United Nations System
Report on the Meeting of the Working Group on Nutrition in Emergencies
Wednesday, 12 April 2000, World Bank, Washington DC
Chairs: Yvonne Grellety (formerly UNICEF) and Sultana Khanum (WHO)
Among the participants were NGOs, bilateral and UN agency members, approximately 60 people in total.
(i) A brief historical perspective of inter-agency collaboration,
A brief historical perspective of inter-agency activities, and outcomes since the 26th Session
Rita Bhatia, UNHCR
A presentation of the alarming excess mortality among refugees and Internally Displaced Populations (IDPs) at the Symposium on Nutritional Issues in Food Aid in Emergencies in 1992 prompted the formation of the SCN Working Group for Refugees and IDPs. In 1993, the RNIS reports (Reports on the Nutritional Situations of Refugees and Displaced Populations) were launched, with the aim of raising awareness about the nutritional situation of IDPs and refugees.
During the 90s, a series of other important workshops and meetings took place including those in Machakos, Kenya in 1994 (Workshop on the Improvement of the Nutrition of Refugees and Displaced People in Africa)) and in Addis Abba, Ethiopia in 1995 (Tools and Strategies in the Management of Nutritional Emergencies). These meetings led to the establishment, following UNHCR's initiative, of the Interagency Group on Nutrition in Emergencies and also the Field Exchange, a tool for sharing and exchanging information. The main purpose of the Group, consisting of operational NGOs, UNHCR and WFP, is to share lessons learned in operational issues, highlight and advocate for best practice and assist in developing training materials and guidelines. The group met in Dublin, Ireland in 1997 (Emergency Selective Feeding Programmes) and in Amsterdam, Holland in 1998 (Food Security Assessments in Emergencies).
Since the 26th SCN session at least three Interagency workshops focusing on specific operational priorities identified by the group have been held. In Washington DC in April 1999, Improving the quality of relief diets (report of the meeting available from Food Aid Management, 300 I Street, NE, Suite 212, Washington DC 20003); in Boston in June 1999, Public nutrition in Emergencies (report of the meeting available in a special issue of Disasters volume 25:4, from Blackwell Publishers Limited, 108 Cowley Road, Oxford OX4 1JF, UK); in Rome in October 1999, Assessment and Targeting in Emergencies (report available from the ENN, Department of Community Health and Practice, Trinity College, 199 Pearse Street, Dublin 2, Ireland).
Update on Adult Malnutrition programs and research in Brazzaville and Burundi
Carlos Navarro, ACF-F Action Contre La Faim)
Dr. Navarro presented a broad overview of some of the problems encountered when trying to treat severely malnourished adults in Burundi and Congo-Brazzaville, where ACF is undertaking an analysis of its operational (nutritional) programmes. The project in Burundi has been operating since 1994 and at least 1,000 persons per month (including 700 adults) have been treated in 5 Therapeutic Feeding Centres (TFCs) in two provinces. The programme in Brazzaville began in July 1999, and has treated approximately 600 patients per month, including 400 adults, in 3 TFCs. The objective of the presentation was not to provide recommendations on cut-offs for defining adult malnutrition as the data has not yet been fully analysed, but rather to present some of the operational dilemmas that arise.
Emergency nutrition interventions aiming to address adult malnutrition, are becoming increasingly common practice in emergencies, for example in South Sudan and Congo-Brazzaville. However, there continues to be an enormous demand for information on diagnostic criteria, and protocol specifications. Consequently, some agencies (e.g. ACF and Medecins Sans Frontières) have begun to adapt nutritional protocols for adult malnutrition based on review and analysis of their own agency's experiences. ACF's recent work undoubtedly reinforces the two conclusions presented in this Working Group last year:
In summary, the following issues were highlighted as operational problems:
Criteria for assessment of acute adult malnutrition
Medical management of patients in TFCs:
The high prevalence of both acute and chronic disease among malnourished adults poses a serious challenge in the management of adult malnutrition. The design of therapeutic feeding for adults must take into consideration some important medical issues. These include:
An agency that wants to assist severely malnourished adults may therefore need to consider a complete revision of the strategy, objectives, training, and other means (including human) that it usually puts in place to cope with severe malnutrition in emergencies.
Oedema and refeeding oedema
Infant Feeding Research during the Kosovo crisis and follow-up action
Anna Taylor, SCF-UK (Save the Children) and Andy Seal, Institute of Child Health
The aims of the presentation were to report key findings relating to policy and practice issues from recent research conducted by SCF (UK) and ICH on infant feeding practices. The research was conducted during the Kosovo crisis in 1999 and assessed the availability and use of guidelines on infant feeding, documented the flow of infant relief items, and described infant feeding interventions and infant feeding practices of the refugee population.
The study findings highlighted issues in two broad categories of policy and practice:
The findings were presented to an Interagency Group on Infant Feeding in Emergencies in a workshop held in London in 1999 (this report is available from SCF-UK, 17 Grove Lane, London, SE5 8RD, UK). A number of follow-up actions were agreed in this meeting including; (i) feed back to staff and agencies in the Balkan region, (ii) the development and effective dissemination of operational guidance for emergency personnel, and (iii) the review of policy instruments and further research.
Since the meeting, a draft of operational guidance aiming to provide essential information for managers, logisticians and health workers on infant feeding issues at the population level as well as basic guidance for decision makers on infant feeding interventions, has been prepared. This draft will be further refined and reviewed by the Interagency Group.
The following research needs in Infant Feeding in Emergencies were identified by the Group:
Of these research needs, the following priorities were identified:
For effective research in this area, as for most research in emergencies, prior funding arrangements are required to ensure that applied field research can be quickly instigated when opportunities present themselves.
Nutritional problems faced by infants in emergencies
Prof. Michael Golden, University of Aberdeen
Prof. Golden outlined a number of important problems/issues regarding infants nutrition.
Nutritional surveys of infants
Refeeding malnourished infants
How to rehabilitate the severely malnourished infant whilst maintaining lactation is a serious dilemma. Critical points to be taken into account include the fact that severely malnourished infants:
A technique to support lactation, known as supplemental suckling, has been developed. The technique, which is simple, involves a catheter attached to the nipple at one end and the other in a cup full of appropriate rehabilitation diet. As the child is fed, milk production is stimulated. The cumulative weight gain increases dramatically (270 g/Kg at 21 days) whilst the infant regains strength. When the supplementation is stopped growth continues at an accelerated rate with exclusive breastfeeding. This technique is now used in all ACF programs worldwide and could be extended further.
HIV/AIDs and Breastfeeding
The use of different anthropometric indices to assess malnutrition
UNHCR and CDC are assessing the utility of the WHO guidelines for the assessment of adolescent malnutrition (BMI for age / 5th centile of NHANES I reference). The agencies have conducted 3 nutritional surveys, 2 in Kenya (Kakuma and Dadaab) and the other in Nepal. When the WHO reference was used the prevalence of low BMI among adolescents in Kakuma and the Dadaab camps was estimated at about 60% and at about 30% in the Nepalese camps. However, the prevalence of malnutrition among children aged 6-59 months, morbidity, mortality and general food distribution records did not indicate a large-scale nutritional problem in the camps. The conclusion of these studies is that the surveys overestimated malnutrition among adolescents for three main reasons, (i) the reference population used may not be appropriate for other populations, (ii) knowledge of age for adolescents is largely uncertain in refugee situations and as thinness indices are highly correlated with age this makes interpretation difficult, and (iii) the use of puberty standards is difficult in most populations.
WHO presented their new guidelines on "The Management of Nutrition in Major Emergencies". Thiamine deficiency and scurvy modules are also newly available; guidelines on pellagra will be available shortly. WHO also announced that they are working towards establishing new growth curves for adolescents.
Working Group participants suggested that WHO's new guidelines should be made available on the WHO Web site. These documents are currently very expensive and difficult to obtain, especially from the developing world.
FAO's focus in emergencies is mainly on assisting communities becoming re-established. The use of the agricultural potential is the key in achieving this goal. Emphasis will therefore be placed on the agricultural sector via seeds and tools distribution, livestock, etc. FAO is also involved in preparedness planning especially in Early Warning systems and food needs assessments.
UNICEF is mainstreaming its capability for emergency response within the country programming process, in line with the activities envisaged in the MOU with WFP. This will require building the capacity of the agency's staff who will need to monitor the distribution of therapeutic feeding products.
USAID have adopted Crude Mortality Rate, for children aged 6-59 months, as well as weight-for-height indices as indicators in nutritional emergencies. The agency would like the group to investigate the issue of the harmonisation of the micronutrient content of fortified foods further.
Prof. Mike Golden
Reported that a Computer Auto Learning system (CAL) has been created and is available on CD-ROM from him. This includes information on the basics of marasmus and its treatment. Feed back is requested.
Dr A. Duffield (SCN) gave a short presentation outlining the RNIS's plan to enlarge its scope to include information on situations caused by natural disasters (at WFP's request). Issues discussed included differences in the nutritional situation of populations displaced for political reasons (i.e.: those involved in complex emergencies) and those displaced by natural disasters. The RNIS will extend its coverage to include the nutritional situation of certain displaced populations of more 100,000 who are believed to have a heightened risk of malnutrition. The usefulness and feasibility of this work will be reviewed at the next Working Group meeting.
Terms Of Reference Of The Working Group For Nutrition In Emergencies
From the early 90's, two parallel groups have been addressing issues and problems of nutrition in emergencies; the SCN Working Group and the Interagency Group.
It is proposed to integrate and strengthen these existing groups and build on their earlier work. Participation of all UN agencies involved in emergency nutrition, inter-governmental bodies, operational NGOs, bilateral and civil society will be encouraged. It is anticipated that most of the detailed discussion of issues relevant to the Working Group will take place in meetings and workshops of the Interagency group, and then synopses of the conclusions of these meetings and other ongoing work will be presented to the annual SCN for further discussion and ratification.
The meetings will continue to focus on gaps and priorities in operational needs and sharing of information on current practices. The priorities will be addressed on the basis Who? How?Why? When? Where?
It is intended that the identification of gaps in knowledge will be defined using a 2X2 matrix of:
Gaps in methodology, guidelines, training, research and evaluation, intervention will be identified and prioritised for action.
The Working Group will nominate a steering committee from which the members will select proposals for the future chairs and rapporteurs. This process will take place by email and will involve members of both the Working Group and the Interagency group. The Emergency Nutrition Network (ENN) will provide a secretariat for the Working Group.
Recommendations of the Working Group to the ACC/SCN for action:
Clarify issues relating to adult malnutrition including its definition, and operational intervention guidelines. Disseminate this information as widely as possible to agencies in need of support and guidance.
Infant feeding issues
Liase with the Breastfeeding and Complementary Feeding Working Group in taking responsibility for further development of the operational guidance, managing the consultative process and coordination of dissemination. Improve the training of humanitarian staff on infant feeding practice. Advocate for the need of experts on infant feeding issues to be present at all emergencies from the outset.
Ask WHO to make their nutritional manuals available on their web site for global, low cost dissemination.
Expand the coverage of the RNIS to include the nutritional situation of groups (of more than 100,000 people who are potentially at risk of malnutrition) displaced by natural emergencies for one year. Review this work at the next SCN meeting.
Functioning and mechanism of the Working Group
Nominate a steering committee from which the future chairs and rapporteurs can be chosen. This process will take place by email and will involve members of both the Working Group and the Interagency group. The ENN will provide a secretariat for the Working Group.