United Nations System
Standing Committee on Nutrition

Working Group on Nutrition in Emergencies

held during the SCN's 33rd Session, Wednesday 15 March, 1300-1600 hours, Geneva

Chair: Fathia Abdallah (UNHCR)
Co-Chairs: Caroline Abla (OFDA/USAID), Caroline Wilkinson (ACF France)

Documentation and Presentations:

• Agenda
• Report of discussions and questions and answers (MS Word)
• Presentations:
  • Summary of Agenda (PDF)
  • Nutrition and Child Development (PDF)
  • Nutrition Assessments Theme Group (PDF)
  • Use of Multiple Micronutrient Supplements in Emergencies (PDF)
  • Infant Feeding in Emergencies (PDF)
  • Innocenti + 15 (PDF)
  • Update on SMART (PDF)
  • Community Based Management of Severe Malnutrition in Children (PDF)
  • IASC Nutrition Cluster: Concept and Practice (PDF)
  • Experience from Pakistan and Lessons Learnt (PDF)
  • LQAS for Rapid Assessment of Children's Nutrition and Health Status (PDF)
  • How Backyard Garden Programmes can Improve Quality of life for Households affected by HIV/AIDS (PDF)
  • A System-Wide Humanitarian Tracking Service (PDF)
  • Dual forms of malnutrition among Saharawi refugee population (PDF also available in Word Version)
  • Food Security, Nutrition and Livelihoods in Crisis (PDF)

The Nutrition in Emergencies working group decided to repeat the pre-session on Sunday that had proved to be such a success in Brasilia in 2005. The morning of the Sunday session was run in conjunction with the Breastfeeding and Complementary Feeding group, in recognition of the cross cutting issues between these two groups. The Sunday afternoon session was focussed more on Assessments in Emergency Situations, with presentations of new methodologies and details of assessment experiences in various contexts.

Morning Session
 

1. Prevention and control of micronutrient deficiencies in populations affected by emergency

Two presentations were made in this part of the morning session, focussing on micronutrient deficiencies.

Use of Multiple Micronutrient Supplements in Emergencies: Joint statement UNIVDE/WHO/WPF (2006)
Tina Van Den Briel WFP

Tina presented the findings of this work on behalf of all of the other experts who have been working on it. The work was triggered by the Tsunami and the joint statement was developed in around a year.

The aim was in preventing and controlling micronutrient deficiencies in populations affected by emergency situations through the distribution of multiple vitamin and mineral supplements for P&L and children 6 – 59 months.

Why?

• High pre-emergency prevalence of different vitamin and mineral deficiencies occurring concurrently and reinforcing each other
• Increased risk of infection combined with decreased dietary quality and quality.

Evidence of effectiveness

• Literature review (de Pee) of 14 studies among young children
• Almost all studies showed increase in Hb and iron status
• Multi- MN Supplements lead to greater reduction in anaemia than Fe alone
• Results for Zinc status are mixed (impact on morbidity not always measured)
• Fe and Zn interact antagonistically it seems and together they lower the impact on Fe status compared to giving iron alone.

Relationship Fe/morbidity and mortality
There is some evidence that Fe supplementation of infants and young children increases morbidity and mortality from infection. The mechanism for this is:

• Unabsorbed Fe in small intestine leads to bacterial proliferation
• Free radical formation and oxidative stress in children who cannot down-regulate absorption
• Therefore: supplements to be given together with food

How much to give?

• RNI is defined as the daily dietary intake of a nutrient sufficient to meet the nutrient requirements of nearly all apparently healthy individuals in a specific population group
• Definition RNI = Definition RDA
• RNIs derived from FAO/WHO recommendation (2005) and IOM (Fe and Vit E)

Issue: which RNI to take?

• RNIs for pregnant or lactation (differences are relatively small)
• Children 7-12, 13-36 or 37-59 months

Guiding principles for implementation (based on Panama consultation, Nov .05

• Daily supplementation of 1 RNI for P&L women and children 6-59 months (15 MNs)
• Children consuming fortified blended foods to receive 1 RNI twice per week
• Mega-dose program Vit A or Ferrous Folate or Zinc supplementation are to continue
• Careful choice of preparation (crushable tablets, powder, spread)
• Distribution through existing channels/programmes with minimal increase in workload of health staff
• Advocacy and education essential
• Careful M&E required
• Delivery to continue until emergency phase is over

Nutrition and child development
Adrian Diaz ACF-Spain

There is clear evidence that nutritional deficiencies, infections and poverty have devastating effects upon infant growth and development. In other words, children that live in poverty are exposed to lower social-environmental stimulation, nutritional deficits and repeated infectious processes that will seriously affect their growth and development to the maximum of their capabilities and impair the development of the whole society.

On the other hand, prevalence studies do not always show a direct association between malnutrition and low child development performance, because it is like photo, which evaluates current status of a population without taking the deficiencies into consideration, except the height for age.

In different studies carried out in Argentina by ACF-Spain, in children under 6 years old and schoolchildren form the first grade, we found that the main nutritional problems were stunting, obesity and anaemia. This confirms the nutritional transition process that is taking place in the whole of the Latin-American Region. Besides this, we found that children living in poverty had a low cognitive development performance, and, in some cases, this situation is related to stunting, anaemia, low mother´s education and low resources for stimulation in the home environment.

It is important to point out that to achieve the millennium development goals of the United Nations, concerning the eradication of poverty and hunger, it is essential put together nutritional, health care and stimulation actions driven towards children, along with working together with families in order to improve living conditions, quality of relationships and upbringing standards. Moreover, it is necessary to include child development indicators into nutritional surveys

2. Infant Feeding in Emergencies (including HIV/AIDS)

In this session Marie McGrath fed back to the group on the work of the Infant Feeding in Emergencies Core Group during the year and laid out plans for the work of the group for the coming year.

Infant Feeding in Emergencies: Update for Emergency Working Group SCN 2006

The IFE Core Group, whose members comprise the IFE thematic group, call on the IFE Core Group members particularly the UN agencies, to fulfil their financial responsibilities to the work of the core group.

Without this commitment we cannot fulfil our workplan for 0/07. Assuming we secure funding from the Core Group members we plan to:

• Produce, print and disseminate the revised Operational Guidance on Infant and Young Child Feeding in Emergencies. Begin the process of review and update of Modules 1 and 2
• Hold or lead on, an interagency meeting to address operational issues hindering the implementation of the Operational Guidance and related policies on IFE.
• Hold a meeting exploring & collating infant feeding in emergencies experiences training needs and funding possibilities on infant feeding in Asia.

The Working Group endorsed the following Statement:

Report on Innocenti + 15 meeting, Declaration and publication

David Clark, UNICEF, spoke about the 15th Anniversary of the Innocenti Declaration, which took place in Florence, Italy on 21 and 22 November 2005. The event took stock of progress made in the protection, promotion and support of breastfeeding since the “Innocenti Declaration” of 1990, including the adoption of the Global Strategy for Infant and Young Child Feeding in 2002. The organising partners were the Academy of Breastfeeding Medicine, IBFAN, ILCA, LLLI, USAID, UNICEF, Wellstart International, WHO, WABA and the Tuscan Regional Authority. A joint publication prepared for the event examined achievements, challenges, new directions, working together for results and the way forward. The publication will be updated to incorporate outcomes, including 2005 Innocenti Declaration, which was adopted in Florence. The 2005 Innocenti Declaration builds on the 1990 Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding, covering infant and young child feeding practices as a whole. It also seeks to identify roles and responsibilities of key players and emphasizes that these responsibilities need to be met in order to achieve a vision of an environment that enables mothers, families and other caregivers to make informed decisions about optimal infant feeding. Finally it issues a call for action to governments, baby food manufacturers, multilateral and bilateral organisations and financial institutions, and NGOs to take the necessary action to protect, promote and support optimal infant and young child feeding practices.

Sunday Afternoon Session

1. Nutrition Assessments

Review of development and use of standard nutrition assessment protocol

• Current guidelines, training materials – SMART, NGOs, Governments
• Software - EPI INFO, Nutrisurvey (SMART)
• Anthropometry, Mortality – general agreement on what to measure and how.
• ‘Non-anthropometric’ nutrition information – e.g. dietary diversity
• Contextual data on health, food security, care – no general agreement and standards
• Dietary Diversity/Food consumption - Indicator of food security and/or indicator of individual dietary adequacy, Ongoing work and development of tools by WFP, FANTA, FAO

Nutrition information management interpretation and use- principles of good practice

• Longer term information systems in place in crisis prone populations
• Multi-partner assessment (including local authorities)
• Consensus on the findings and recommendations
• Clear statement for users of the information
• Inter-sectoral assessments / contextual analysis / concurrent food security or livelihoods assessments
• Archiving of raw data in the country
• Sharing of training resources and opportunities
• Sincere capacity development for local nutritionists

Use of nutrition information - influencing decision-making?

• Acknowledge crisis prone populations – not just emergencies
• Anthropometry – use and abuse e.g. high levels of malnutrition required as evidence of crisis
• Promote use of non-anthropometric data e.g. food consumption
• Document and publicise experiences
• Recommendations reflecting underlying causes; Understand the history
• Information for decision-making / advocacy; what information required – whose responsibility?

Issues needing further attention / ongoing discussions

• Classification systems for humanitarian crises/famine/food insecurity.
• Relationship between malnutrition and mortality
• Linking nutritional status with food security data
• Methods for assessing the underlying causes of malnutrition
• Sampling for dispersed rural populations
• Use and interpretation of W/H and MUAC
• Mortality surveillance during periods of crisis
• Comparisons in W/H, W/A and H/A among populations. Understanding differences in body proportions and growth patterns among populations.
• Use of median to represent nutritional status of population

Other interesting initiatives

• Proposed Humanitarian Tracking Service
• Greater Horn of Africa Regional Food Security and Nutrition Working Group
• Integrated Humanitarian Phase Classification reference tool
• Implications of WHO Multi-Centre Growth Reference Study (MGRS) on interpretation of nutrition data. (New reference available in April 2006)
• Ongoing work by UNICEF and Tulane University on regional analysis of nutrition information in Africa.

Overall conclusion: Nutrition assessment work will need to be carried on in the working plan 2006/2007.

2. SMART Session

Positive Points
Accessing the web site and downloading easy

• Easily determining the sample size and cluster selection
• Standardised training: The statistical test is automatic and provides an objective validation of measurement quality
• Data entry: Data is easy to enter. It gives you the W/H index calculation at the end of every child (only Z-score)
• Checking for measurement bias: Standard deviation, kurtosis, skewedness, distribution of cases of malnutrition per cluster, digit preference par team…
• Automatic analyses of the results and completion of the report

Weaknesses of the software:

• Table for cluster sampling: Number of geographic units limited
• Standardised training: limited number of enumerators
• Standardised training: too many measurements on each child.
• The additional data have to be exported to excel to be analysed
• The interpretation of the results of the data quality checking requires a higher degree of competence
• The MUAC results are not included in the word report
• Not possible to save the population size in the mortality sample: solved
• Data entry cannot be entered using different computer
• The causes of death are not included
• The software is easy to use but the interpretation of the results of the checking for measurement bias requires a high degree of competence.
• Risk to mix the traditional methodology with the SMART methodology in the field with experienced nutritionist
• In March 2006 two nutritional surveys have been carried out in Mali and Niger, with the lesson learnt from the last experience

3. LQAS for Rapid Assessment of Children’s Nutrition and Health Status

LQAS approaches have been adapted to allow for rapid collection and analysis of statistically representative data on global acute malnutrition (GAM) in emergency settings. Together with Save the Children (SC)/US, FANTA conducted a field validation of the approach in two administrative units (Fur Baranga and Habila) in West Darfur, Sudan. FANTA programmed the survey instrument onto Personal Data Assistants (PDAs) and with SC/US operationalized the automated entry data collection method in West Darfur.

Why:
WHO, national governments, and international agencies use trigger or threshold levels of key indicators for classifying the severity of a situation e.g., GAM ≥ 15% is defined as a critical situation. Also there is a need for rapid, cost effective and valid tools to determine levels of key indicators such as GAM and SAM (e.g. SMART indictors).
LQAS is a quality control statistical method, which is highly relevant for detecting threshold levels of indicators and analyzing data according to a pre-defined classification system

How:
LQAS Designs (33x6 and 67x3) were implemented simultaneously alongside a traditional 30 x 30 cluster design and the results of the different designs compared in terms of GAM threshold analysis, point estimate analysis, and time required for data collection. The small number of observations per cluster (6 and 3) and the larger number of clusters sampled (33 and 67 clusters) for the LQAS designs is based on computer simulations which found for a sample size of 200, a small number of observations in a cluster (up to size 6) produce similar error to SRS for assessment of GAM thresholds of 10%, 15%, and 20% .

Variables:
GAM and other child- and household-level data were collected and analyzed. Time data were collected and reported for the three different designs.

Results:

33x6 and 67x3 LQAS designs allow for probability-based decision with known statistical error about whether the prevalence of GAM is above or below the thresholds of 10%, 15%, and 20%.

33x6 and 67x3 LQAS designs provide statistically reliable point estimate data with reasonable CI widths for most child and household level indicators (notable exception is mortality) 33x6 and 67x3 LQAS designs offer substantial benefit over 30x30 cluster design in terms of sample size and time required for data collection

33x6 and 67x3 LQAS designs are appropriate for purpose of rapid assessments in food insecure and emergency settings

Next Steps:
Publish methods of computer simulations and findings from Ethiopia and Sudan field studies in peer reviewed journals

4. Food Security experience

IFCR presented a session on how backyard garden programmes can improve quality of life for households affected by HIV/AIDS an experience in Swaziland

Positive lessons learned:

• Spillover effect: threefold increase in project members.
• Selection through the Home Based care facilitators guaranteed the right beneficiaries.
• Its simple design and quick revenues caused enthusiasm throughout the community and desire to be included in the project.
• If members died: membership passed on other household members (continuity!). New additional members: included after identification by the Home Based care facilitators.
• Some project members were on ARVs and the project increased the quality of their food, which presumably will have increased their quality of life.
• The individual set-up assured commitment and responsibility of each project household. The crops could provide food within 1-3 months and no other decision takers but the household members were involved in when to consume or cash in revenues…..
• Most backyard gardens planted throughout the year with alternating crops.
• No project members’ withdrawals.

Negative:

• Water collection partially failed: internal disagreement - alternatives should have been sought quicker and tested.
• Training was systematically provided to new project families, but never repeated for households from which initially trained project members had died.
• Young people were not systematically engaged in the cultivation or in training.
• Targeting mainly the elderly and PLWHA could be a threat in commitment and sustainability
• Lack of proper baseline data to measure impact fully
• To date lacking information on cost-efficiency

In addition, during this session, FAO, informed participants of the recent shift of FAO emergency response from agriculture rehabilitation to restoration of agriculture-based livelihoods. She summarised recent discussions in the food security sector on the need to ensure better linkages between information and action and suggested that more attention be given to biodiversity and food safety in crisis situations. She insisted on the importance of involving and building up capacity of local institutions as well as increased use of participatory approaches (including beneficiary assessment). She concluded with a plea to move forward to joint core assessment to facilitate complementary programming for protecting and promoting nutrition in crisis situations.

5. Supplementary Feeding Review

There was a brief update on the interagency supplementary feeding review lead by Save the Children-UK. Subsequently a side session meeting was held on this during the SCN main meeting where all concerned parties have participated in this meeting.

6. Work Plan Discussion

During the pre-session meeting of the NIE WG, it was recognised that:

• The review of the 2005 working plan was not systematically covered;
• The days presentations were not fully reflecting the working plan, only selected subjects were covered (MN, assessments, infant feeding);
• The 2006-2007 working plan needed to be developed and endorsed, but because of time constraint, difficult to cover in 30 minutes;
• The terms of reference of the themes were absent and need to be specified.

Main Recommendations

1. It was recognised that the pre-meeting on Sunday was enough to discuss all the issues related to nutrition in emergencies and as such longer meeting e.g. 3 days was recommended to take place before the next SCN meeting.
2. Thematic areas need to be revised with new focal points as required. Therefore, Saskia van der Kam (MSF) and Andrew Thorne Lyman (WFP) are newly appointed focal points for the HIV/AIDS thematic area.

There was no time to update on all aspects of the working group’s 2006 work plan and it was recommended that a more detailed work for shaping the work plan for 2007 is required. This could be part of the meeting proposed above to include the following possible objectives:

• Review of NIE WG achievements to date;
• Define or re-define TOR of NIE WG;
• Prioritize the themes and identify gaps/needs/new emerging topics (brainstorm) - avoid duplication but enhance coordination with other WG;
• Review evidence-based achievements of theme groups

Summary of the Tuesday Meeting for the Nutrition in Emergencies Working Group
 

Session 1:

The two hours session began with a summary from the all day Sunday meeting (please refer to the notes and presentations from the Sunday session for a summary and details). The working group reviewed the 2005 work plan and discussed a new plan for 2006 and 2007. Participants expressed an evident need for more time: To systematically review the work plan; cover a wider range of topics; and define the roles of the members of the working group.

The following were proposed:

• A separate interagency annual meeting of approximately 3 days to be held mid way between two SCN meetings, organised by a steering committee of the NiE WG - perhaps with ENN as a permanent member
• Review evidence based achievements of theme groups
• Identification and prioritisation of themes / gaps / emerging topics
• Review of NIE WG achievements to date
• Networking opportunities
• UNHCR may be able to host the first of this kind of meeting in 2006

Outstanding Issues:

1. Consensus on annual interagency meeting?
2. Future of the Care Practices Group?
3. Future of Adult malnutrition Group?
4. Focal point for Community Based Therapeutic Feeding Group?

Session 2:

Andre Briend from the World Health Organization provided a brief summary of the proceedings from the November 2005 WHO informal consultation on community-based management of severe malnutrition in Children. The main points of the meeting include:

• In addition to weight-for-height < 70% or < -3 Z-scores of the median NCHS/WHO reference values and/or bilateral oedema, MUAC < 110 mm can be used independently as a criterion for admission to a therapeutic feeding program for children aged 6-59 months
• High coverage (both temporal and spatial) of the programs, achieved through active case-finding activities, as established in the SPHERE minimum standards must be a key objective for therapeutic feeding programs.
• It is highly desirable to manage severely malnourished children with no complications in the community without an inpatient phase. These are severely malnourished children who are alert, have good appetite, are clinically well, are not severely oedematous, and have reasonable home-care circumstances.
• Children with severe malnutrition and complications should be referred to an inpatient treatment facility with trained staff. These children include severely malnourished children with anorexia, children with severe oedema or children who are clinically unwell.
• Ready to Use Therapeutic Foods (RUTF) is useful to treat severe malnutrition without complications in communities with limited access to appropriate local diets for nutritional rehabilitation.
• When families have access to nutrient-dense foods, severe malnutrition without complications can be managed in the community without RUTF, by means of carefully designed diets using low-cost family foods, provided appropriate minerals and vitamins are given.
• The general principles and guidelines for the care of severely malnourished children in areas of high HIV prevalence do not fundamentally differ from those where HIV is rarely seen
• WHO to develop guidelines for the community based management of severe malnutrition including specifications for RUTF production
• WHO and partners (UNICEF, WFP, UNHCR) to advocate for community-based management of severe malnutrition and assist countries to introduce community-based management into health policy and health systems.

Session 3:

Flora Sibanda (UNICEF) and Anne Callanan (WFP) shared information on the “IASC Nutrition cluster, concept, and practices”. In a nutshell,

• The cluster approach enabled a delineation of responsibilities and tasks into smaller and more manageable sectors and areas, enabling Government departments, UN agencies, NGOs to remain focused on their areas of expertise. The clusters also provided a forum for accelerating information sharing and decision-making, agencies to quickly identify needs, resource gaps and requirements. The overall result was a more rapid, coordinated and appropriate response.
• Heads of Cluster meetings were chaired/led by non-operational agencies which frequently failed to consider the operational demands of those agencies/staff involved in aid delivery. Critical management staff spent an average 5-6 hours per day in meetings. We have yet to see a clear definition of the "cluster approach" and how it distinguishes itself from the very practical "sectoral approach
• Anne Callanan provided an example of the cluster approach in the recent response to the Pakistan Earthquake. The cluster approach in Pakistan enabled a delineation of responsibilities and tasks into smaller and more manageable sectors and areas, enabling Government departments, UN agencies, NGOs to remain focused on their areas of expertise. It also provided a forum for accelerating information sharing and decision-making, agencies to quickly identify needs, resource gaps and requirements. The overall result was a more rapid, coordinated and appropriate response. However there were challenges such as: scarce agency presence and many meetings, multiple reporting demands for different entities, new concept and difficulties, lack of clear guidance, and insufficient Govt presence

Session 4:

Alessandro Loretti (WHO) discussed the “humanitarian tracking services”. The humanitarian tracking services approach was initiated by the IASC at the request of the Emergency Relief Coordinator to address two concerns:

1. The allocation of attention and resources to humanitarian crises is not based on objective and impartial evidence; and
2. There is no agreed system for monitoring trends and measuring the effectiveness of humanitarian action.

The goal is to improve performance and accountability in the context of the international humanitarian system reform. So the purpose was to establish systematic arrangements to provide programme managers, donors and policy makers with impartial, credible, timely and analytical information on the Mortality, Health, and Nutrition status of populations of humanitarian concern. (Further details are provided in the Session 4 document)

Session 5:

Marika Ferrari (NRIFN) presented a case study demonstrating the double burden of malnutrition. Several surveys in the Saharawi refugee population reported a high rate of malnutrition among infants and young children. Furthermore, anaemia, overweight and obesity have been reported in women in fertile age. In the study that Dr. Ferrari conducted, malnourished children coexisted with maternal overweight or obesity in 37,6% of the households. Dr. Ferrari concluded that the coexistence of children malnutrition and maternal overweight asks for more attention from public health programs, that will have to identify and consider the magnitude of households dual burden and then to develop more targeted interventions (see detailed presentation and word document in session 5 attachment).

Session 6:

Discussion and Election of New Chair Person
A question and answer session followed, for details of the questions asked and the answers provided, please see Session 6 QA attachment.

At the end of the session, the UN chair to the working group, Fathia Abdalla, announced that she was stepping down as the UN representative co-chair and suggested that Zita Weiseprinzo (WHO) and Anne Callanan (WFP) could co-represent the UN co-chair on the working group. The working group agreed to the two new nominations and that the co-chairs write an official letter submitting the above mentioned names to the Steering committee for approval.