a) Have any nutrition surveys been conducted?

b) Are there any data from mother and child health clinics?

c) Are there any data from existing supplementary or therapeutic feeding centres?

d) What information exists on the nutritional situation of the affected population prior to the current crisis (even if people are no longer in the same place)?

a) Are there any reports of disease outbreaks which may affect nutritional status, such as measles or acute diarrhoeal disease? Is there a risk that these outbreaks will occur? (See Control of communicable diseases standards).

b) What is the estimated measles vaccination coverage of the affected population? (See Control of communicable diseases standard 2).

c) Is Vitamin A routinely given in measles vaccination? What is the estimated Vitamin A supplement coverage?

d) Has anyone estimated mortality rates (either crude or under five)? What are they and what method has been used? (see Health systems and infrastructure standard 1).

e) Is there, or will there be, a significant decline in ambient temperature likely to affect the prevalence of acute respiratory infection or the energy requirements of the affected population?

f) Is there a high prevalence of HIV/AIDS, and are people already vulnerable to malnutrition due to poverty or ill health?

g) Have people been in water or wet clothes for long periods of time?

a) Is there a change in work patterns (e.g. due to migration, displacement or armed conflict) which means that roles and responsibilities in the household have changed?

b) Is there a change in the normal composition of households? Are there large numbers of separated children?

c) Has the normal care environment been disrupted (e.g. through displacement), affecting access to secondary carers, access to foods for children, access to water, etc?

d) What are the normal infant feeding practices? Are mothers bottle feeding their babies or using manufactured complementary foods? If so, is there an infrastructure that can support safe bottle feeding?

e) Is there evidence of donations of baby foods and milks, bottles and teats or requests for donations?

f) In pastoral communities, have the herds been away from young children for long? Has access to milk changed from normal?

g) Has HIV/AIDS affected caring practices at household level?

a) What is the capacity of the Ministry of Health, religious organisations, HIV/AIDS community support groups, infant feeding support groups, or NGOs with a long- or short-term presence in the area?

b) What is available in the food pipeline?

c) Is the population likely to move (for pasture/assistance/work) in the near future?

Appendix 5

Measuring Acute Malnutrition

Children under five years

The table below shows the commonly used indicators of different grades of malnutrition among children aged 6-59 months. Weight for height (WFH) indicators should be taken from the NCHS/CDC reference data. The WFH Z score is the preferred indicator for reporting anthropometric survey results and WFH percentage of the median is preferred to determine eligibility for treatment. Mid Upper Arm Circumference (MUAC) should not be used alone in anthropometric surveys, but it is one of the best predictors of mortality, partly because it is biased towards younger children. It is, therefore, often used as part of a two-stage screening for admission to feeding programmes. The cut-offs commonly used are <12.5cm: total malnutrition and <11.0cm: severe malnutrition, among children aged 12-59 months.

* sometimes known as global malnutrition

There are no agreed anthropometric cut-offs for malnutrition in infants below six months, apart from the presence of nutritional oedema. The NCHS/CDC growth references are of limited use since they are drawn from a population of babies fed artificially, whereas breastfed babies grow at a different rate. This means that malnutrition will tend to be overestimated in this age group. It is important to assess infant feeding practices, particularly access to breast milk, and any medical conditions in order to determine whether malnutrition in this age group may be a problem.

Other age groups: older children, adolescents, adults and older people

There are no internationally accepted definitions of acute malnutrition in other age groups. This is partly because ethnic differences in growth start to become apparent after the age of five years, meaning that it is impractical to use a single reference population to compare all ethnic groups. A further reason is that, in most circumstances, information on the nutritional status of the group aged 6-59 months is sufficient for planners to make their decisions, and thus there has been little impetus to undertake research into malnutrition in other age groups.

However, in major nutritional emergencies, it may be necessary to include older children, adolescents, adults or older people in nutrition assessments or nutritional programmes. Surveys of age groups other than children aged 6-59 months should only be undertaken if:

• a thorough contextual analysis of the situation is undertaken. This should include an analysis of the causes of malnutrition. Only if the results of this analysis suggest that the nutritional status of young children does not reflect the nutritional status of the general population should a nutrition survey for another age group be considered;
  
  
  
• technical expertise is available to ensure quality of data collection, adequate analysis and correct presentation and interpretation of results;
  
  
  
• the resource and/or opportunity costs of including other age groups in a survey have been considered;
  
  
  
• clear and well-documented objectives for the survey are formulated.
  
  
  

Research on defining the most suitable indicators of malnutrition for people aged more than 59 months is currently being undertaken, and this information is liable to change in the next few years.

Older children (5-9 years)

In the absence of alternative measures of nutritional status in older children, use of the NCHS/CDC references is recommended to determine WFH Z score and percentage of the median and the same cut-offs as for younger children should be applied (see table above). As for younger children, nutritional oedema should be assessed.

Adolescents (10-19 years)

There is no clear, tested, agreed definition of malnutrition in adolescents. Guidance on assessment can be found in the list of references in Appendix 9.

Adults (20-59 years)

There is no agreed definition of acute malnutrition in adults, but evidence suggests that cut-offs for severe malnutrition could be lower than a Body Mass Index (BMI) of 16. Surveys of adult malnutrition should aim to gather data on weight, height, sitting height and MUAC measurements. These data can be used to calculate BMI. BMI should be adjusted for Cormic index (the ratio of sitting height to standing height) to make comparisons between populations. Such adjustment can substantially change the apparent prevalence of undernutrition in adults and may have important programmatic ramifications. MUAC measurements should always be taken. If immediate results are needed or resources are severely limited, surveys may be based on MUAC measurements alone.

Because the interpretation of anthropometric results is complicated by the lack of validated functional outcome data and benchmarks for determining the meaning of the result, such results must be interpreted along with detailed contextual information. Guidance on assessment can be found in the references.

For screening individuals for nutritional care admission and discharge, criteria should include a combination of anthropometric indices, clinical signs and social factors (e.g. access to food, presence of carers, shelter, etc). Note that oedema in adults can be caused by a variety of reasons other than malnutrition, and clinicians should assess adult oedema to exclude other causes. Individual agencies should decide on the indicator to determine eligibility for care, taking into account the known shortcomings of BMI, the lack of information on MUAC and the programme implications of their use. Interim definitions of adult malnutrition for screening for treatment can be found in the references.

MUAC may be used as a screening tool for pregnant women (e.g. as a criterion for entry into a feeding programme). Given their additional nutritional needs, pregnant women may be at greater risk than other groups in the population (see General nutrition support standard 2). MUAC does not change significantly through pregnancy. MUAC <20.7 cm (severe risk) and <23.0cm (moderate risk) have been shown to carry a risk of growth retardation of the foetus. The risk is likely to vary according to the population.

Older people

There is currently no agreed definition of malnutrition in older people and yet this group may be at risk of malnutrition in emergencies. WHO suggests that the BMI thresholds for adults may be appropriate for older people aged 60-69 years, but these are subject to the same problems as in younger adults. In addition, accuracy of measurement is problematic because of spinal curvature (stooping) and compression of the vertebrae. Arm span or demi-span can be used instead of height, but the multiplication factor to calculate height varies according to the population. MUAC may be a useful tool for measuring malnutrition in older people but research on appropriate cut-offs is currently still in progress.

Disabled people

No guidelines currently exist for the measurement of individuals with physical disabilities and thus they are often excluded from anthropometric surveys. Visual assessment is necessary. MUAC measurements may be misleading in cases where upper arm muscle might build up to aid mobility. There are alternatives to standard measures of height, including length, arm span, demi-span or lower leg length. It is necessary to consult the latest research findings to determine the most appropriate way of measuring disabled individuals for whom standard weight, height and MUAC measurement is not appropriate.

Appendix 6

Measures of the Public Health Significance of Vitamin A and Iodine Deficiency

Indicators of vitamin A deficiency (xerophthalmia) in children aged 6-71 months

(prevalence of one or more indicators signifies a public health problem)

Indicators of iodine deficiency (goitre)

The indicators shown in the table below are those that may be possible to measure in a disaster. The prevalence of at least one and, more definitely, two indicators signifies a public health problem. These indicators of iodine deficiency may be problematic: biochemical indicators may not be possible to measure in many emergency contexts, and clinical assessment risks high levels of inaccuracy. Nevertheless, while assessment of urinary iodine is necessary to obtain a full picture of iodine status, a rough indication of the severity of the situation can be obtained by clinical examination of a valid sample of children aged 6-12 years.

Appendix 7

Nutritional Requirements

The following figures can be used for planning purposes in the initial stage of a disaster:

There are two important points to consider before using the requirements listed above. Firstly, the mean per capita requirements for population groups incorporate the requirements of all age groups and both sexes. They are therefore not specific to any single age or sex group and should not be used as requirements for an individual. Secondly, these requirements are based on a particular population profile, as follows:

As the demographic structure of different populations varies, this will affect the nutritional requirements of the population concerned. For example, if 26% of a refugee population is aged under five, and the population consists of 50% males and 50% females, the energy requirement is reduced to 1,940 kcals.

Energy and protein requirements should be adjusted for the following factors:

- the demographic structure of the population, in particular the percentage of those under five years old and the percentage of females (this may change in populations affected by HIV/AIDS);

- mean adult weights and actual, usual or desirable body weights. Requirements will increase if the mean body weight for adult males exceeds 60kg and the mean body weight for adult females exceeds 52kg;

- activity levels to maintain productive life. Requirements will increase if activity levels exceed light (ie 1.55 x Basal Metabolic Rate for men and 1.56 x Basal Metabolic Rate for women);

- average ambient temperature and shelter and clothing capacities. Requirements will increase if the mean ambient temperature is less than 20°C;

- the nutritional and health status of the population. Requirements will increase if the population is malnourished and has extra requirements for catch-up growth. HIV/AIDS prevalence may affect average population requirements (see General nutrition support standard 2).

Whether general rations should be adjusted to meet these needs will depend on current international recommendations.

If it is not possible to incorporate this kind of information into the initial assessment, the figures in the table above may be used as a minimum in the first instance.

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