Introduction of the coordination mechanisms
– More effective lesson-learning
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Challenges in nutrition in emergencies

• Lack of impartiality in responding to nutrition

emergencies
• Dominance of food aid
• Constraints of the operational environment
• Physiologically vulnerable segments
• Lack of an evidence base for interventions
• Lack of skills and expertise in nutrition in
emergencies

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 Levels of food insecurity during emergency
(Source: Darcy, J and Hofmann, C-A. According to need? Needs assessment and decision-making in the
humanitarian sector. HPG Report 15. September 2003)

Level Responses
Chronic (or periodic) food Typical indicated responses:
insecurity •Longer-term strategies:
•Access to food limited, often support to livelihoods,
seasonally, and diet food security, existing
inadequate for good health public health system;
•High prevalence of chronic social safety nets
malnutrition (stunting) and •Information systems
likely to be some seasonal required: early warning
increase in mortality, systems; health and
morbidity and acute nutrition surveillance
malnutrition (wasting)

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 …
Level Responses
Acute food crisis Typical indicated response:
•A crisis of food access generally •Emergency responses and ‘stepping up’
precipitated by a shock but may of longer-term strategies; targeted
be compounded by longer-term general ration; possibly targeted
vulnerabilities (e.g. poverty, supplementary and therapeutic feeding;
diseases etc) increased health care provision; targeted
•National capacity (or will) to agricultural production inputs; livelihood
respond exceeded (e.g. lack of and food security support.
strategic food reserves) •Information systems required: early-
•CMR and wasting levels remain warning systems (food availability and
normal initially but rise as crisis prices); health and nutrition surveillance;
persists multisectoral assessments (including
household food security, livelihoods,
health and nutrition status, access to
water and sanitation); mortality and
nutrition surveys.

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 …
Level Responses
Extended food crisis Typical indicated response:
•A long-term crisis of food access •Longer-term strategies together with
often associated with poverty, some emergency responses;
lack of investment, erosion of strengthening civil organisations
livelihoods and political (especially of marginalized groups);
marginalisation sustainable livelihood support; targeted
•Wasting levels remain general ration; supplementary and
chronically high and fluctuate therapeutic feeding.
depending on season and level •Information systems required: health
of humanitarian aid (if provided). and nutrition surveillance; multi-sectoral
assessments (including household food
security, livelihoods, health and nutrition
status, access to water and sanitation);
mortality and nutrition surveys.

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 …
Level Responses
Famine Typical indicated response:
•A food crisis that •Major and immediate emergency
results in major response. Blanket general ration
excess mortality distribution; extensive
and very high levels supplementary and therapeutic
of severe acute feeding; health service support.
malnutrition (both •Information system required:
children and adults) health and nutrition surveillance;
repeated multi-sectoral
assessments; repeated mortality
and nutrition surveys.

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 Impact of emergency on nutrition

• Impact on population
– Destruction of infrastructure (roads, markets, etc)
– Large-scale migration
– Breakdown of essential services (health, water,
sanitation, etc)
– Loss of property and business (houses, land,
animals, stock, etc)
– Social disruption

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Impact of emergency on nutrition…
• Impact on households
– Reduced access to food
– Residence in overcrowded settlements
– Lack of water, hygiene, sanitation
– Loss of earnings and access to health services
– Families split

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Impact of emergency on nutrition…
• Impact on individuals
– Malnutrition
– Disease
– Death

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 Key Messages
• Protecting the nutritional status of vulnerable groups affected by
emergencies is essential to prevent acute malnutrition, disease and death
• Malnutrition does not result simply from lack of food but from a complex
mix of factors
• Acute malnutrition is used as one indicator of distress to classify the
severity of nutrition emergency
• Nutrition emergencies are mainly caused by severe shortages of food
combined with disease epidemics
• Acute malnutrition is a major concern during emergencies but chronic
malnutrition and micronutrient deficiencies also arise and have negative
effects
• A range of food and non-food interventions are typically implemented
during an emergency to address and prevent malnutrition

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The international humanitarian
system

Human Nutrition
Department
Coordination mechanisms in emergency
situations
• The international humanitarian system
– Includes a wide range of organisations that have a
role in alleviating human suffering arising from
emergencies
– Included are several of the United Nations (UN)
agencies, the Red Cross movement, non-
government organisations (NGOs) and donor
agencies

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 …
• These organisations are guided by certain
humanitarian principles
– Humanity
– Impartiality
– Independence, and
– Neutrality

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 ….
• Definitions
– Humanity
• The right to receive humanitarian assistance, and to
offer it, is a fundamental humanitarian principle, which
should be enjoyed by all citizens of all countries
– Impartiality
• Aid is given regardless of the race, creed or nationality
of the recipients and without adverse distinction of any
kind. Aid priorities are calculated on the basis of need
alone

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 …
– Independence
• Humanitarian aid is not a partisan or political act and
should not be viewed as such. Aid will not be used to
further a particular political or religious standpoint

– Neutrality
• Humanitarian assistance should be provided without
engaging in hostilities or taking sides in controversies of
a political, religious or ideological nature

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Composition of the UN humanitarian system

• Composed of six key actors:

– United Nations High Commissioner for Refugees (UNHCR)
– World Food Programme (WFP)
– United Nations Children’s Fund (UNICEF)
– World Health Organisation (WHO)
– Food and Agriculture Organisation (FAO)
– United Nations Development Fund (UNDP)
• Each UN agency typically supports a range of
nutrition-related activities in emergencies

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 Roles of the various actors
• Donors
– Foreign governments either provide aid bilaterally
(government to government) or channel
assistance through UN agencies
• NGOs (local and international)
– Undertake many different activities in nutritional
crises but usually on a relatively small scale
• National Governments
– Responsibility for coordination of relief rests with
the authority of the national governments
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 Types of nutrition-related activities UN
agencies support in an emergency
Agency name Activities
United Nations High •Food security and nutrition needs assessment of refugees and
Commission for monitoring (jointly with WFP)
Refugees (UNHCR) •Monitoring nutrition status of refugees
•Nutrition surveys and surveillance systems
•Ration planning (jointly with WFP)
•Distribution of food commodities
•Selective feeding
•Monitoring micronutrient status and provision of
supplements
•Mobilising complementary food commodities (local fresh
foods, therapeutic milk)
•Transport and storage of foods

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Agency name Activities
World Food •Food security assessment and monitoring
Programme (WFP) •Transportation and distribution of general rations
•Commodity pipeline monitoring
•Food basket monitoring
•Monitoring food distribution
•Emergency school feeding
•Feeding for vulnerable groups including orphans, people living
with HIV and AIDS, TB
•Provision of blended or fortified foods
•Provision of food for selective feeding

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Agency name Activities
United Nations •Support for nutrition co-ordination at national level
Children’s Fund •Technical support
(UNICEF) •Assessment and communication on the nutrition situation of
children and women
•Provision of micronutrients (vitamin A, iron, iodine, folic acid,
zinc, multivitamins and minerals)
•Provision of nutritional supplements (therapeutic milk, F-75,
F-100, ReSoMal and vitamin or mineral preparations)
•Treatment of severe acute malnutrition and training
•Feeding of moderately malnourished children and women
•Infant feeding in emergencies
•Support for nutrition status monitoring and nutrition
surveillance
•Provision of equipment and supplies for feeding
•Capacity development in NIE

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Agency name Activities
World Health •Nutrition surveillance
Organisation •Technical nutrition support
(WHO) •Capacity development in NIE
Food and •Assessment of the food security and nutrition
Agriculture situation
Organisation •Provision of livelihoods support e.g. seeds and
(FAO) farm tools, fertilizer, livestock, fishing
equipment
•Technical support for establishing home
gardens and other food security-related
activities

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 Key Messages
• Humanitarian coordination is about delivering assistance in a
cohesive and effective manner in order to save lives and
reduce suffering among those affected
• Humanitarian coordination is about delivering the right
assistance, to the right place, and at the right time
• Responsibility for coordination of relief rests with the national
government authority controlling the territory affected by the
emergency
• A number of different agencies (e.g. UN, NGO, Red Cross)
support nutrition-related activities during emergencies
including nutrition assessment, delivery of food aid, selective
feeding programmes

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Measuring Malnutrition in
Emergencies

Human Nutrition
Department
 Introduction
• The prevalence (rate) of malnutrition is
frequently assessed in emergencies and
used to
– Determine response
– Identify target groups and geographical areas at
risk.

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 …
• Malnutrition can be assessed through
anthropometry (body measurements)
– Age
– Sex
– Weight
– Height (or length in children under 24 months or
under 85 cm in height)
– Edema (fluid retention) and
– Mid upper arm circumference (MUAC)

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 Building Blocks of Anthropometry

• The four building blocks or measures used to

undertake anthropometric assessment are:

Department of Human Nutrition

Measuring malnutrition in children
• The nutritional indices commonly calculated
for young children are:
– Weight for height
• A measure of wasting or acute malnutrition
– Height for age
• A measure of stunting or chronic malnutrition
– Weight for age
• A measure of underweight
– MUAC
• A measure of wasting or acute malnutrition
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Classification of malnutrition in children
Nutrition indicator Well nourished Moderate Severe
malnutrition malnutrition
Edema No No Yes
Weight for height +2 to –1 SD -2 to -3 SD <-3 SD
(wasting) (90 to 120%) (70 to 79%) (<70%)
Height for age +2 to –1 SD -2 to -3 SD <-3 SD
(stunting) (95 to 110%) (85 to 89%) (<85%)
Weight for age -2 to -3 SD <-3 SD
(underweight) (60 to 80%) (<60%)
MUAC >13.5 cm <12.5 cm < 11.5 cm

MUAC for <-3 SD

age/height

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Measuring malnutrition in adults
– Acute malnutrition in adults is measured using body mass
index (BMI) or weight/height2
– MUAC in combination with clinical signs (inability to stand,
evident dehydration and presence of oedema) is often
used to screen adults for admittance to feeding centres
– MUAC is particularly important for pregnant women, as
body weight is greater due to the growing foetus.
– There is no international consensus on the cut-off points
for classifying severe malnutrition in adults using BMI or
MUAC
• The following are commonly used during emergencies

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Classification of malnutrition in adults
Nutrition Well nourished Mild Moderate Severe
indicator malnutrition malnutrition malnutrition
Edema No No No Yes
Body Mass ≥ 18.5 18.4 to 17 16.9 to 16 < 16
Index
MUAC (Ferro- <22 cm women -2 to -3 SD < 16
Luzzi 1996) <23 cm men (85 to 89%)
MUAC (Collins >18.5 cm <18.5 to 16 cm < 16
2000) plus clinical
signs

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 Key Messages
• Nutritional indices are calculated by comparing an individual’s
measurements with that of a reference/standard population
• In emergencies, weight for height in children from six to 59
months is the nutritional index of most concern because it
reflects recent conditions while young children are generally
the most nutritionally vulnerable
• Adult malnutrition is assessed through body mass index (BMI)
or MUAC
• Global acute malnutrition (GAM) refers to moderate and
severe or SD <-2 while severe acute malnutrition (SAM) refers
to severe or SD <-3

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Food and Nutrition Security in
emergencies

Human Nutrition
Department
 Introduction
• Food security
– Is a situation that exists when all people, at
all times, have physical, social and economic
access to sufficient, safe and nutritious food
that meets their dietary needs and food
preferences for an active and healthy life

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 …
• Food self-sufficiency
–Being able to meet consumption needs
(particularly for staple food crops) from
own production rather than buying
or importing

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 Differences b/n food security and
food self-sufficiency
• Food security
– Being able to get adequate and sufficient food,
regardless of where it comes from
• These days, it comes from all over the world
• We are able to buy food from all over the world
because we have the money to purchase the food
• Food self-sufficiency
– Is when we grow all the food we need, right here
at home

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 …
• There is a long-standing debate on whether
food self-sufficiency is a useful strategy to
achieve food security
• Supporters of this proposition argue that relying on the
market to meet food needs is a risky strategy because
of volatility in food prices and possible interruption in
supplies
• The opposing view is that it is costly for a household (or
country) to focus on food self-sufficiency rather than
producing according to its comparative advantage and
purchasing some of its food requirements from
the market

Department of Human Nutrition

 Nutrition security
– Access of all people at all times to sufficient food,
including adequate utilization and absorption, in
order to be able to live a healthy and active life
– A household achieves nutrition security when it
has secure access to food coupled with a sanitary
environment, adequate health services and
knowledgeable care to ensure a healthy life for all
household members

Department of Human Nutrition

Conceptual framework of food security and
nutritional status at household level

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 Energize Agriculture - NSA

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How can agriculture be energized to become a more powerful tool to tackle

the persistent problems of food insecurity, malnutrition and poor health?

Department of Human Nutrition

 Nutrition Sensitive Agriculture (NSA)

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Department of Human Nutrition

Nutrition and Agriculture

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Suggested strategies for NSA
– Diversify production of vegetables and fruits with micro-nutrient rich
varieties
– Promote production of animal sourced foods for improving diets and
nutrition
– Protect biodiversity to protect the quality of diets
– Select crops based on nutritional content in addition to yields and
market value
– Breed plants and livestock that enhance nutritional quality
– Reduce post-harvest losses via improved handling, preservation,
storage, preparation, and processing techniques
– Train extension workers and households in basic nutrition and food
preparation skills to ensure that food security is translated into
nutrition security

Department of Human Nutrition

 Food security assessment
• Three components to food security
– Availability
• Sufficient quantities of appropriate food are available from
domestic production, commercial imports or food assistance
– Access
• Adequate income or other resources to access appropriate food
through home production, buying, barter, gifts, borrowing or food
aid
– Utilization
• Food is properly used through appropriate food processing and
storage practices, adequate knowledge and application of nutrition
and child care, and adequate health and sanitation services

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 Food security assessment
• In emergencies, the way people obtain food is
often disrupted
– Doing emergency food security assessments
(EFSA) is essential to plan interventions to protect
food security and potential malnutrition through
distribution of food aid or cash, agricultural and
economic support

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Approaches to food security assessment

• There is no single standard method for

assessing food security in emergencies
– Different agencies have developed their
own approaches and there is huge variation
in
• The indicators collected
• The methods used, and
• The degree to which nutrition data are included

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Approaches to food security assessment…

• EFSA approaches can be classified

into three groups
–Early warning and surveillance
approaches
–Economic and livelihood approaches
–Nutritional status approaches

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 Early warning and surveillance
approaches
• Early warning
– has been described as a process of information
gathering and policy analysis to allow the
prediction of developing crises and action to
prevent them or contain their effects
– Is related to preparedness and contingency
planning on the one hand, and preventive
intervention on the other
– Is most commonly used to predict crisis rather
than to assess need
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 …
• This form of assessment depends on the continuous
collection and interpretation of information
– The system rely heavily on secondary data (information
already collected by another agency), which come mainly
from national government statistics on rainfall, crop
production, prices and imports/exports and from satellite
imagery
– Such systems have generally been successful in predicting
impending food crises, although not so good at pin
pointing exactly when a crisis is likely to occur

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 …
• Most food security monitoring systems collate
data from the following four sources:
– Agricultural production such as crop production
and livestock farming
– Markets such as domestic and international trade
(import/export), prices of key staples and livestock
– Vulnerable groups such as monitoring poverty
– Nutrition and health status of populations

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Economic and livelihood approaches
• These approaches view food security within a
broad economic or livelihoods (means of
living) context
– One-off surveys are usually carried out and
information collected on a variety of indicators
both quantitative (based on amounts or numbers)
and qualitative (based on qualities or opinions)
– The information is used to estimate the household
food deficit and to project what the deficit may be
in the future
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Nutritional status approaches
• Food security has an indirect effect on
nutritional status
– Nutritional status approaches tend to be
one-off surveys collecting a variety of
information

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 Implementation of food security
assessment
• Most EFSAs are carried out to address four
broad objectives
– Estimation of the severity of food security;
– Projection of future food security;
– Identification of vulnerable groups;
– Identification of appropriate interventions.

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 Steps t to implement EFSA
• Step 1: Preparation
– Develop hypotheses on the effects of the crisis on food security and nutrition to guide
information requirements and most appropriate assessment approach
– Formulate clear objectives
– Select the assessment team and draft terms of reference based on the objectives, time
and resources available.
– Define the assessment area. A clear geographical, livelihood-related or emergency-
affected definition of the assessment area is needed. This will ensure that appropriate
secondary information can be collated and help to decide which locations should be
visited to collect primary information.
– Find out what other organisations are doing assessments, where and why and make sure
the assessment design is complementary and does not duplicate.
– Organise logistics and finances (travel plan, field equipment, transport, translators etc.)
– Inform authorities and obtain authorisation to visit assessment areas.
– Train the team on the assessment methodology and ensure the team is sensitised to
cultural issues.

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 Steps t to implement EFSA…
• Step 2: Secondary information collection
– Collate and analyse secondary information (data
collected from a secondary source rather than
directly from the affected area)
– Identify sources of secondary information from
national capital, provincial and district town level.
The most common sources are government
officials, local authorities, non-governmental
organisations (NGOs) and United Nations (UN)
agencies

Department of Human Nutrition 74

 Steps t to implement EFSA…
• Step 3: Primary information collection
– Collect and analyse primary information (data collected
directly from the affected area)
– Identify which food security indicators will be collected.
Food security, unlike malnutrition, cannot be measured
through a single indicator. Instead multiple measures have
to be used
– Examples of indicators classified by the three pillars of
food security and dietary intake and coping strategies
indices are used as a proxy measure of food security.

Department of Human Nutrition 75

Steps t to implement EFSA…
– Identify what methods of data collection are appropriate
and viable. These may include:
• Questionnaires. Technical expertise is required to develop a good
questionnaire. An alternative is to develop a checklist that includes
areas to cover.
• Measurement. Assessment of malnutrition through measurement
may be done at the same time as an EFSA.
• Observation. Observation of the environment can help verify or
triangulate information collected using other methods.
Information that can be obtained through observation include
condition of livestock, crops, infrastructure, the environment, the
population, mills, marketplaces and shops.

Department of Human Nutrition 76

Steps t to implement EFSA…
• Interviews. Interviews are usually semi-structured, i.e. they
include some structured and some ‘open-ended’ questions.
Interviews can be with households and/or individuals (key
informants). Household interviews can provide information about
the household economy. Key informant interviews are carried out
with key people who have specific knowledge about certain
aspects of the community such as traders, school teachers,
religious leaders or local government officials.
• Focus group discussions involve 6-12 people to discuss a subject of
common interest and usually include those from a similar
backgrounds such as people from the same livelihood group or a
group of women. Focus groups are useful to investigate an issue in
detail from a particular perspective
– Identify which tools or techniques are appropriate and
viable
Department of Human Nutrition 77
 Indicators of food security
Categories of indicators Examples of indicators
Food availability •Rainfall
•Crop production
•Livestock holdings and status
Food access •Income and food sources
•Essential expenditure
•Assets
•Livelihood strategies
•Market prices of key staples and assets
•Coping strategies
Food utilization •Nutritional status
•Health status
•Feeding practices
•Food consumption
Dietary intake •Individual dietary diversity score
•Household dietary diversity score
•Food consumption score
•Cornell-Radimer hunger scale
•Household food insecurity access scale
Department of Human Nutrition 78
Coping strategies •Coping strategies index
 Steps t to implement EFSA…
• Step 4: Analysis
– Analyse the data collected during the assessment. This helps to
identify what information should be collected next, what might be
missing or what may not be making sense. All analyses should include:
• Problem identification
• Causes of the problem
• Future risks
– Include an analysis of the political, economic, social, institutional,
security (conflict where appropriate) and environmental conditions.
– Develop scenarios as a way of forecasting the future.
• What is likely to happen given a range of different events/factors
– Identify and analyse response options
• Interventions should be guided by an assessment of their feasibility and
appropriateness.

Department of Human Nutrition 79

 Steps t to implement EFSA…
• Step 5: Report writing and dissemination of results
– Produce a succinct report and disseminate findings to
• Government, donors and other humanitarian actors for programming,
resource mobilization and advocacy purposes
• Managers, who require reliable and transparent information to make
sound decisions about the scale and scope of a crisis
• Programmers, who rely on EFSA reports for designing interventions that
are appropriate and operationally feasible
– Disseminate a summary report with key findings within a few days of
completing the assessment.
– Disseminate the final report which should be clear and concise
avoiding language that could be ambiguous or misunderstood such as
jargon and the excessive use of acronyms.
– Feedback the findings to all those involved in the fieldwork including
the affected community and local authorities.

Department of Human Nutrition 80

The priority matrix

Department of Human Nutrition 81

 Key messages
• Inadequate food security is one of the three
underlying causes of malnutrition
• It is vital to do EFSAs to plan interventions to protect
food security and ultimately nutritional status
• Food security cannot be measured through a single
indicator so multiple measures have to be used
• Including nutrition information in a food security
assessment improves the quality of the results and
ensures an appropriate response

Department of Human Nutrition 82

Emergency Nutrition
Interventions

Human Nutrition
Department
 Introduction
• In emergency situations
§ Nutritional security is often severely threatened
causing increased risk of malnutrition, disease and
death.
§ Emergency health workers/organizations have the
responsibility to try to cure the malnourished,
prevent malnutrition amongst the vulnerable and
promote adequate distribution of food to allow a
healthy existence.

Department of Human Nutrition 84

 Potential Interventions
• A range of potential interventions for alleviation of nutritional
emergencies
§ Emergency food interventions
• Provision of food is the first relief priority in nutritional
emergencies
§ Other complementary public health interventions
• Prevention and treatment of the most prevalent diseases
• Disease prevention, including prompt attention to immunization
and to the various aspects of environmental health (e.g. safe water
supply, sanitation facilities, etc.), should be a priority

Department of Human Nutrition 85

Emergency food interventions
• 1. General Food Distribution (GFD) program
provides
§ Food to an affected population in order to sustain
life by ensuring that food is indeed available to,
and accessible by, all persons experiencing food
crises and famines
§ The aim of GFD is to
• Cover the immediate basic food needs of a population
• Prevent deterioration of nutritional status leading to
malnutrition, famine and death.

Department of Human Nutrition 86

 …
§ 2. Selective feeding programs
• Aim to cover special nutritional needs of
certain vulnerable groups:
§ Supplementary Feeding Programs
» Blanket Supplementary Feeding
» Targeted Supplementary Feeding
§ Therapeutic Feeding

Department of Human Nutrition

Supplementary feeding programs (SFPs)

• SFPs are implementation modalities for

Moderate Acute Malnutrition Management
(Care plan B)
– There are two types of SFPs
• Blanket or
• Targeted

Department of Human Nutrition 88

Blanket Supplementary Feeding Program
(BSFP)
• Is normally an emergency response for drought or
other nutritional emergencies
• Is a food supplement to all members of a specified at
risk group, regardless of whether they have MAM or
not
• Is usually implemented in combination with the
General Food Distribution (GFD)
• It can also be implemented as a standalone program
(while waiting for the GFD to be established) or as
short term measure during a seasonal hunger gap

Department of Human Nutrition 89

 …
• Irrespective of their nutrition status, young children,
PLW, the elderly, disabled and chronically sick are
included in beneficiary lists of communities receiving
relief food to
– Benefit from an extra ration of super cereal plus or
fortified Corn Soya Blend (CSB+)
• Individual nutritional status is not monitored during
the duration of the BSFP because
– The objective is to provide nutritional support at
population level (i.e. prevent development and/or
deterioration of malnutrition)

Department of Human Nutrition 90

Timing of the initiation of BSF
§ The initiation of Blanket SFPs is indicated in
critical situations when one or a combination of
the following circumstances is present:
• At the onset of an emergency when general food
distribution systems are not adequately in place
• Problems in delivering/distributing the general ration
• Prevalence of Global Acute Malnutrition > 15% [GAM –
percentage of child population (6-59 months) with WFH
z - score is < -2 and/or manifesting bilateral edema] in
presence of aggravating factors

Department of Human Nutrition 91

 …
• Prevalence of Severe Acute Malnutrition > 5%
[SAM – percentage of child population (6-59
months) with WFH z – score < -3 and/or
manifesting bilateral edema]
• Anticipated increase in rates of malnutrition
due to seasonally induced epidemics
• In case of micronutrient deficiency outbreaks,
to provide micronutrient-rich food to the target
population

Department of Human Nutrition 92

 …
• Timeframe
§ Blanket SFPs should be needed only temporarily – average
time limit of 3 months
• Target group
§ All children 6 – 59 months (< 110cm) and all individuals of
other vulnerable groups including elderly, medically
referred cases (malaria, tuberculosis, HIV/AIDS, etc.) and
certain social groups (orphans, disabled persons, refugees,
IDPs, etc.)
§ Pregnant women from time of confirmed/detected/visible
pregnancy - usually between 4 & 6 months
§ Lactating mothers until 6 months post-delivery

Department of Human Nutrition 93

 Closing BSFP
• BSFP can be closed down when some or most of the following
conditions/criteria are met:
§ ⇒ When the prevalence of GAM among children under 5
is < 15% with no aggravating factors OR
§ ⇒ When the prevalence of GAM among children under 5
is < 10% in presence of aggravating factors
§ ⇒ When there is reliable and adequate food accessibility
and availability meeting minimum nutritional
requirements
• Food security may be ensured through general food distribution or
local production but GFD should continue for a minimum of 4-6
months after SFP closure

Department of Human Nutrition 94

 …
– ⇒ When no seasonal deterioration of nutritional
status is expected/anticipated
– ⇒ When mortality among children under 5 years
is < 2/10,000/day AND the crude mortality rate is
< 1/10,000/day
– ⇒ When no major population influx (coming in) is
expected
– ⇒ When there has been a consistent decrease in
SFP admissions/beneficiaries for 2 consecutive
months

Department of Human Nutrition 95

 Targeted Supplementary Feeding
• Provides nutritional support to individuals with MAM
• Generally targets children 6-59 months, pregnant
and breastfeeding mothers and other nutritionally
at-risk individuals
– Targeted children with MAM will receive Plumpy Sup or
super cereal plus with regular monitoring of their
nutritional status
– For all the other groups, super cereal plus or fortified Corn
Soya Blend (CSB+) is given

Department of Human Nutrition 96

 TSFP implementation
• Monthly/bi-monthly distribution
– Admission depends on a diagnosis of MAM
through anthropometry at health post (HP) level
by the health extension workers (HEWs) following
the admission criteria
– On admission and on each distribution day, a
standard protocol is followed which includes
assessment of nutritional status, provision of
deworming tablet, Vitamin A supplement and
health/nutrition promotion.

Department of Human Nutrition 97

 …
– For management of MAM among children 6-59
months
• Plumpy Sup of one sachet (92gm) per day or super
cereal plus 200gm per day is given
– For the other groups, super cereal 250gm per day
or CSB+ 208gm per day is provided
• When CSB+ is given 31gm of fortified vegetable oil is
added to the ration
– Individuals are discharged based on their
anthropometric status and according to pre-
defined criteria
Department of Human Nutrition 98
 …
– The quarterly Community Health Days (CHD) or bi-
annual Enhanced Outreach Strategy (EOS)
screening exercises are used for
• Identification of malnourished children for targeted
supplementary feeding in food insecure priority one
Woredas
• This is not to replace the routine screening and
treatment of the moderately malnourished, rather to
use the opportunity as “mopping up” all cases that are
missed during routine screening

Department of Human Nutrition 99

 …
• OTP Discharge Rations
– Children discharged from OTP will receive
• One sachet (92gm) of RUSF or
• 200gm of Super cereal plus per day on monthly
basis for two consecutive months

Department of Human Nutrition 100

Management of acute malnutrition in
other groups
• Similar protocols of acute malnutrition management are used
for all patients irrespective of their HIV, TB or other infection
status
– They respond well to the treatment regimen, usually regaining
their appetites and gaining weight at the same rate as other
patients
– A harmonized treatment algorithm has been developed
mapping the treatment of severely and moderately
malnourished children with or without communicable disease.
– The treatment modalities will remain the same
– In the event when the cut-off criteria for admission are
different, it is reflected in the harmonized algorithm

Department of Human Nutrition 101

 Establishment of TSFP
§ Targeted SFPs must be initiated when
there are
• Significant levels of malnutrition and/or
• The general ration is not adequate for
nutritionally vulnerable groups
§ Reliable nutrition survey data must guide both
the initiation process and the targeting of
admissions

Department of Human Nutrition 102

 Initiation of TSFP
• TSFP is indicated in serious situations when:
§ Prevalence of GAM > 15%
§ Prevalence of GAM 10 - < 15% in the presence of
aggravating factors
• In decision-making for the establishment of Targeted
SFPs, one must consider the relationship between the
prevalence of malnutrition and other factors such as
CMR and U5MR, morbidity rates, season/harvest,
options for coping mechanisms, etc
• Trends in nutritional status/nutrition survey results
must also be considered
Department of Human Nutrition 103
 Closing TSFP
• Priority conditions recommended prior to
closure of a Targeted SFP:
§ Linkage to ENCU/DPPC and MOH (through existing
health facilities) for follow-up monitoring of future
situation including status of general food
distribution (GFD)
§ Capacity building of personnel from local health
centers/clinics through appropriate training to
assure close monitoring and referral of severely
malnourished children
Department of Human Nutrition 104
 …
§ Introduction of the use of weight-for-height
indicator in local health facilities in addition to
weight-for-age indicator used currently for
screening and management of malnutrition
§ Collection of appropriate data to determine if
established closure criteria for SFPs have been
fulfilled
§ Linkage with organizations working on
rehabilitation/post-emergency activities where
possible

Department of Human Nutrition 105

 …
• TSFP can be closed down when some or most
of the following conditions/criteria are met:
• When the number of malnourished children under 5 is
reduced so that the prevalence of global acute
malnutrition is < 10% with no aggravating factors
• When there is reliable and adequate food accessibility
and availability meeting minimum nutritional
requirements. Food security may be ensured through
general food distribution or local production (GFD
should continue for a minimum of 4-6 months after SFP
closure)

Department of Human Nutrition 106

 …
• When no seasonal deterioration of nutritional
status is expected/anticipated
• When mortality among children under 5 years is <
2/10,000/day AND the crude mortality rate is <
1/10,000/day
• When no major population influx is expected
• When there has been a consistent decrease in SFP
admissions/beneficiaries for 2 consecutive months

Department of Human Nutrition 107

 …
§ Targeted SFPs may be closed when some or
most of the above closure criteria/conditions
are met with the following observations:
• In some situations where prevalence of GAM is <
5% in presence of aggravating factors or < 10%
with no aggravating factors, the absolute number
of malnourished children remains considerable.
• A progressive decreasing trend in malnourished
individuals is observed in screening activities

Department of Human Nutrition 108

 …
• In the instances where the GAM is within a “poor”
range (between 5 & 10%) and in an unstable/
insecure situation, the closure of a Targeted SFP may
not be appropriate and may be maintained as a
‘safety net’
– Subsequently, a nutrition survey must be carried out in
order to verify the actual number of malnourished
children and to justify the future closing down of the
Targeted SFP.

Department of Human Nutrition 109

 Area prioritization
§ The prioritization of areas for the allocation of
supplementary food is based on the use of
Food Insecurity Indicators together with other
nutrition-related data
§ Areas can be categorized into
• Poor/Risky
• Serious
• Critical

Department of Human Nutrition

 …
• Priority I – CRITICAL:
• Nutritional survey data of acceptable standards that indicates a
prevalence of GAM >15% in the presence of aggravating factor
and/or SAM > 5%
• In the absence of nutrition survey data, verified reports of Phase III
Famine indicators triangulated when possible with objective and
quantitative indicators of increased malnutrition such as records
from MOH health facilities demonstrating abnormally high levels
of severe acute malnutrition (< 60% WFA*) expressed as total
numbers or proportion of < 60% WFA in clinic population
• Presence of Therapeutic Feeding Center or Program
§ In Ethiopia, growth monitoring utilizes weight for age.

Department of Human Nutrition

 …
• Priority II – SERIOUS:
§ Nutritional survey data of acceptable standards
that indicates a prevalence of GAM >15% with no
aggravating factors or GAM 10% - < 15% in the
presence of aggravating factors
§ Significant change in nutritional status when
compared to historical data – immediately verified
by data from standard nutrition surveys
§ Verified reports of Phase II Food Crisis indicators

Department of Human Nutrition 112

 …
• Priority III – POOR/RISKY:
§ Nutritional survey data of acceptable standards
that indicates a prevalence of GAM 10% - < 15%
with no aggravating factors
§ Verified reports of Phase I Food Shortage
indicators

Department of Human Nutrition

 Food insecurity indicators
• Phase I - Food Shortage Indicators
• Prolonged drought/onset of natural disaster
• Increased hoarding of grains by dealers
• Increased price of staple food
• Rise in price ration of staple grain to prevailing wages
• Seed shortage or increased cost of seed
• Increase in sales of livestock and decrease in average sale price (other than oxen)
• Increase in deaths among livestock in crop dependent areas
• Unusual sales of possessions such as roofing, jewelry, furniture, utensils, etc. (non-productive
assets)
• Widespread sale/leasing of land at abnormally low prices
• Defaults on loans/credit or increase in lending rates in the informal sector
• Political instability as a result of food shortage and affecting food availability and access
• Changes in consumption levels (e.g. reduction in meal frequency and quantity eaten)
• Consumption of animals by pastoralists
• Consumption of non health-threatening wild or famine foods

Department of Human Nutrition 114

• Phase II - Food Crisis Indicators:
§ Prolonged migration (men do not return from seasonal
migration)
§ Seed consumption
§ Consumption of health-threatening famine foods
§ Widespread sale of oxen and decrease in average sale price in
crop dependent areas
§ Widespread death of livestock in livestock dependent areas
§ Stealing of crops (standing or harvested)
§ Community structure collapses; skilled and educated people
(e.g. health staff) migrate

Department of Human Nutrition 115

• Phase III Famine Indicators:
§ Migration of entire households in search of food
§ Excessive unseasonal morbidity e.g. diarrheal
disease
§ Excessive mortality (under 5 population >
2/10,000/day or general population >
1/10,000/day)
§ Severely reduced consumption levels

Department of Human Nutrition 116

 Aggravating factors
§ Poor household food availability and accessibility, general food ration
below mean energy requirement
§ Crude mortality rate >1 per 10,000 per day
§ Epidemic of measles, whooping cough (pertussis), cholera, shigella and
other important communicable diseases
§ High prevalence of respiratory or diarrheal diseases
§ High prevalence of HIV/AIDS
§ Outbreaks of diseases (malaria, etc.)
§ Low levels of measles vaccination and vitamin A supplementation
§ Inadequate safe water supplies and sanitation
§ Inadequate shelter
§ War and conflict, civil strife, migration and displacement

Department of Human Nutrition 117

 Allocation Plans
• Once the areas have been prioritized, allocation of
supplementary food should be based on the
following guidelines:
§ In the absence of sufficient resources, only Priority I
areas will receive supplementary food, but Priority II
areas should also receive supplementary food
whenever possible.
§ As malnutrition cannot be addressed with a single
distribution of supplementary food, Priority I areas will
receive a minimum three-month allocation

Department of Human Nutrition 118

Classification Tool for Implementation of
Selective Feeding Programs

Department of Human Nutrition 119

 Types of food distribution
§ 1. On-site feeding or wet supplementary feeding
• Supplementary feeding intended for moderately
malnourished individuals can be distributed through
on-site or wet feeding programs
• Involves the daily distribution of cooked food/meals at
feeding centers
• Malnourished children must be brought to the centers
by parents or caregivers where they are provided 2 – 4
meals to be consumed on-site daily

Department of Human Nutrition 120

Types of food distribution…
§ 2. Take-home or dry supplementary feeding
• Supplementary feeding intended for moderately
malnourished individuals can be distributed through
take-home or dry feeding programs
• Involves the regular (weekly or bi-weekly) distribution
of food in dry form to be taken home for preparation
and consumption
• In comparison, dry rations are usually larger than wet
ones, because beneficiaries may share with siblings or
other family members.

Department of Human Nutrition 121

 Comparison

Department of Human Nutrition 122

Department of Human Nutrition 123
 Therapeutic Feeding Programs

§ Provide a rehabilitative diet together with

medical treatment for diseases and
complications associated with the presence of
severe acute malnutrition
§ Aim of TFPs is to
• Reduce mortality among acutely severely malnourished
individuals and to restore health through rehabilitation
• Reduce mortality by providing intense medical and
nutritional therapy.

Department of Human Nutrition 124

 Initiation of TFPs
§ TFPs must be initiated when:
• The number of severely acutely malnourished
individuals exceeds the capacity of the local health
system/facility OR

• When the prevalence of severe acute malnutrition

is > 3% [SAM – percentage of children (6-59
months) with WFH z-score < -3 and/or
manifesting bilateral edema]

Department of Human Nutrition 125

 TFP approaches
• TFP is a combination of
– Inpatient (SC) and
– Outpatient (OTP) therapeutic feeding for the
treatment of severe acute malnutrition
• Implementation modalities for SAM
management are based on three phases
– Phase 1 Inpatient
– Transition Phase
– Phase 2 Inpatient

Department of Human Nutrition 126

Phase 1 Inpatient (Care plan C inpatient)
– Patients with failed appetite, and/or with a major medical
complication are initially admitted to an in-patient facility
for Phase 1 treatment
– All children with +++ oedema or with Marasmic
kwashiorkor are also first admitted to phase 1 inpatient
care
– The formula used during this phase (F75) promotes
recovery of normal metabolic function and nutrition-
electrolytic balance
– Rapid weight gain at this stage is dangerous, that is why
F75 is formulated so that patients do not gain weight
during this stage

Department of Human Nutrition 127

 Transition Phase
– Exists only for those children that start treatment from
phase 1 above
– Is a 24 hour F100 or RUTF introduction phase where the
health worker ensures that there is adequate intake of
RUTF and regain of appetite to enable continuation of the
rest of the treatment on an ambulatory basis at OTP
– The quantity of F100 given in transition phase is equal to
the quantity of F75 given in Phase 1
– As this is resulting in a 30 percent increase in energy
intake, the weight gain should be around 6 g/kg/day
• This is less than the quantity given, and rate of weight gain
expected, during Phase 2

Department of Human Nutrition 128

 Phase 2 Inpatient
– Meant for children who cannot be discharged to
OTP soon after stabilization
– This group of severely malnourished may remain
to continue Phase 2 at in-patient either
• Temporarily for family or social reasons, or
• Because there is no OTP service in reasonable distance
from their home environment
– During this phase, the patients start to gain weight
as F100 or RUTF is introduced.

Department of Human Nutrition 129

Outpatient treatment program (OTP), care
plan C– outpatient)
• Patients enter OTP whenever they
– Have good appetites and no major medical complications
or
– Have + and ++ oedema and do not have marasmic
kwashiorkor
• In OTP, they are given RUTF according to look-up
tables
– Those formulas are designed so that patients rapidly gain
weight (more than 8 g/ kg/day)
– The look-up tables are scaled so that the same tables can
be used to treat patients of all weights and ages

Department of Human Nutrition 130

Admission procedures and triage

Department of Human Nutrition 131

Criteria for classification of acute malnutrition among
young Infants 0 to 6 months

Department of Human Nutrition 132

Criteria for classification of acute malnutrition among
children 6 to 59 months of age

Department of Human Nutrition 133

Criteria for classification of acute malnutrition among
children 5 to 18 years of age

Department of Human Nutrition 134

Criteria for classification of acute malnutrition
among adults 18 years or older

Department of Human Nutrition 135

 Closure of TFPs
§ Priority conditions recommended prior to
closure of a TFP:
• Linkage to ENCU/DPPC and MOH (through existing
health facilities) for follow-up monitoring of future
situation including status of GFD
• Capacity building of personnel from local health
centers/clinics through appropriate training to
assure close monitoring and referral of severely
malnourished children

Department of Human Nutrition 136

 Closure of TFPs…
– Introduction of the use of weight-for-height
indicator in local health facilities in addition to
weight-for-age indicator used currently for
screening and management of malnutrition
– Collection of appropriate data to determine if
established closure criteria for TFPs have been
fulfilled
– Linkage with organizations working on
rehabilitation/post-emergency activities where
possible

Department of Human Nutrition 137

 Closure of TFPs…
§ TFPs may be closed when the following criteria/conditions are
met and the capacity of the local health facilities has been
evaluated:
• Decrease in admissions to TFP over 2 consecutive months AND the
number of inpatients in the TFC/Phase I of TFP is within the capacity of
the local health system
• Under-five mortality rate < 2/10,000/day
• Prevalence of SAM is following a downward trend and must be evaluated
in the context of population size and capacity of local health system
• Prevalence of GAM is < 10% in presence of aggravating factors
• Referral facility for therapeutic feeding available
• Presence of targeted SFP for referral/follow-up of TFP participants

Department of Human Nutrition 138

Summary of interventions on feeding
programs

Department of Human Nutrition 139

 Complementary Public Health
Interventions
§ Although the provision of food is the first relief priority in
nutritional emergencies, the close link between health and
nutrition must be re-emphasized
• Disease contributes to malnutrition and malnutrition makes
individual more susceptible to disease and consequently more
likely to die
• It is crucial that emergency nutrition interventions include
appropriate measures for prevention and treatment of the
major/most prevalent diseases and deficiencies linked to
nutritional status
• In Ethiopia, these deficiencies/ diseases include vitamin A and Iron
deficiencies, measles, diarrheal disease due to intestinal parasites
and malaria.

Department of Human Nutrition 140

 IYCF interventions
• Why is IYCF key in emergencies?
§ Disruption and displacement of populations in emergency situations
greatly impacts on the health and nutrition status of infants and young
children
§ During emergencies, the rates of child mortality can soar from two to
70 times higher than average and even in previously healthy
populations, child morbidity and crude mortality rates can increase
twenty-fold
§ Adequate nutrition and care of children has been identified as one of
the key factors to promote child health and stability and IFE support
has consequently become a major strategy in reducing child morbidity
and mortality during humanitarian emergency response.

Department of Human Nutrition 141

Treatment of diarrhea with Oral Rehydration
Therapy (ORT)/ Zinc
• Why is ORT/Zinc key in emergencies?
§ Every year approximately 2.2 million people in developing countries,
most of them children, die as a result of diarrhea and dehydration
§ During emergencies, the risk of diarrhea is exacerbated and
transmission rates soar
§ Poor access to clean water, poor food hygiene practices, introduction
to new or unusual foods, disrupted eating patterns and high rates of
infectious illness due to overcrowded/insufficient living conditions and
moving populations create a perfect environment for diarrheal disease
§ Providing ORT/Zinc in emergencies is a simple and cost-effective
intervention that can greatly reduce the length and severity of the
diarrhea preventing severe dehydration, malnutrition and death.

Department of Human Nutrition 142

The Prevention and Treatment of Vitamin
A Deficiency
• Why is vitamin A key in emergencies?
§ Vitamin A intake is often limited in emergency situations
where the food supply is either inadequate or
inappropriate and access to vitamin A-rich foods is
reduced. Without proper food support, body reserves of
vitamin A become severely depleted
§ In the emergency context, there is an increase in
communicable and infectious diseases due to over-
crowded shelter conditions and disruption due to
population displacement and the demise of health
infrastructures.

Department of Human Nutrition 143

The Prevention and Treatment of
Vitamin A Deficiency…
• Transmission of illnesses such as diarrhea, measles and
pneumonia are exacerbated and lead to increased
childhood mortality
– Measles is especially common in emergencies and can trigger
acute malnutrition and aggravate vitamin A deficiency to
dangerous levels. Vitamin A provides an essential part of the
treatment protocol for children already infected with measles and
supplementation during mass measles vaccination campaigns
provides protection against further vitamin A deficiency and the
severity of potential measles infection.

Department of Human Nutrition 144

Prevention and Treatment of Micronutrient
Deficiencies (MND)
• Why is addressing MNDs key in emergencies?
§ Like other forms of malnutrition, micronutrient
deficiencies are exacerbated by the emergency context
due to disrupted or insufficient access to micronutrient-
rich foods
§ Deficiencies can lead to enhanced susceptibility to
infectious diseases, which in emergency contexts are often
a by-product of over-crowded or poor, unhygienic living
conditions after population displacement
• If individuals are suffering from MND, there is an increased
risk of acute morbidity and death due to common illnesses
that arise during emergencies

Department of Human Nutrition 145

Iron and Folic Acid Supplementation for Moderately
Malnourished Vulnerable Groups

§ Iron and folic acid supplementation is offered due

to the widespread prevalence of iron deficiency in
Ethiopia
§ Iron deficiency particularly affects
• Young children
§ Especially low birth-weight infants
• Women of reproductive age
§ Especially those who are pregnant,
§ Current FMOH – Ethiopia protocols should be
followed for the supplementation of iron and folic
acid
Department of Human Nutrition 146
 …
• De-worming treatment
§ De-worming treatment should be given routinely to all SFP
participants above 1 year on admission
§ In Ethiopia many malnourished children are infested with intestinal
parasites
• Intestinal parasites compete for a significant portion of food intake
furthering the deterioration in nutritional status of the already
malnourished child.
• Intestinal parasites such as hookworm not only affect nutritional status
but also may lead to iron deficiency anemia, depending on the number of
worms in the body.
• As a result, treatment of all moderately malnourished children should be
instituted based on the current FMOH – Ethiopia protocols

Department of Human Nutrition 147

The Psychosocial Components of
Nutrition
• Why are psychosocial issues key in emergencies?
§ In emergency situations, the social destruction and
physical violence suffered by the population have an
impact on psychological well-being and family structure
§ Families may have experienced acts of violence and
extreme distress, such as witnessing death, family
separation, rape (which may have resulted in unwanted
pregnancies), loss of possessions and shelter and disrupted
food and survival systems.

Department of Human Nutrition 148

The Psychosocial Components of
Nutrition …
§ This psychological trauma together with the physical
impact of hunger, and the dependence on humanitarian
aid for survival, produces changes in behavior and
emotions, which impact on feeding practices
• These difficulties may disrupt patterns of effective parenting and
mother-child interactions and can create a sense of apathy or loss
of dignity affecting ability to face the new situation (such as their
capacity and desire to provide food, prepare meals, or work to
nourish their families)

Department of Human Nutrition 149

The Psychosocial Components of
Nutrition...
• The poor nutritional, mental or physical health of
caregivers in an emergency context may render them
unable to provide psychosocial stimulation to their
children. Similarly, the capacities to care for children or
any other vulnerable groups within the population
might be overwhelmed, increasing the risk of
malnutrition and potentially limiting the efficiency of
nutrition treatment.
– As a result, emergencies can provoke and aggravate cases of
chronic or acute malnutrition and micronutrient deficiencies
through the impact they have on psychosocial well-being.

Department of Human Nutrition 150

Nutritional Care for Groups with Special
Needs in Emergencies
• Why is nutritional care for groups with special
needs key in emergencies?
§ Emergencies are often characterized by a high prevalence
of acute malnutrition and micronutrient deficiency
disease, which in turn lead to increased risk of death
among the affected population and in particular among
vulnerable groups
§ Different groups have different needs and these needs
must be taken into consideration to undertake effective
nutrition programming.

Department of Human Nutrition 151

Food Handling, Preparation and Storage
• Why are Food Handling, Preparation and Storage interventions key in
emergencies?
§ In the emergency context, displaced or devastated communities are
often dependent on the provision of food aid to meet their basic
nutritional requirements
§ During emergencies, issues around food handling, preparation and
storage are highlighted because the normal food systems, including
cooking facilities and access to fuel and water are often disrupted and
yet food must continue to be prepared and eaten
§ In an emergency, food-borne illnesses are common due to inadequate
hygiene and poor infrastructures
• The link between food safety and malnutrition is very clear with poor food
handling leading to diarrhea and other gastro-intestinal complaints.

Department of Human Nutrition 152

 Household Food Security (HFS) and
Livelihoods
• Why is Household Food Security and Livelihoods
key in emergencies?
§ The underlying causes of malnutrition, including
micronutrient deficiencies, often rest, inter alia, in poverty
and insufficient agricultural development, leading to food
insecurity at national and household levels
§ Actions that promote an increase in the supply, access and
consumption of an adequate quantity, quality and
variation of foods for all population groups are central.

Department of Human Nutrition 153

§ During crisis and recovery, it is vital to support sustainable
food-based programs and strategies to improve nutrition
with the aim that all people can obtain, through a variety
of different foods, a diet providing energy and all macro-
and micronutrients in order to achieve a healthy and
productive life.
§ Ensuring the food, nutrition and livelihood security of
affected and vulnerable households and individuals is
therefore both a key element of disease prevention and
protecting and promoting good nutrition in emergencies.

Department of Human Nutrition 154

Complex Emergencies

Human Nutrition
Department
 Introduction
• Complex emergencies are often
characterized by a high prevalence of
– Acute malnutrition (wasting)
– Nutritional edema
– Micronutrient deficiency diseases
• Current humanitarian response to
nutritional crises originated in the 1940s
and 1950s
Department of Human Nutrition
 …
• The earliest efforts to estimate the extent and
severity of the problem of malnutrition
occurred during the
– Nigerian civil war in Biafra
– Famines in Ethiopia
– Cambodian refugees in Thailand
• As a result, guidelines on nutritional surveys
and nutrition programs in complex
emergencies were subsequently published
Department of Human Nutrition
 …
• But, there are situations where complex emergencies
have occurred without resulting in an increased
frequency of wasting. For example
– After the North Atlantic Treaty Organization air-strike on
Kosovo in 1999, the prevalence of acute malnutrition in
the refugee camps in Macedonia remained stable at 2·4%

– Similarly in Afghanistan, surveys in the major cities in 2000

showed the prevalence of acute malnutrition to range
from 5·6% to 8%

Department of Human Nutrition 158

 …
• Many complex emergencies are not short
term but protracted or recurrent, such as
– The situation in southern Sudan
• Complex emergencies are at time politicized
– Aid being increasingly treated as a component of
foreign policy
– Absence of impartiality in donor allocations of
resources
• Emergencies in Africa are allocated less, relative to
need, than emergencies in Asia and eastern Europe

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 …
• Despite the relative absence of wasting in the
above two complex emergencies
– Nutritional risk is evident in almost every complex
emergency
• In protracted or recurrent crises, such as those
in the Horn of Africa (Ethiopia, Kenya, Somalia,
Sudan) or Asia, frequency of stunting (chronic
malnutrition) might also be relevant

Department of Human Nutrition 160

 …
• Micronutrient deficiency disorders,
particularly deficiencies of vitamin A, iron and
iodine, are frequently a major public health
threat
– Outbreaks of scurvy in Afghanistan in 2001,
– Pellagra in Angola in 2001
– Angular stomatitis among refugees in Bangladesh
in 1997 and refugees in Nepal in 2000, have
shown that the consequences of micronutrient
deficiency have yet to be adequately addressed.
Department of Human Nutrition 161
 …
• Despite the existence of proven interventions,
the prevalence of acute malnutrition has
remained high in complex emergencies during
the past decade as indicated in the following
table

Department of Human Nutrition 162

Department of Human Nutrition 163
• Nutrition during complex emergencies emphasize on
the broad range of interventions and strong
programmatic links that are needed to address the
three groups of underlying causes of malnutrition

Department of Human Nutrition

• A range of combined strategies is needed to
protect, promote and support nutrition
(beyond treatment of malnutrition)
• Activities that have a more direct effect on
population nutritional status in complex
emergencies are shown in the following table

Department of Human Nutrition 165

Department of Human Nutrition 166
Nutritional needs of at risk groups
• In complex emergencies, sex, age, HIV status,
and other characteristics have a role in
establishing nutritional risks, which can be
exacerbated by changes in social networks and
support structures

Department of Human Nutrition 167

 Infants
• In complex emergencies, in which hygiene and care
practices might be compromised and overcrowding is
common, the risk of diarrhea and other infections is
high and breastfeeding is even more essential
– Exclusive breastfeeding for 6 months reduces morbidity
and mortality from a range of infectious diseases including
diarrhea
– Policies and guidelines on infant feeding in complex
emergencies are based on protecting, promoting and
supporting exclusive breastfeeding

Department of Human Nutrition 168

• In complex emergencies
– The conditions required for clean water, facilities for
hygiene and sanitation, and a regular supply, are difficult
to guarantee and the associated risks are higher
– The scarcity of appropriate complementary foods for
young children when blended food is not included in
general food rations, difficulties addressing the nutritional
needs of large numbers of unaccompanied infants and
young children and poor awareness of the benefits of
breastfeeding all contribute to poor outcomes

Department of Human Nutrition

Pregnant and lactating women
• The nutritional requirements of pregnant and
lactating women are higher than the population
average and therefore exceed the amounts provided
in the general food ration
– The International Committee of the Red Cross provides an
increased general food ration in part to compensate for
these increased needs, while other relief agencies provide
all pregnant and lactating women with a food supplement
through supplementary feeding programs
– Although compliance with daily supplementation protocols
is difficult to maintain, pregnant and lactating women
should receive daily supplements of iron and folic acid

Department of Human Nutrition

 Older people
• The effect of emergencies on older people is
increasingly recognized
– HelpAge International have advocated strongly for
better recognition of the rights, needs, and
contributions of older people in emergencies
– In besieged areas of Bosnia Herzegovina, older
people were at greater risk of undernutrition,
which was associated with disease, cold,
psychological stress, and difficulties with food
preparation
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– Among older Rwandan refugees, nutritional risk
was related to lack of mobility, income, access to
land, access to food rations, and other essential
services, and to psychosocial trauma
– Loss of social networks and support systems
increases the vulnerability of older people
– Increasingly, older people are also acting as
caregivers for young adults and family members
who have been affected by HIV, thereby incurring
both physiological and financial costs that affect
their nutritional status
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– Generally, more programming strategies are
required to address the needs of older people
without undermining their capacity to support
themselves
– The Sphere Minimum Standards advocate the use
of community-based systems to ensure
appropriate care for older people

Department of Human Nutrition 173

• Recommended actions include
– Improving access to the existing general food
rations and supplementary feeding programs
– Ensuring food rations are easy to prepare and
consume, and
– Ensuring that rations meet the additional
nutritional requirements, specifically
micronutrients

Department of Human Nutrition 174

 People living with HIV
• The HIV/AIDs epidemic is
– Threatening the ability of communities to recover
from famine, because the most productive
household members are predominantly affected
by the disease
• Furthermore, people living with HIV/AIDS are
– At increased risk of malnutrition because of a loss
of appetite, eating difficulties, malabsorption of
micronutrients, increased metabolic rate, and loss
of nutrients
Department of Human Nutrition
 – Optimum nutrition in a form that is digestible and
appropriate can help maintain health and prevent weight
loss as long as possible in the asymptomatic period, and
later mitigate the symptoms of the disease
• WHO has recommended that
– Asymptomatic people living with HIV receive 10% more
energy
– Symptomatic people living with HIV receive 20-30% more
energy, and
– Children receive 50% more than HIV negative individuals

Department of Human Nutrition 176

– Recent recommendations have suggested only
increased energy and not protein requirements.
– However, no specific standards are available for
planning nutrition programs for people living with
HIV in complex emergencies, although some relief
agencies have discussion documents and policy
statements

Department of Human Nutrition 177

 The future
• Major advances in the field of public nutrition
in complex emergencies have been made in
the past decade, including
– Technical advances in anthropometry, survey
methods, fortification, and treatment of severe
malnutrition
– More generally, conceptual advances have been
made in understanding the causes of malnutrition
associated with complex emergencies

Department of Human Nutrition

– Further refinement is needed in a number of
specific areas
• Institutionalisation of nutrition will require
development of national capacity, especially within
governments in countries affected by chronic or
recurrent complex emergencies
• Multisectoral nature of nutrition, several government
ministries will be responsible but one ministry will still
need to take a leadership role

Department of Human Nutrition 179

Nutritional Surveillance

Human Nutrition
Department
 Learning objectives
• By the end of the session students should be
able to
– Understand the meaning and importance of
surveillance
– List potential data sources for nutrition
surveillance
– Discuss steps to establish and operationalize a
nutrition surveillance system

Department of Human Nutrition 181

 Introduction
– Nutritional surveillance
• Is a system organized to monitor the food and
nutrition situation of a country or region within a
country on a continuous and regular basis
• Is a set of activities to assemble information to
assist in policy and program decisions to influence
the nutritional status of the population
• It usually involves the regular and timely collection,
analysis and reporting of nutrition relevant data

Department of Human Nutrition

 Introduction…
• Nutritional surveillance
– Means to watch over nutrition in order to make
decisions which will lead to improvements in
nutrition of populations
– Provide regular information about nutrition in
populations
– Draw data from the most suitable sources that are
already available, including surveys and
administrative data

Department of Human Nutrition

 Introduction…
– In sum, nutrition surveillance is data for action
• Collection of nutrition data without sharing and using it
is NOT nutrition surveillance
• If no plan to take action, no need waste time and other
resources doing nutrition surveillance
• If there is need to take action, but need data to do so,
consider surveillance as one of the data collection
methods available
• Surveillance can often produce information which is
more timely than information gathered by other
methods, such as surveys

Department of Human Nutrition

Characteristics of surveillance
• Three important ones
– Dynamic – it is continuous
– Timely
– Information for action
• A surveillance system may track
– Infectious diseases, chronic diseases, vital events, injuries ,
risk factors of behaviors, health related behaviors,
occurrence of malnutrition, etc
• A surveillance system that trucks malnutrition is
called nutrition surveillance

Department of Human Nutrition 185

 Nutrition surveillance
– First came into prominence at the World Food Conference
of 1974
– Watches over nutrition in order to make decisions that
lead to improvements in nutrition in populations
– These decisions may be in relation to
• Policies and programs that affect people's living standards in the
long term
• Programs that provide immediate alleviation of hunger and
malnutrition (timely warning and intervention programs)
• Any immediate measure

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The surveillance loop

Department of Human Nutrition 187

Assessment of GMP as a triple A process

Department of Human Nutrition

Purpose of surveillance

Department of Human Nutrition

Purpose of surveillance…

Department of Human Nutrition 190

Questions that need to be answered by nutritional surveillance
information to aid health and development planning decisions

Department of Human Nutrition

 …

Department of Human Nutrition

Why should we do nutritional surveillance?

– To follow trends in the nutritional status of a

population over time
– To establish nutrition care and public health
priorities
– To ensure those with greatest nutritional need are
prioritized
– To detect and respond to nutritional emergencies
– To evaluate the effectiveness of nutrition
programs and services
– For advocacy
Department of Human Nutrition
 Common data sources for nutritional
surveillance
Sources of information Nature of information Nutritional implications
1. Agriculture data food Gross estimates of Approximate availability of
balance sheets agricultural production, food supplies to a
agricultural methods, soil population
fertility, predominance of
cash crops, over production
of staples, food imports and
exports
2. Socioeconomic data Purchasing power, Unequal distribution of
(information on marketing, distribution and storage of available foods among the
distribution and storage) food staffs socioeconomic groups in
the community and within
the family
3. Food consumption Lack of knowledge, erroneous
patterns (cultural and beliefs, prejudices,
anthropological data) indifferences

Department of Human Nutrition

 …
4. Dietary surveys Food consumption Low, excessive or
unbalanced nutrient
intake

5. Special studies on foods Biological values of diets, Special problems related to

presence of interfering nutrient utilization
factors (e.g. goitrogens),
effects of food processing

6. Vital and health statistics Morbidity and mortality Extent of risk to the
data community, identification
of high risk groups

7. Anthropometric studies Physical development Effect of nutrition on

physical development

Department of Human Nutrition 195

 …

8. Clinical nutritional Physical signs Deviation from health

surveys due to malnutrition
9. Biochemical studies Levels of nutrients, Nutrient supplies in the
metabolites and other body, impairment of
components of body biochemical function
tissues and fluids
10. Additional medical Prevalent disease Interrelationships of
information patterns, including state of nutrition and
infections and disease
infestations

Department of Human Nutrition 196

Data sources for assessing micronutrient deficiencies

Department of Human Nutrition

 Types of surveillance
• Passive
– Occurs when data are routinely collected and
forwarded to the body conducting the surveillance
• Active
– Occurs when the body conducting the surveillance
initiates procedures to obtain reports
– Data are sought out by
• Visiting or contacting the reporting sites or
• Contacting the reporting sites or
• Conducting active data collection

Department of Human Nutrition 198

 …
• Passive surveillance
– Advantages: low cost, sustainability
– Limitations: low compliance, irregularity, and
incompleteness with reporting, inconsistencies in case
definition
• Active surveillance
– Advantage: allows collection of in-depth information,
better compliance, regularity and completeness,
consistency of case definition
– Disadvantage: expensive and less sustainable

Department of Human Nutrition 199

 …
• Active surveillance is appropriate when:
– The area is judged to be at high risk of
malnutrition
– Secondary data sources are not available/reliable
– For periodic evaluation of ongoing systems
– For programs which have time limit of operation

Department of Human Nutrition 200

 Other commonly used terms in
surveillance
• Case surveillance
– Involves the ongoing and rapid identification of cases for
purpose of taking action to stop progression of malnutrition
• Aggregate surveillance
– Interested in the aggregated number of cases so as to monitor
the problem and inform public health policy making
• Sentinel surveillance
– Occurs when only selected sites report data. This can be used to
monitor trends and collect more detail information
– Usually nutrition surveillance is limited to hotspot areas

Department of Human Nutrition 201

 Initiation of NS
• When initiating a nutrition surveillance, the following issues
should be considered
– The public health significance of the problem (malnutrition) in terms
of
• Frequency (prevalence and incidence)
• Severity(mortality, disability..)
• Feasibility for detecting of cases
• Associated cost
• Social inequity
– International and local interest
– The system should worth the effort (money, human resource)
– Relevant data should be easily available
– Action can be taken based on the data

Department of Human Nutrition 202

 Steps in establishing nutrition
surveillance system
• 1. Establish objectives of the surveillance
system
• 2. Decide on the population/area of interest
including population group to be monitored
– Usually nutritional status of 6 – 59 months is taken
as a proxy indicator for the entire community
– Its also good to include other vulnerable subjects
including pregnant and lactating women and
adolescents

Department of Human Nutrition 203

 …
• 3. Determine data source
– Primary data for the surveillance system
– Medical records (clinical, anthropometric)
– Periodical nutritional and dietary surveys
– Vital reports
– School records
– Food availability and market surveys, including agricultural
production food stocks and food balance sheets
– Economic data related to purchasing power
– Metrological data, etc

Department of Human Nutrition 204

Data sources for Uganda Nutrition
Information System

Department of Human Nutrition 205

 …

Department of Human Nutrition 206

 Ethiopia Nutrition Information System
Data flow
Data interpretation
and
feedback
Data interpretation
and
feedback Federal
Level
data is exported and
emailed to the Regional Level
Regional HMIS Focal
HC enter offline data
to DHIS2- on flash to Zonal Level
There are approximately
woreda HMIS Focal
6 weeks delays in
Woreda availability of nutrition
Level data in DHIS2
Paper forms HMIS
from HPs to HCs Health
post/Cluster
Health center)
Department of Human Nutrition 207
 …
• 4. Specify indicators to be monitored and set the trigger level
• 5. Develop data collection, analysis and information
dissemination mechanism
• 6. Collect the data passively or actively
• 7. Analysis and interpretation of the data
– Rapid analysis is needed (using ENA SMART software, Epi Nut)
– Descriptive data analysis by time, place and person
• Including short term and secular changes
• Spatial distribution,, clustering
• Description by age, sex, economic status, etc
– Rates of acute malnutrition in relation to the trigger level
– Rarely: analytic type of analysis

Department of Human Nutrition 208

 …
• 8. Feedback and dissemination of findings
– Decision makers, policy makers, affected
community, those who provided the information
• 9. response/action through forming a link to
concerned bodies

Department of Human Nutrition 209

 …
• 10. Evaluation of the system – based on criteria including
– Appropriateness of the indicators under follow-up
– Acceptability by stakeholders
– Simplicity of the program
– Cost effectiveness
– Follow up and supervision mechanisms
– Data quality (completeness and validity of the data)
– Representativeness of the data
– Feedback and information dissemination mechanisms
– Timeliness
– Level of usefulness of the data

Department of Human Nutrition 210

Summary of the steps in carrying out nutritional
surveillance
Scope Assessment Implementation
1. Data 1. Data needed to generate 1. Data collection action
information
2. Information 2. Information needed to 2. Data analysis, the
aid in decision making transformation to
information
3. Decision 3. Potential decisions 3. Decisions made based
regarding policies and on information
interventions
4. Intervention 4. Proposed polices and 4. Intervention enacted
intervention strategies based on decision
5. Impact 5. Problem identification 5. Actual impact
including desired impact of
action taken

Department of Human Nutrition

Challenges of nutrition surveillance
systems
• Difficulty to sustain the system
• Difficulty to link information to action including lack of institutional
system
• Politicization of the system
• Lack of active involvement of stakeholders
• Lack of action to address the detected problem
• Lack of timeliness
• Lack of information dissemination mechanism
• Lack of data quality
– While many NS systems involved in significant data collection, too few data
were being compiled, fewer were being communicated and ultimately, very
few were used to improve nutrition related action

Department of Human Nutrition 212

Nutrition surveillance in Ethiopia
• Early 1970s food and nutrition information system established
under the Ethiopian Nutrition Institute (ENI)
• The national Emergency Warning System (EWS) was
established in 1976 under Relief and Rehabilitation
Commission (RRC)
– It was the first national EWS in Africa
– Food aid oriented system
– Major activities of EWS were
• Monitoring food supply indicators (rainfall, crop production)
• Monitoring social stress indicators (market, migration data)
• Monitoring individual stress (nutritional status)

Department of Human Nutrition 213

 …
• Save the Children UK’s Nutritional Surveillance
Program (NSP) in Ethiopia (1986 – 2002)
– Sentinel site surveillance system
– Data collected by regular surveys
– Areas were draught prone areas
• Tigray, N and S Wollo, Wag Himra, W and E Harerghe, Wolaita
– Nutritional status was monitored as an early indictor of
crisis
– Food production, market and rainfall data were also
collected
– Gradually integrated into government system (DPPC)

Department of Human Nutrition 214

 …
• 1991 RRC changed to Disaster Prevention and
Preparedness Commission (DPPC)
• DPPC was decentralized to the regional level in 1994
• In 2009, National Policy and Strategy on disaster risk
management developed
– Disaster risk management and food security under MoARD
become responsible to monitor data on agricultural
production
– Ministry of health is responsible to monitor occurrence of
malnutrition

Department of Human Nutrition 215

 …
• Currently, the Community based Management of
Acute Malnutrition (CMAM), CBN and GMP collect
information on the nutritional status of U5C for
screening purpose
– The data can be used for surveillance purpose
• CSA conduct different surveys
– Demographic and health survey
– National agricultural sample survey
– Household income survey
– Ethiopian households consumption – expenditure survey

Department of Human Nutrition 216

 …
• EPHI conducts different surveys
– National nutrition survey
– National micronutrient nutrition survey
– National food consumption survey
• Universities
– Surveillance sites that mostly monitor vital
events
• AAU, MU, JU, HU, AMU, GU, BDU, JJU(?)

Department of Human Nutrition 217

Indicators to be monitored in NS
• Food security indicators
• Anthropometric measurements like wasting, underweight and
stunting
• Agricultural production indicators (type and quantity of
production)
• Market price indicators (crop and livestock prices)
• Rainfall level
• Relief food/aid distribution and access
• Others
– Underlying and root causes of malnutrition
– Indicators of micronutrient deficiencies

Department of Human Nutrition 218

 What do the different indicators of
nutritional status mean?
• Indicators can be broadly grouped into three
categories
– Outcome
– Process
– Context
• Nutritional status indicators are measures of
outcome

Department of Human Nutrition

 …
– Outcome
• Refers to population-level change in the prevalence of, for
example, child wasting or low birth weight and therefore
re f l e c t s t h e i m m e d i ate c a u s e s o f m a l n u t r i t i o n a s
represented in the UNICEF conceptual framework.
– Process
• Refers to program-related activities such as coverage,
quality, targeting etc
– Context
• Reflects the basic and underlying causes of malnutrition
(women’s education level, quality and coverage of health
services etc)

Department of Human Nutrition

List of Suggested Indicators at the
National Level

Department of Human Nutrition

 …

Department of Human Nutrition 222

 …

Department of Human Nutrition

List of suggested indicators at the
community level

Department of Human Nutrition

 …

Department of Human Nutrition

Appropriate nutritional surveillance systems

Department of Human Nutrition 226

 …

Department of Human Nutrition 227

Anthropometric indicators
– Different anthropometric indicators measure
different things
– It therefore follows that different measures are
appropriate in different situations/scenarios
– For example, in countries where the prevalence of
Low Birth Weight (LBW) arising from poor
maternal nutrition is particularly high, monitoring
LBW as a key outcome indicator is important to
measure the impact of programs designed to
address intrauterine development

Department of Human Nutrition

Anthropometric indicators commonly collected in
surveillance systems

Department of Human Nutrition

Micronutrient indicators commonly collected
in surveillance systems

Department of Human Nutrition

 Comparison of NS with other data
collection methods
Rapid assessment Surveillance Survey
Often collects qualitative or Collects quantitative data Collects quantitative data
semi-quantitative data
Collects wide variety of data Collects limited data Can collect wide variety of data

Collects data on convenience Often tries to collect data on Usually collects data on sample
sample of people and facilities every case of illness of population

Collects data at a single point in Collects data over ongoing, Collects data at single point in
time prospective time period time
Collects only data for numerator Collects only data for numerator Collects data for numerator and
of prevalence and incidence of incidence and prevalence denominator, allowing
rates; Denominator must come rates; Denominator must come calculation of prevalence or
from separate source from separate source. incidence rates

Department of Human Nutrition