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Nutrition Module Session 4

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Nutrition Module Session 4

The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training Modules.

    2004

    Nutrition Module: Session 6

    Micronutrient deficiency diseases (MDDs)

General nutritional support standard 1: all groups (page 137)

    “The nutritional needs of the population are met”

Correction of malnutrition standard 3: micronutrient malnutrition (page 152)

    “Micronutrient deficiencies are addressed”

Overall Objective

    ? To gain a familiarity with and understanding of the standards, key indicators and guidance

    notes.

Specific Objectives:

    ? To outline why certain Micronutrient Deficiency Diseases (MDDs) are of particular concern

    during an emergency.

    ? To review causes, clinical signs and risk factors for certain micronutrients.

    ? To discuss concepts and constraints associated with assessing MDDs.

    ? To outline preventative and treatment strategies for MDDs.

Main messages:

    ? The most common micronutrient deficiency diseases occurring both in stable and emergency

    situations are goitre, anaemia and xerophthalmia.

    ? Scurvy, pellagra, beri-beri and riboflavin deficiency are rarely observed in stable situations

    but do occur in emergency affected populations, especially among populations that are reliant

    on food rations.

    ? The assessment of MDDs is based on clinical diagnosis and/or biochemical analyses.

    ? Diagnosis of clinical signs and symptoms are used most commonly in emergency situations

    but there are many constraints and problems associated with this type of assessment.

    ? Assessment of risk factors for MDDs are important in emergency situations.

    ? Strategies to address MDDs should be based on a range of options.

    ? If a population is at risk of suffering from a MDD, or if an outbreak occurs, it is important to

    establish a surveillance system.

    Reading

    ? WFP Food and Nutrition Handbook. Annex 1.1. Micronutrient functions, sources and effects

    of processing. Pages 99-103.

Handouts:

    ? Handout 1a: Revolving MDDs: Question and Answer Form and photos of MDDs

    ? Handout 1b: Summary of answers to revolving MDDs exercise (at end of exercise)

    ? Handout 2: Case study: Scurvy outbreak in Kohistan, Afghanistan [example case study]

Resources required for Session 6

    ? Flip chart and marker pens

    ? Handouts and reference reading.

Timeframe

     Slides and discussion Exercises

    Objective 1 5 mins Objective 2 Ex 1: 30 mins

    Objective 3 20 mins Objective 4 5 mins Ex 2: 30 mins

The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training Modules.

    2004

Slide 1

For all slides in this document, please refer to corresponding Power Point Files „S6 MDDs –

    visuals.ppt‟

? This session covers the General Nutritional Support: All Groups and also the Correction of

    Malnutrition: Micronutrient malnutrition standard.

    ? Ask a participant to read out the two standards

    ? Ask participants to take a minute to read through the key indicators relating to

    micronutrients.

    ? Recommend to the participants to number any key indicators not already numbered, so that

    reference can be easily made to them.

Slide 2

Slide 3

? Remember in session 3 we have already discussed the need for access to a diversified diet

    which includes micronutrients.

    ? Hence in this session we will explore the two indicators under General Nutritional Support:

    All Groups which refer specifically to MDDs.

Slide 4

    ? The session will also address the 3 indicators under Correction of Malnutrition Standard 3:

    Micronutrients.

Slide 5

? Introduce the objectives of the session.

Objective 1: To outline why certain Micronutrient Deficiency Diseases (MDDs) are of

    particular concern during an emergency.

Slide 6

? Ask participants: What are the three micronutrient deficiency diseases that are of most

    public health significance in the world?

    ? Answer: The most common micronutrient deficiency diseases occurring both in stable and

    emergency situations are goitre, anaemia and xerophthalmia. These are endemic and are

    widespread in many developing countries.

The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training Modules.

    2004

    ? However, scurvy, pellagra, beri-beri and riboflavin deficiency are rarely observed in stable

    situations but do occur in emergency affected populations, especially among populations that

    are reliant on food rations (see GN 5 page 140).

    ? The occurrence of any of these diseases in a population would suggest that their nutritional

    needs are not being met. Or more specifically, the populations‟ requirements for these

    specific micronutrients are not being met.

Slide 7

Objective 2: To review causes, clinical signs and risk factors for certain micronutrients.

     Exercise 1 30 mins REVOLVING MDDS

    The aim of the exercise is to allow the participants, in different groups, to identify and discuss the nutrient

    deficiency, signs and symptoms, risk factors and recent outbreaks of the MDDs

    1. Divide the participants into 6 groups. 2. Each of the groups is given a question and answer form (handout 1a) and a photo of one disease (from

    handout 1a)

    3. Each group then answers question 1 on the form [ie. „name the specific nutrient that is deficient and the

    name of the deficiency disease‟ and „name any reported outbreaks that have occurred in recent

    emergencies?‟]

    4. The form and photo is then handed to the next group to respond to question 2 [ie „List the clinical signs

    and symptoms of the disease‟] on the form. 5. This is repeated once more so that question 3 [ie „Which specific populations are at risk of becoming

    deficient?‟] is addressed.

    6. There is a time-limit of 5 minutes on each ROUND. 7. At the end, one person from each group gives brief feedback by summarizing the answers (see below

    for answer sheet).

    8. Participants can refer to any documentation that they want to for help with the answers.

    9. Give the answer sheet handout 1b at the end.

The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training Modules. 2004

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The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training Modules.

    2004

Objective 3: To discuss concepts and constraints associated with assessing MDDs.

Slide 8

? Let‟s move on to objective 3: to discuss concepts and constraints associated with assessing

    MDDs.

    ? Make reference to GN 6 (page 140) in which it states that „tackling micronutrient

    deficiencies within the initial phase of a disaster is complicated by difficulties in identifying

    them. The exceptions are xerophthalmia and goitre for which clear „field –friendly‟

    identification criteria are available.‟

? There are two main ways to assess MDDs; biochemical analyses and clinical diagnosis.

    ? Biochemical analysis requires that blood or urine is analysed under laboratory conditions.

    Samples need to be stored in suitable conditions until analysed. The methodology requires

    specialised equipment, expertise, is expensive and is relatively invasive. However,

    biochemical analyses allows the problem to be identified at an earlier stage.

    ? In emergency situations, biochemical analyses are not usually feasible. Therefore, clinical

    diagnosis is usually the more commonly used method for diagnosing a „problem‟.

    ? The clinical manifestation of a MDD is assessed by physically observing for specific signs

    and symptoms. For survey purposes, diagnosis will be based on a case-definition. An in-

    depth interview with the person is helpful towards making a more accurate diagnosis. Often,

    diagnosis is made by treatment since treatment is not harmful.

    ? The clinical symptoms for each of the diseases have been discussed during the exercise.

    ? However, the problems associated with clinical diagnosis are many.

Slide 9

? Ask participants to guess the deficiency

    ? Answer: Riboflavin deficiency Angular stomatitis

Slide 10

? Ask participants to guess the deficiency

    ? Answer: Scurvy Perifollicular hemorrhages

    ? The two photos show that accurate diagnosis of MDDs are very difficult to make.

Slide 11

? The two previous slides highlight some of the problems of assessment using clinical diagnosis:

    (i) health staff are unfamiliar with symptoms (ii) symptoms are non-specific.

    ? Ask the participant: What other problems exist?

    ? Answer: Others problems include; (iii) lack of diagnostic tools (iv) lack of expertise (v) with

    MDDs, lack of guidelines for determining adequate sample sizes etc.

    ? Note that one of the indicators under correction of MDDs now addresses the need for training:

    Health staff are trained in how to identify and treat micronutrient deficiencies to which the

    population is at most risk (KI 3 of the micronutrient malnutrition standard on page 152). The

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The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training Modules.

    2004

    GN 2 (page 152) makes reference to the strategies for the prevention of micronutrient

    deficiencies given in General nutrition support standard 1 (as briefly discussed in Session 3).

Slide 12

? The other major issue associated with relying on clinical signs and symptoms is that evidence

    of a clinical case indicates that the problem is much wider. In other words, it is likely that

    when clinical cases are presenting, a larger proportion of the population suffers from a

    deficiency.

    ? This is the reason that Sphere states that even one case of scurvy, pellagra, beri-beri or

    riboflavin deficiency is unacceptable (see GN 5 page 140).

Slide 13

? In many situations, it will not be possible to carry out a survey (using clinical diagnosis or

    biochemical analyses). Rather than waiting for clinical „cases‟ to occur, some simple

    questions on risk factors can be asked in all situations. If there is reason to believe that one or

    more risk factors are present, it is necessary to take appropriate action and monitor the

    situation.

    ? Go through each question in the slide.

Slide 14

? Cases of micronutrient deficiency can be picked up through an established surveillance

    system.

    ? This slide shows an example of a surveillance system established for Bhutanese refugees in

    Nepal. Following identification of a large number of cases in early 1994, a surveillance

    system was maintained for the duration that the refugees were at risk.

    ? A surveillance system like this one, identifies confirmed cases through the health centres with

    an outreach system to refer suspected cases and increase coverage.

    ? This is one of the Procedures to respond efficiently to micronutrient deficiency to which the

    population may be at risk are established. (KI 2 in Micronutrient malnutrition standard see

    page 152).

? Ask participants: What other mechanisms to pick up problems could be established?

    ? Answer: Nutrition Education of the community e.g. to detect MDDs

Objective 4: To outline preventative and treatment strategies for MDDs.

Slide 15

? This slide outlines a range of possible options to prevent and/or address micronutrient

    deficiencies.

    ? This addresses the final objective of this session “to outline preventative and treatment

    strategies for MDDs”.

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The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training Modules.

    2004

? Different strategies will need to be prioritised depending on the situation.

    ? Give / ask for brief examples of each strategy to ensure participants understand.

    ? The process of prioritising the different strategies will be explored in the following case

    study

Slide 16

     Exercise 2 30 mins PRACTICAL EXERCISE: “DEVELOPING AN EFFECTIVE STRATEGY TO ADDRESS AN OUTBREAK OF X IN COUNTRY Y” The aim of the exercise is to show that no single intervention is adequate to address a micronutrient intervention.

     The case-study should preferably be one that the participants are familiar with i.e. from their country or

    region experience. If possible, one or two of the participants should be asked to prepare the case-study prior

    to the workshop.

     The case study should be ? - 1 page in length and be structured as follows: (i) Background to the emergency situation and affected population (ii) Types of food interventions (iii) Description of mechanism and number of cases diagnosed and identified The case-study should be distributed prior to the session and participants should have read and be familiar with the issues.

     1. Split the participants into four groups. Three groups represent different NGOs. One group represents a

    donor agency who is interested in funding a strategy to address the problem.

    2. Each NGO wants to support a different intervention. Each NGO should prepare a rationale and justification for why this intervention will be effective in addressing the problem. 3. Each NGO gives a brief 2 minute presentation to the donor. 4. The donor must try to identify gaps and inadequacies in the proposals. Concluding discussion should include:

    ? Importance of using a number of different strategies.

     ? Importance of thinking through practical/logistical/cultural issues

     Reference should particularly be made to General Nutritional Support standard 1: all groups KI

     Correction of malnutrition standard 3: micronutrient malnutrition KI 2 & 3 and GN 2

     An optional example is included as Handout 2

Slide 17

? Re-cap on the objectives and check whether there are any outstanding questions.

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    Sphere Nutrition Module Session 6: Handout 2

Nutrition Module Session 6: Handout 2

    1 page to each participant

    Case study: Scurvy outbreak in Kohistan, Afghanistan 1April 2001

Background:

    More than twenty years of conflict has destroyed much of Afghanistan‟s infrastructure and decimated the economy leaving Afghanistan one of the poorest countries in Asia. The fighting has

    led to population displacement and drought over 3 years from 1999 to 2001 has exacerbated the

    situation.

Kohistan:

    Kohistan is one of the most remote districts of Faryab Province in Afghanistan and is inaccessible

    by car for about six months of the year. It has a population of 57,630. The district economy is

    reliant on the production of rain-fed wheat and barley but drought has had a devastating impact on

    the food and economic security. Health services are almost non-existent, with no doctors or

    routine vaccination programme. Infectious diseases are common.

Emergency response in Kohistan:

    In response to the conflict and drought, WFP attempted a „one-off‟ wheat distribution for part of

    the population in Kohistan in November 2000. Only a few people benefited, however, due to

    logistical problems. Other emergency interventions included emergency cash loans, cash for work

    activities and 'complementing' WFP's wheat ration with pulses and oil.

Scurvy outbreak:

    A survey conducted in April 2001 found a widespread prevalence of vitamin C deficiency disease

    locally known as "Seialengia" (black legs), affecting up to 10% of the population in some villages.

    The disease affected people of all ages and gender, but to a lesser extent children under the age of

    2 years. The most severely affected groups were adolescent boys (10 - 18 years) and the elderly.

    Seialengia mainly affected the poorer families with usually more than one case per family. Wild

    green leaves were available in the spring. Seialengia cases were hesitant to eat the leaves,

    however, thinking it would aggravate their problem and/or due to general lack of appetite. Leaves

    are cooked for long periods so reducing vitamin C content and the water in which they are cooked

    is not consumed.

Exercise:

    Four NGOs are looking for funding to start interventions to address scurvy in Kohistan.

    ? NGO „Hope‟ wants to promote the consumption of wild green leaves. ? NGO „Faith‟ wants to initiate supplementation of vitamin C.

    ? NGO „Charity‟ wants to distribute complementary foods such as pulses, oil and

    blended/fortified foods.

    ? NGO „Mercy‟ wants to support livelihoods as a long term strategy.

1. Prepare a rationale and justification for your particular intervention.

    2. Briefly outline how you envisage implementing the intervention.

     1 Fitsum Assefa 2001. Scurvy outbreak and erosion of livelihoods masked by low wasting levels in drought

    affected Northern Afghanistan. ENN Issue 13: 14-16.

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