NUTRITIONAL

EMERGENCIES
OVERVIEW AND CASE STUDY
Fernanda Falero Cusano
Salford Royal PhD Studentship
HCRI, UoM
Focusing in:

 Definition, assessment of causes, forms and main indicators of

malnutrition.

 Exemplification in a Case Study: a MSF project in Matala, Angola, 2002-

2004.

 Description of the treatment of Severe Acute Malnutrition in Therapeutic

Feeding Center (TFC) and of Moderate Acute Malnutrition with mobile
clinics, using F75, F100, BP100, PumplyNut and Unimix (Premix).

 Explanation of changes in the MSF approach to the response to

nutritional emergencies after 2006.

A FIELD EXPERIENCE FROM A NON MEDICAL HUMANITARIAN

WORKER.

OBJECTIVES
 Malnutrition essentially means “bad nourishment”.

 It concerns not enough as well as too much food,

 the wrong types of food,

 and the body's response to a wide range of infections that result in

malabsorption of nutrients or the inability to use nutrients properly to
maintain health.

 Clinically, malnutrition is characterized by inadequate or excess intake of

protein, energy, and micronutrients such as vitamins, and the frequent
infections and disorders that result.

(WHO, 2001)

Malnutrition: definition
 Assessment of food and nutritional situation:

1. Understand causes –political, social, economic context. Identify causal

factors –access to food, health services and/or social care system.

2. Define the stage of the food security problem –

a) food insecurity -usually temporary, coping mechanisms reversible, harmless
for future,
b) food crisis -coping mechanisms irreversible, compromise future, or
c) Famine -absolute lack of food, no coping mechanisms at all, distress
migration of entire villages

3. Identify appropriate and feasible interventions according to the stage

and context.

4. Establish a system of nutritional surveillance.

(MSF, 2006)

Food and Nutritional Assessments

1. Understanding causes (UNICEF, 1990; Valid Intl, 2006)
2. Defining the stage of the crisis
  The Global Malnutrition, the severe malnutrition
rate and the severe malnutrition in adults are
measured from the individual nutritional status.

 Then, determine what proportion of the population

falls below a certain threshold according to the
evaluation.

 Theindividual nutritional status may be measured

using: clinical, biochemical and/or
anthropometrical evaluations.

2.1 Measuring malnutrition

•The anthropometrical measures are those
that you take for each individual.
MEASURES

•The combination of these measures will

give you, for each individual, an indice. INDICES

•The indicators are indices that are applied

to a population to give you information
about the nutritional status of this
population.
INDICATORS

2.2 Evaluating the nutritional Status

 • Weight

• Scale :
– 25 kg graduated at 100 g
– Accurate to 100 g approximately
– Frequent Calibration (tarage)
• Child undressed.
• Reset to zero between weighing.
• Read balance facing exactly the front.
• Do not touch the child during measurement.

Anthropometric measures
 Height

• Measurement using the metric system.

• Height board and 2 people measuring.
• < 2 yrs or < 85 cm : measure child lying down.
• > 2 yrs or > 85 cm : measure child standing up.

Anthropometric measures
 • MUAC (Mid Upper Arm Circumference)
• Measured (in mm) with MSF ribbon or bracelet
• Mid-upper left arm relaxed
• Accuracy: 2mm

• Best death risk indicator (MUAC < 110 mm)

• MUAC : Measures the lean body mass

• Utilization based on the principal that MUAC

varies little between 12-59 months (about 1.5 cm)

• Fast and easy to use

• Highly used for mass screening

Anthropometric measures
Age

Obtained on the basis of:

• Child’s date of birth

• A local events calendar

• Some markers:

– Children of > 6 months = > 65 cm

– Children of < 59 months = < 110 cm

Anthropometric measures
 • Oedema
• Bilateral pressure for 3 seconds with thumbs on the upper surface of
the feet.
• Nutritional oedema if appearance of a bilateral pitting (in both feet).
• KWASHIORKOR sign.
• Gravity sign.

Anthropometric measures
MEASURES

INDICES

INDICATORS
 • Weight for height (W/H)
Indices : combination of 2
measures • Height for age (H/A)

• Different ways of expressing them

• Weight for age (W/A)
but same principle, compare to • (Body Mass Index)
a reference value
• International reference standards
 Curves of National Centre of Health Statistics (NCHS)
 Created on the basis of measurement of thousands of children (USA)
 Adopted by WHO/CDC in 1977
 Allows international comparisons
 Quality standard
 Child Growth standards (WHO, 2006)

Sign : •Oedema
Measure : •MUAC

Anthropometrical indices
 Example: children of same age

Normal Marasmus Stunting

Marasmus Obesity

H-A     
W-A     
W-H     
Mortality risk increased

Meaning of anthropometrical indices

• Comparison with standards uses statistics laws
• Three methods used:
 Percentage of median
 Z-score (Standard deviation)
 Percentils

WHO 2006 Child Growth Standards

• Weight-for-age
• Weight-for-length/height
• Length/height-for-age
• Body mass index-for-age

Expresing Anthropometrical indices

 W/H W/H MUAC
NUT. STATUS
Z-SCORE % OF MEDIAN (6-59 months)

Global acute <-2 < 80% < 125 mm

malnutrition or oedema or oedema or oedema

Moderate acute
< - 2 to  - 3  70% to 80% 110 mm to < 125 mm
malnutrition

Severe acute <-3 < 70% < 110 mm

malnutrition or oedema or oedema or oedema

• Threshold values proposed by WHO for BMI

• > 17 – 18,5 = at risk malnutrition 
• = 16 –16,9 = moderate malnutrition
• < 16 = severe acute malnutrition

Thresholds for determination of individual nutritional

status (6-59m and adults)
 Infants………………….Weigh for Height, clinical
Pregnant women……MUAC, Hematocrit
Older people………….BMI, MUAC, clinical
Adults……………………BMI, MUAC, clinical

Anthropometrical indices in other groups

• Anthropometric indices
– W/H : current acute malnutrition
– H/A : chronic malnutrition
– W/A : combination of both
– BMI : adult malnutrition
• Anthropometric measures
– MUAC : risk of death

• Anthropometric signs
– Oedema : aggravating sign

Indices and type of malnutrition

 Moderate Severe
Normal At risk Malnutrition Malnutrition

         
Weight for 90 à 120 % 80 à 89 % 70 à 79 % < 70 %
Height (+2 à -1 Z) (-1 à -2 Z) (-2 à -3 Z) (-3 Z)
WASTING
Height for 95 à 110 % 90 à 94 % 85 à 89 % < 85 %
Age (+2 à -1 Z) (-1 à -2 Z) (-2 à -3 Z) (-3 Z)

STUNTING
Bilateral
oedema ---- ---- ---- Yes
KWASHIORKOR

MARASMATIC KWASHIORKOR

Clasification of malnutrition
Moderate:
Weight for Height: Severe:
• -3 < -2 Z-scores. Weight for
• 70 < 79 % Height:
median. • < -3 Z-scores.
MUAC • < 70 %
• 110 < 125 mm median.
MUAC
Progressive if no • < 110 mm
food.
~ 2 months ? High mortality
~ 1 month ?
Nutrition support.
Medical and
nutrition support.

Types of malnutrition: marasmus

 Bilateral pitting oedema.
High mortality
Medical and nutritional support (delicate
!)

Marasmatic Kwashiorkor:
Highest mortality.

Types of malnutrition: Kwashiorkor

 Stunting or growth retardation.
Chronic / past nut deficiencies.
“Adaptation” ?
Repeated acute malnutrition.
Height for age.
Not a priority in emergencies

21months 8 years

Chronic malnutrition
MEASURES

INDICES

INDICATORS
•Global Malnutrition is the prevalence of acute malnutrition,
that is % of children of a given population global,
moderate or severe malnourished.
•Severe malnutrition rate is the % of severe acute
malnourished in the total of < 5 years.
•Severe malnutrition in adults is the % of severe
malnourished adults in total adult population.

Determining the indicators of malnutrition

 Prevalence Nutritional status of population

< 5% acceptable

5 -10% precarious

11- 20% severe

> 20% very severe

-The nutritional stage may be food

insecurity, food crisis or famine.

-Should ALWAYS be interpreted within the

context.

Determining the nutritional stage

2. Defining the stage of the crisis
 General
Intervention Nutritional
Objectives:
Reduce
programmes
mortality and
morbidity due to
malnutrition

 Ensure that needs for

food are covered according
to the food insecurity level
of the population at risk
Food
programmes

3. Intervention according to the stage and context (1)

Blanket feeding program + GFD + Supplementary Feeding program
Supportive Feeding Program (SFP)

Therapeutic Feeding Centre (TFC)

3. Intervention according to the stage and context (2)

 Assessment of food and nutritional situation:

1. Understand causes –political, social, economic context. Identify causal

factors –access to food, health services and/or social care system.

2. Define the stage of the food security problem –

a) food insecurity -usually temporary, coping mechanisms reversible, harmless
for future,
b) food crisis -coping mechanisms irreversible, compromise future, or
c) Famine -absolute lack of food, no coping mechanisms at all, distress
migration of entire villages

3. Identify appropriate and feasible interventions according to the stage

and context.

4. Establish a system of nutritional surveillance.

(MSF, 2006)

Food and Nutritional Assessments

 Ongoing, systematic collection, analysis and
interpretation of data. Detects trends.

Objectives
• To detect and predict changes in the food and
nutritional situation (particularly a deterioration)
• To quantify changes in food security or in the
nutritional environment
• To provide information for advocacy and lobbying
messages
• To identify areas needing further investigation

4. Nutritional Surveillance
Types of data collection:

 Systematic data collection (periodic: weekly,

monthly). Trends. Weekly mortality rates, GFD,
admissions and indicators of feeding centers, market
prices, etc. Sentinel sites may be used.

 Intermitent data collection. Snapshot investigations

to confirm the trend and measure the extent of the
change. Anthropometric surveys, measles vacc
coverage surveys, retrospective mortality surveys, etc.

4. Nutritional surveillance: Data collection

Case
study, Angola

2002 :

End of the civil

war, Savimbi killed

Around 4 million
IDPs

 Assessments in
Huambo, Bie and
Huila provinces
(inaccessible during
the war)

(Report MSF, 2007)

  Findings:

1. Mortality rates: 6,1/10,000/day <5 and 4,5/10,000/day gen.

population (MSF, May 2002)

2. Global acute malnutrition: 57%, Global Severe malnutrition: 35%

(MSF, May 2002)

Emergency situation
  TFC
 SFC
 SFP +GFD (WFP)

Matala, Huila Province

Provides intensive medical and nutritional
Treatment for severely
malnourished individuals

Objectives :
 Reduction of mortality
among severely malnourished
individuals. (All ages)
 To treat severe malnutrition

Capacity: 100 max

Matala TFC
 Phase I: Inpatient intensive medical and nutritional
care for severely malnourished w/ life threatening
conditions

 Phase II: severely malnourished no complications

 Follow up: SFC

 Medium stay: 4-6 weeks

Health education

 Milk F75, F100, BP100, Plumpy Nut +

Systematic Protocole (Amoxi, Antipalu,
Folic Acid, Vitamin A, Antihelmintique)

Matala TFC
 Ambulatory program, objectives:

Follow up of discharged TFC

patients
medical and nutritional treatment of
moderately malnourished
Prevention of severe malnutrition

 Admission: W/H and MUAC

Capacity:
 1200-1500 week

Matala SFC
 Every 2 weeks

 Health education

 Provides fortified food supplements: dry rations of PREMIX

1000-1500 calories/day

Matala SFC
a) Outcome indicators c) Average weight gain
Proportion TFP SFP
of exits Objective Objective
TFC: 10 g/Kg/day
Cured > 80% > 75%
ATFC: 5 g/Kg/day
Defaulter < 10% < 15% SFC: 3-5 g/Kg/day

Deaths < 5% < 2% d) Attendance Rate

TFC  85%
SFC  75%
b) Mean/Average
leangth of stay

TFC < 30-45 days

SFC < 60 days

Reference values
 SFP
Pregnant / Lactating women
Inpatients at hospital
TB patients

GFD WFP Ration

2113 kcal
Food monitoring
11% proteins
Lobbying, advocacy 18% fats

Supportive Feeding Program + Food Distribution

 TFC

SFC

Program disadvantages
 Community-based Therapeutic Care (CTC). Empowers communities,
continuum between “emergency” and “development”.

 Severe acute malnutrition are treated with therapeutic RUFs in outpatient

feeding centres. Home based treatment+education and support (outreach
workers, mothers). Only children with complicating conditions still need to
be hospitalised.

 Distribution of supplemental RUFs, which complements regular meals and

compensates for deficiencies in regular diet. More preventive mesure.

 Pilot programs in Ethiopia with very positive results (Collins, 2001).

 NEW APPROACH NIGER

New approach
(Collins, 2001)
 Uncomplicated
Severe cases
Complicated Severe
& moderate cases
Ambulatory
TFC (80%) Ambulatory
TFC
Supplementary
Supplementary
INPATIENT
TFC
Uncomplicated (20%)
Moderate cases
Ambulatory
Ambulatory
TFC
TFC
Supplementary
Supplementary

ITFC & ATFC organisation

 • Until 93/94: Treatment given in
hospitalisation (TFC 24/24) with a milk
made up of oil, sugar, milk in powder.
 Cured rate of more or less 75%,
capacity of treatment limited to 100
patients, strategy using important
means (HR, log). “Amateur” approach
(low coverage, low quality)

• 94 to 2000: F100 formula for the

treatment of the severe acute malnutrition.
“Classical” approach (low coverage, high
quality)
 Cured rate of 85%, improved
treatment (F100) but the operational
model stays the same (TFC 24/24).

Evolution of the malnutrition treatment (1)

 • 97: Plumpy’nut. F100 formula
in pasta ready-to-use form,
simple to use without need of
adding water.
• 99: BP100. Instant-milk,
blended and enriched flour,
precooked, compacted into biscuit
form.
 Creation of the conditions
allowing the decentralisation of
the treatment.
• 2001/4: Development of the
ambulatory approach.
 « New approach » (!) (high
coverage, high quality)

Evolution of the malnutrition treatment (2)

 (UNICEF, 2007)

State of the world´s children

 Collins, Steve, Changing the way we implement famine relief programmes,
Lancet, August 2001
 MSF, Medical supplies and equipment, Reference Books by ITC, V.2,2009
 MSF, http://www.starvedforattention.org campaign
 MSF, 18,000 civilians in Severe Nutritional Distress in Chipindo, Press
Release, May 2002, www.doctorswithoutborders.org
 MSF, Informe sobre la Misión de Médicos sin Fronteras en Angola, April 2007
 MSF, Nutrition Guidelines, Reference Books by ITC, 2006
 UNICEF, Causes of Malnutrition, 1990 www.unicef.org
 Valid International, Community Based therapeutic Care, A field Manual, 2006
 WHO, Child Growth Standards, 2006 http://www.who.int/childgrowth/en/
 WHO, Water related deseases, Malnutrition,
 WHO, State of the World Children 2007, Geneva, 2007 www.who.int

REFERENCES
THANK YOU!