NUTRITION Memento Draft Version

7/31/2019 NUTRITION Memento Draft Version

1/27

NUTRITION

- SITUATION WITH DISPLACEMENT OF POPULATION -

Draft version 2011


2/27

MSF/B Draftversion2011 Pocket Guide Nutrition2

Editor

Brengre LeurquinSonia Peyrassol

In collaboration with

Pascale DelchevalerieMarie-Christine Ferir

Yannick GarbusinskiPeter Maes

Jean-Pierre Mustin

Michel Van Herp

O.C. Brussels Operations Department / C.O. Bruxelles Dpartement des Oprations


3/27

MSF/B Draftversion2011 Pocket Guide Nutrition 3

INTRO

This pocket guide, conceived on the model of a "quick start manual '"is part of a seriesdedicatedto the activities to implement in the first phase of an emergency (0 to 3 months) with displacementof population.

It has the advantage of being short, simple and light (in your pocket)... and thus does not contain

all the details.... which you will find in the different guidelines quoted in the pocket guide.

You consulted the guidelines and still do not have the information you are looking for ? Do nothesitate to ask advise to your field coordinator and/or medical or technical coordinator.

There are technical sheets linked to this pocket guide.These technical sheets will facilitate you theimplementation of the various activities. They are available on the CD-Emergency

Your Comments

are more then welcome.

You do not see how to use one or the other sheet... perhaps because the sheet is badly designedor the insufficient explanations... your comments will help us to improve the tool.

You were confronted with particular situations which led you to adapt the strategy, you have tricksand easy ways, documents or comments which could enrich the next version of this CD? Do nothesitate to contact us so that we can share your experience with everybody.

THIS IS A DRAFT VERSION, MADE AVAILABLE FOR THE NUTRITION E-LEARNINGSESSION OF MAY 2011.

ADAPTED ANNEXES WILL BE SOON AVAILABLE AND SEND TO THE FIELD.


4/27


TABLE OF CONTENTS

Nutrition is one of the 10 priorities in the emergency phase......................................................5

- General Objective- Specific Objective- MSF Policy- Acute Malnutrition/Chronic Malnutrition

Evaluation of the nutritional situation...........................................................................................6

- Rapid MUAC Assessment- Nutritional Survey- Nutritional surveillance and systematic screening

Calculation and interpretation of the results...............................................................................8

- Calculate the estimation of the prevalence of global, moderate and severe acute malnutrition- Interpret the results in their context

What action ?..................................................................................................................................9

- To treat the cause

- To treat the cases of malnutrition

Installation of a nutritional programme......................................................................................11

- Calculate the number of beneficiaries expected in the programme- Decide the type of approach (care and organization) for each programme- Calculate the number of centres needed- Order the food, the material and the drugs- Recruit and train the staff- Construction and location of the structure- Water, hygiene and sanitation- Inform the population

Organization of a TFC..................................................................................................................17

- Waiting area- Admission- Medical treatment- Nutritional treatment- Registration- Psycho-social follow-up- Medical and nutritional follow-up- Discharge

Organization of a SFC.................................................................................................................19

- Waiting area

- Admission- Registration- Medical treatment- Nutritional treatment- Medical and nutritional follow-up- Discharge

Evaluation of the nutritional programmes...............................................................................21

References..................................................................................................................................23

List of the technical sheets on the CD.....................................................................................25


5/27


Nutrition is one of the 10 priorities in the emergencyphase.

The risk of malnutrition is higher in a displaced population because:- the causes of their flight and their flight in itself are hardships which have weakened them- on arrival, their living conditions are very precarious: drastic reduction in food availability

and/or access, deterioration of their environment (lack of water, poor hygiene, lack ofhealthcare, no shelters to protect them against the bad weather...).

Malnutrition is a major cause of mortality in itself (e.g. famine) but also because it increases thevulnerability to other diseases (thus severity).

General Objective

To reduce mortality and morbidity resulting from acute malnutrition by preventive andcurative actions.

Specific Objective

To treat people suffering from severe and moderate acute malnutrition

To prevent a deterioration of the nutritional situation in the vulnerable groups (children,pregnant and lactating women, elderly, handicapped)

To promote the distribution of a minimal1quality food ration of 2,100 kcal/person/day

MSF Policy

The responsibility for food assistance to refugee/displaced is divided between the HCR(High Commissioner for Refugees) and WFP (World Food Program).

In general MSF will not be involved in a general food distribution and will prefer toconcentrate on targeted nutritional programmes. However, MSF has the responsibility toensure the follow-up of the quality, the quantity and the equity of the distributions.

If there are no other organizations present and ready to deal with this priority, MSF willmake an emergency general food distribution while lobbying at the HCR and WFP totake the necessary measures.

Acute malnutrition/Chronic Malnutrition

Malnutrition is a group of clinical disorders due mainly to a deficiency in energy and protein butalso in vitamins and minerals. It is attributed to insufficient or unsuitable food supply.There are 2 types of malnutrition: chronic malnutrition and acute malnutrition.

1The factors which impose an increase in the ration are the age and the sex, the medical and nutritional status of the

population, period of strong activity and the outside temperature (it is necessary to add 100 kcal/person/day for each 5Cbelow 20 C)


6/27


In emergency, we are interestedinACUTE malnutrition; its indicators are Weight/Height(W/H), the presence of bilateral oedema and the mid-upper arm circumference (MUAC).

Sheet n1 : Theoretical concepts on malnutrition

EVALUATION OF

THE NUTRITIONAL SITUATION

This evaluation is an essential part of the initial assessment and includes 2 parts:

- The evaluation of the food resources of the population (see: Pocket Guide "Initialassessment")

- The evaluation of the nutritional status of the children less than 5 years2

1. Rapid MUAC Assessment

It is a first estimation3 of the nutritional status of the population by the checking of the possiblepresence of bilateral oedema and by the measurement of the mid-upper arm circumference

(MUAC) in the children from 65 to 110 cm4.

- The main objective of this rough estimation is to detect the children with a high-risk ofmortality in order to take immediate life-saving action.

- This method has the advantage of being easy to implement, as it does not requirecomplex technical skills, nor specialized staff

- It can easily be coupled with a measles vaccination campaign

Moderate acute malnutrition MUAC between 115 and 125 mm (= Orange) with no oedema+ +

Severe acute malnutrition MUAC < 115 mm (= Red) OR oedema= =

Global acute malnutrition MUAC < 125 mm OR oedema

Sheets n2 Rapid MUAC assessment in practicen3 Job Descriptionsn4 Measurement of the MUACn5 OedemaAssessmentn6 Tally sheet

2. Nutritional Survey

As soon as possible, plan a nutritional survey coupled with a retrospective mortality survey withthe aim of :

refining the analysis of the situation

2This group of children less than 5 years is representative of the population because it is particularly sensitive to the

changes of the nutritional situation and international reference values can be used.3 Estimation: because it is the indicator W/H which is most reliable to measure the nutritional status of a population (therisk of measurement error is high with the MUAC) ; Only with a nutritional survey conducted according to the rules canone state the prevalence of malnutrition in a given population at a given period of time.4

What corresponds to the children from 6 months to 5 years. Children < 2 years (65 to 84,9 cm) are registeredseparately (see tally sheet) because the results are interpreted differently.


7/27


evaluating the coverage of the nutritional programmes already set up.

To do so, it is essential to call in a person specially trained in this kind of survey. If this personis not available on the field, ask the HQ to send somebody. (Be aware that, even if it is somebodyexternal to the field team who comes to make the survey, he/she will need resources (material andhuman) available on the field to be able to conduct it.)

See on this CD : - Nutrition Guidelines MSF- Rapid Nutritional and Mortality Surveys. Step by Step - Kit of folders Nut Survey

3. Nutritional surveillance and systematic screening

Whatever the result of the evaluation of the nutritional situation, set up :

A nutritional surveillance system

Objective : To follow the evolution of thenutritional situation

Systematic measurement of the MUAC in children less than 5 years old in your routineactivities will enable you to follow the trends of the nutritional situation and to be alerted intime. Indeed, a situation is never unchanging and can always develop very quickly in onedirection as in an other. (Examples: the trucks of WFP do not arrive, change of climatic conditions(passage of the dry season to the wet season, dryness, flood...) or of security... )

Do not get caught out!

A systematic screening of acute malnutrition in children less than 5 years old

Objective : To treat all cases of acute malnutrition

One generally uses the MUAC (fast tool for initial screening), but the admission in anutritional programme must rely on the Weight/Height index. The children presenting with aMUAC < 135 mm or oedema will be referred to the points of W/H measurement.

These 2 activities take place:

- At home by thehome visitors;- In the health structures ;- In the reception centres of the camp or site if they exist.


8/27


CALCULATION AND

INTERPRETATION OF THE RESULTS

1. Calculate the estimation of the prevalence of global, moderate and

severe acute malnutrition.

Prevalence of moderate acute malnutrition (%) =

Number of children with a MUAC between 115 mm and < 125 mmwith no oedema X 100

Total number of children investigated

Or more accurately :

Number of children with Weight/Height - 3 Z-score or < - 2 Z-scoreX 100


Prevalence of severe acute malnutrition (%) =

Number of children with a MUAC < 115 mm OR oedema X 100



Number of children with Weight/Height < - 3 Z-score OR oedemaOR

X 100


Attention: the presence of bilateral oedema always indicates severe acute malnutrition!!!

Prevalence of global acute malnutrition (%) = 1 + 2 =

Number of children with a MUAC < 125 mm OR oedema X 100



Number of children with Weight/Height < - 2 Z-score OR oedemaX 100


Example:In the displaced camp of Sar-e-Pol (Afghanistan) where the total population is estimated to 25,000person, MSF made a rapid MUAC assessment and measured 3,000 children from 65 up to 110 cm andfound :

- 2,333 children with a MUAC green ;- 112 children with a MUAC yellow ;- 459 children with a MUAC orange ;


9/27


- 82 children with a MUAC red ;- 14 children with oedemas

The calculation of the estimation of the prevalence of the acute malnutrition is thus : Prevalence of moderate acute malnutrition = 459 / 3,000 * 100 = 15.3 % Prevalence of severe acute malnutrition = (82 + 14) / 3,000 * 100 = 3.2 % Prevalence of global acute malnutrition = (459+ 82 + 14) / 3,000 * 100 = 18.5 %

2. Interpret the results in their context

Contextual information is essential for this interpretation. Most significant are:

- Crude mortality rate (CMR) and under 5 mortality rate (U5MR)- General food rations and accessibility of food

- Diseases with epidemic potential present- Precariousness of the living conditions (climate, shelters, access to drinking water...).- Time and season of year (end or beginning of hungergap)- Other actors working in the area on nut side (WFP, UNDP,MoH,NGOs)

This information, which normally has been collected during the initial assessment (see: Pocket

Guide Initial Assessment), will help you to understand the causes as well as the severity of apossible nutritional problem.

Note: If you face cases ofmalnutrition in adults, you have to investigate to know the cause of it: if thismalnutrition is not caused by a chronic disease like tuberculosis or AIDS but by a lack of food, it is a signof severity of the nutritional situation and thus asignal of alarm to which you must react as soon aspossible!!!

The calculation and the interpretation of the results will be used to set up an adapted answer.5

WHAT ACTION

The choice of the strategy will depend mainly on:

Availability of the food ration Prevalence of malnutrition "Worsening factors"6 which influence the nutritional situation

Human, material or financial resources cannot be a barrier to the interventions of MSF; ifthe needs are real, move heaven and earth to obtain what is necessary for the activities tobe set up!

5 If you have doubts about the strategy to set up, you will find support and advice from your medical coordinator, themedical person in charge for your cell and nutrition advisor of the medical department6

CMR > 1/10,000/day or U5MR > 2; General food ration insufficient (< 2100 kcal/person/day); Epidemics of measles,shigellosis and other transmissible diseases; Intense cold and unsuitable shelters; An unstable situation, e.g. caused byan influx of refugees.


10/27


Sheet n7 Decision-making flow chart for the nu tritional interventions.

If there is a real nutritional problem, it will be necessary simultaneously :

1. To treat the cause

if problem linked to food (availability, access) :

- In case of massive nutritional emergency, in the first phase : distribute BP5 (energybiscuits):

Complete ration for an adult = 1 box (= 9 bars) of BP5 per day is 2,275kcal/person/day

Complete ration for a child = box

This solution "Quick and dirty" will unfortunately not enable you to save the severelymalnourished children but will avoid as much as possible a degradation of the generalnutritional situation.

- Lobby the HCR and WFP for a general food distribution (GFD) of minimum 2,100kcal/person/day. The calorie level of the total ration is not the only significant criterion. A

balanced composition

7

(proteins, fats, minerals and vitamins) and a regular distributionmust also be guaranteed.

Sheet n8 Automatic calculation Worksheet of the nutritional value of a ration (COMPONUT)

- Inform the organizations concerned8 that certain people or groups of people do not haveaccess to these distributions.

- When the access to food is such that a fast deterioration of the nutritional situation is tobe feared, organize a targeted food distribution (TFD) for the vulnerable groups or a .

- Selective Food Distribution (SeFD) covering specific nutritional and micronutrient needsbut only a part of the overall energy needs of groups with particular physiologicvulnerability (e.g. young children, pregnant and lactating women, people with chronicillness) can also be organised.

Sheets n9 Targeted Food Distributionn10 Diagram and practical organization of a dist ribution

if problem linked to health :

- Control the epidemics, treat the diseases.

Reminder : malnutrition involves a weakening of the defence mechanisms, responsible forserious infections, while the viral infection of measles is in itself responsible for a reductionin the immunizing capacities with its serious consequences for the malnourished children

Examples :

measles epidemic launch a measles vaccination campaign for all the children from 6months to 15 years and treat the cases(Seer : Pocket Guide Measles Vaccination)

epidemic of malaria inform the population, spray the shelters, distribute mosquito netsand treat the cases

7A minimal ration of 2,100 kcal/person/day, with at least 10 % of energy coming from protein and 20 % coming from fat

is recommended.8

Donors such as WFP, USAID or distributors ("implementing agency") such as The Red Cross, Care, EmergencyCommittees


11/27


case of diarrhoea treat water, communicate the importance of the washing of thehands and the use of the latrines, detect actively and treat the cases (if necessary, installORS corners)

if problem linked to water (availability, access, quality) :

- Control the effectiveness (*) of the WHS programme (water, hygiene and sanitation)which must provide as soon as possible 15 to 20 litres of drinking water/person/day.

- (N.B. In the very first days of the emergency a minimum of 5 litres of water/person/day is

acceptable but this quantity will have to be increased asap).

See : Pocket Guide Water, Hygiene and Sanitation

(*) Is water of good quality ? Is transportation of water (if water-trucking) assured and regular? Does all ofthe population of the camp have access to it ?

and

2. To treat the cases of malnutrition

ATTENTION : ALL CASES OF MALNUTRITION MUST BE TREATEDeven if there is no nutritional programme set up!9

Vulnerability of the children of less than 5 years old10, and their high risk of mortality make themthe priority targets of the specific nutritional programmes:

- Therapeutic Feeding Programme (TFP) for the treatment of the severely malnourishedchildren

- Supplementary Feeding Programme (SFP) for the treatment of the moderatelymalnourished children

Sheet n11 - Malnutrition in infants

Note :Older children (from 5 to 10 years), pregnant or lactating women, teenagers, adults or

malnourished elderly can also be admitted on a case by case basis in these programmes.

If you face a famine i.e. with a significant number of teenagers and/or malnourished adults, theywill have to benefit from a specific treatment in a structure specially intended for them.

Sheet n12 - Malnutrition in teenagers and adults

INSTALLATION OF

A NUTRITIONAL PROGRAMME

1. Calculate the number of beneficiaries expected in the programme

9Taking care of the malnourished patients, if they are not enough to open a specific structure, should be done on a caseby case basis in the health structures (health centres, services of paediatric or medicine of the reference hospital).

10Infants (from 0 to 6 months), in theory, are protected by breast-feeding; however, problems of breast feeding linked to

the mother (insufficient milk, stress) or to the child (disease...) can lead to malnutrit ion in infant. See sheet n11 for themanagement of these specific cases.


12/27


The number of malnourished children can be estimated starting from the results of a rapidMUAC assessment or a Nutritional Survey:

- Total population of less than 5 years old = total population X 17 %11- Total population of less than 5 years old X prevalence of severe acute malnutrition =

total number of severely malnourished children that will have to be admitted in the TFP.- Total population of less than 5 years old X prevalence of moderate acute malnutrition =

total number of moderately malnourished children that will have to be admitted in theSFP.

See example below (point 3)

2. Decide the type of approach (care and organization) for eachprogramme

The choice will depend on:

- The size of the target population- The constraints (geographical, cultural, HR, logistics and financial, security...)

Various approaches can be combined.

Sheet n13 - Definitions, advantages and disadvant ages of the various types of approach forthe nutritional programmes

In the first phase of an emergency, the extent of the emergency and/or the meansavailable generally lead us to privilege the following solutions :

ITFC or paediatric unit for the malnourished children (severe and moderate) withmedical complications

Day Care or ambulatory for the severely malnourished children with no medicalcomplication

SFC dry ration for the moderately malnourished children with no medicalcomplication

The type of approach must be evaluated continuously and adapted according to the nutritionalsituation and the acceptability of the local population. Thus, be flexible!!!

3. Calculate the number of centres needed

TFP :- TFC 24/24h = 1 for 60 to 100 malnourished children (maximum 150 children)- TFC day care = maximum 250 children- TFC ambulatory = 100 to 150 per day of distribution and per team

11Attention: the composition of the population can deviate from the "standard repartition" according to the context. Adapt

the % of children under 5 years following the results of the initial assessment, the nutritional survey or the mapping ifavailable (see Pocket Guide "Initial Assessment").

TFP

- ITFC (TFC 24/24h)- TFC Day Care- ATFC (Ambulatory)

SFP

- SFC Dry Ration


13/27


SFP :- SFC (dry ration) = 150 to 200 beneficiaries per day of distribution and per team

Example (continuation):In the displaced camp of Sar-E-pol. (Afghanistan) where the total population is estimated at 25,000people, the rapid MUAC assessment gave high prevalence rates of severe and moderate acutemalnutrition.A general distribution of food (2,400 kcal/person/day for one month) was made in emergency by theICRC and lobby is made at WFP so that it takes over. Consequently, it is decided to open a therapeutic

nutritional programme as well as a supplementary nutritional programme containing dry rations targetedon the malnourished children under 5 years.

Total population in the camp 25,000Population of children < 5 year (17 %) 4,250Prevalence of acute severe malnutrition 3.2 %Number of children severely malnourished expected (TFP) 4,250 x 3.2 % = 136Prevalence of acute moderate malnutrition 15.3 %Number of children moderately malnourished expected (SFP) 4,250 x 15.3 % = 650136 children should be admitted in a TFC 1 centre (*)650 children should be admitted in a SFC 1 centre (dry ration)

open 3 to 4 days per week

(*) In Afghanistan, women cannot sleep outside their house ; it was necessary to choose to open daycare feeding centre for the children of the camp combined with ambulatory feeding centre for the children

of the distant villages.

The real number of children admitted in the various programmes will depend on accessibility to thecentres (see Chap. 7 Evaluation).

4. Order the food, the material and the drugs

The food

Calculate the needs in food according to:

- Dietary protocols: the choice of food and thus of the protocol will also depend on the

local resources, then national and finally international12. (Attention: the choice of theprotocol will influence the whole logistic chain! Think it over when you make changes...)

Sheets n14 Specialized Foodn15 Dietary Protocols TFCn16 Dietary Protocols SFC

- Number of expected beneficiaries

- The required period of time (Attention: to avoid stock shortage, foresee a buffer stockaccording to the delivery time (often one month minimum) and add 10 % for the possible losses!)

Note: If you chose a TFC 24/24h or a day care TFC, do not forget to also foresee the meals for

accompanying care givers (the mother,).

Sheet n17 - Meals for accompanying care givers

Example:Our SFC admits 650 beneficiaries who receive a weekly dry ration of porridge (Premix) made up of 1.8kg CSB, 200 g of sugar and 300 g of oil. The quantity of CSB necessary to nourish these beneficiariesfor a 3 month period is:

12Before making an international order, find out if there is any possibility of getting specialized food from other

organizations (other MSF sections included!) present on the ground or in capital such as WFP, UNHCR, UNICEF or theICRC for example..


14/27


1. Daily ration of CSB per child: 1,800 g / 7 days = 257 g2. Daily ration of CSB for 650 children: 0.257 kg X 650 = 167 kg3. Quantity of CSB for 120 days (3 months + 1 month of buffer stock): 167 kg X 120 = 20,040 kg4. Add 10% of losses: 20,040 kg + 2,004 kg (10%) = 22,044 kg5. The total in Tons: 22,044 kg/1000 = 22,044 Tons, rounded with 22 Tons

Sheets n18 Automatic calculation Worksheet of food order (SIMUFOOD)n19 Standard Order Sheet WFP

Once the order is made, it will be very important to check each week the real consumptionof each food:

- To adapt theoretical calculations to the effective needs- To compare consumption with the number of beneficiaries to control the preparation and

the unexplained losses of food.

Ensure the transportation, the reception and the storage of food :

- Foresee an appropriate place (clean, sufficiently large, protected from the bad weather,rodents...)

- Train a storekeeper in the good management of food

Sheets n20 Management and quality control of foodn21 How to store foodn22 Stock Card

The logistic material

If the nutritional kits are not available quickly, order the kitchen utensils locally. Try also to getfurniture locally (made by the local carpenter or improvise with what you find on the spot!).

Sheets n23 Kits Nutritionn24 Logistic Material needed to open a TFCn25 Logistic Material needed to open a SFC

The drugs and the medical material

It is strictly prohibited, on the other hand, to buy drugs on the local market: even if you havegood intentions, some of these drugs, whose quality is not controlled, can do more harm thangood to your patients!

Make your order and ask the capital or the HQ to send the necessary drugs ASAP! (Attention:inform yourself about the national protocol for malaria and/or what will be necessary for you to set up

before ordering the drugs against malaria). Dont forget the vaccines.

Sheets n26 - TFC : Needs in drugs and medical m aterialn27 - SFC : Needs in drugs and medical material

It will be then essential to put tools in places to follow the consumption of the drugs and toadapt the next orders to the real needs for the various centres.

5. Recruit and train the staff

The emergency should not make you forget that the recruitment, the organization of work andthe training of the staff are essential steps in the opening of a nutritional centre and do nothappen on their own! (Attention: to skip one of these steps in order to take care of the malnourished


15/27


children more quickly (but not as well !) is not a good calculation; you will have to pay the piper sooner orlater...)

The first step is to determine the number of staff necessary, by category, by basing yourselfon the activities to be carried out.

Sheets n28 Needs in staff by type of nutrition al centre

Then, it will be necessary to prepare a job description for each category of staff, and toestablish a flow chart for each programme. These two tools will remain essential during the

duration of the programme. Sheets n29 Job Description ITFC

n30 Job Description ATFC/SFCn31 Flow chart ITFCn32 Flow chart ATFC/SFC

A standard policy for the staff must be laid down and aligned to the labour regulations of thehost country. Several administrative aspects should be tackled rather early in the emergencyphase: salary scale, what is the most suitable type of contract, what is the legal status ofrefugee/displaced workers, etc. These aspects will be handled by the administrator of themission while the person in charge of the programme will deal with the selection and therecruitment of the workers.

Sheets n33 Example of work schedulesn34 Job Interview

Several types of training will be necessary (theoretical courses, practical exercises...) and inthe emergency phase, it is clear that the staff will have to be trained quickly; this means that itwill be necessary to limit, to the basic, the number of tasks to be taught and simplify to themaximum

Example: Calibrate the balance with the standard weight is useful but not essential in the emergencyphase.

Sheet n35 Plan of training

Evaluating and following the training curriculum is part of the process of supervision whichmust be on a regular basis, with the aim of identifying new needs in training, for which it will benecessary to answer through continuous on-the-job training.

6. Construction and location of the structure

While the medical expatriates trains the staff, the logistician will prepare the structure which willaccommodate the malnourished patients.

Location

- The feeding structure must be located in a safe and accessible place for the

beneficiaries; a TFC must be accessible within 30 to 45 minutes walk for the targetpopulation while a SFC (dry ration) must be able to be reached in less than 2 hourswalk.

- Foresee a sufficiently large location to be able to increase the capacity of your structure.(You have perhaps only 50 children today, but what will you do if in one week you have 300 ofthem?)

- Dont forget the water supply, feeding structures should be, if possible, close to a watersource

- Feeding structures should be close to a health facility (hospitals, clinics, health centres)to facilitate patient care and transfer.

- When several centres are necessary, their geographical distribution should allow a goodcoverage of the population.


16/27


Construction

In the first phase of emergency,

- Either you find buildings available and adapt them into a nutritional centre- Or you use tents (82 m for 20 beds)- If these two options are not possible, it remains the possibility of quickly building a light

structure (in bamboo, stems of millet...) while waiting to have time and materials

necessary to build semi-permanent structures.

INSULATE your structure against the cold. One of the frequent causes of mortality inmalnourished children is hypothermia.

N.B. It is advised, for the severely malnourished children, and more particularly for the smallest ones(premature, small weights of birth...), the construction of a hotroom, i.e. a room particularly wellinsulated against the cold (it should be noted that even in the very hot countries the nights can bevery cold and the differences in temperature day/night are always very significant... if we appreciatethis freshness after one day under a blazing sun, the severely malnourished children, whosemetabolism is disturbed, will have difficulties of adapting to such variation of t).Unfortunately the tents are particularly unsuited to protect from the cold. You will thus have, as soonas possible, to built a semi-permanent structure. While waiting, you can:

- Cover the children with bonnet, clothing, covers ;

- Provide mattresses ;- Protect against the wind :

Avoid orienting the entry of the tent facing the dominant winds ; Place the TFC tent so that it is protected by other tents ; Double the interior of the tent with natural fibre mats ; Put wind screens in front of the entry ;

- Insulate the floor (groundsheet)and isolate from the ground (bed or bench)- Insulate the roof (for example by tightening a double roof or mats above the top of the

tent... do not forget to leave a space between the two roofs)..

During the construction of your semi-permanent structure, in order to insulate it as well as possible,do not hesitate to ask advise at your CoTL and the Expert Construction of the Logistic Department

See on this CD Temporary & Semi-Permanent Buildings for Health Structures in RefugeesCamps

.Waiting AreaYou will have many children and accompanying care givers who will sometime have to wait forlong periods:

- Foresee sufficient waiting areas shaded and protected from the bad weather- Foresee also points of distribution of drinking water (It would be a pity that children arrive at

the centre completely dehydrated because they had to wait under the sun and without water infront of this same nutritional centre !)

Sheets n36 - Plan TFC and TFC Ambulatory and sta ndards to follown37 - Plan SFC dry rations and standards to follow

7. Water, Hygiene and Sanitation

Nutritional centres should open only when:

- Supply of drinking water- Elimination of the excreta- Drainage and treatment of waste water- Waste collection and disposal

Priority


17/27


- Means of vector control

are set up ; all these measures will contribute to improve the conditions of hygiene of thepatients and of the nutritional centre(s) and are essential to reduce the propagation of thetransmissible diseases.

Inform yourself about the local practices and the practices of hygiene of the population beforelaunching in the construction of perhaps perfect installations at the technical level but which willremain unutilised because socially unaccepted! (It is sometimes better to have an improved trenchlatrines correctly located, planned and used than latrines badly located, badly maintained and misused,by, for example, a nomadic population accidentally settled!)

Moreover, if it is important to get adapted installations, it will also be essential to associate itwith a programme of hygiene promotion of the population and training of the local technicians.

Sheet n38 Water, hygiene and sanitation in a n utritional centre

8. Inform the population

It is important to inform the population about the objectives of the programme but especiallyabout the localisation of the nutritional centres and their methods during meetings with the

representatives of the community (heads of the camp), and during the mass screening of themalnourished children.The existence of a good network of home visitors will also promote the collaboration of thepopulation.

ORGANIZATION OF A TFC

1. Waiting Area

- Pass regularly in the lines and make a regular triage of the patients who wait in order todetect the most serious cases and to treat them in priority (Attention with dehydration in thequeue : foresee a place protected from the bad weather and drinking water! )

Sheet n39 - The triage

2. Admission

- Take the anthropometric measurements : MUAC, oedema, weight and height.- Calculate the W/H index in Z-scores and note the target weight13- Admit the new patients according to the admission criteria ; refer those which do not meet

the criteria to the appropriate place (SFC, health structure)

Sheets n40 Measurement of the weightn41 Measurement of the heightn42 Reference Tables Weight/Heightn43 Admission Criteria TFC

13The target weight is the weight that the child must reach at his exit: it depends on the discharge criteria of the TFC

and generally corresponds to 80% of the index W/H (85% if no SFC)


18/27


3. Medical Treatment

- Make a complete clinical examination: medical history + physical examination- In the areas where malaria is endemic, systematically do a rapid test malaria (Paracheck)- Vaccinate the child against measles (non discriminating approach), check other necessary

vaccinations (see vaccination calendar for severely malnourished)- Prescribe the systematic treatment and give it without delay- If the child suffers from medical complications (severe malaria, pneumonia, severe

dehydration,...), prescribe a specific treatment accordingly (see Clinical and Therapeutic

Guide, MSF) and take him in charge immediately in hospitalisation (ITFC)- If the child has a good clinical status, assess his appetite by keeping him in observation the

time he eats (or not!) the RUTF14. If his appetite is ok, he can be treated in ambulatory(ATFC), if not he has to stay in the ITFC.

Sheets n44 How to do a complete clinical examin ation in a malnourished childn45 Systematic Treatment TFCn46 Oral Rehydration for severely malnourished c hildren

4. Nutritional Treatment

- Prescribe the dietary protocol to be followed by the child according to his/her weight andgive it without delay

- Phase 1 (Attention : maximum 7 days !)/ phase 2- Fill in the individual milk card(ITFC, Day Care)- For ATFC, at the end of the day, identify the defaulters and organize visits at home

Sheets n15 Dietary Protocol TFCn47 IndividualMilk Cardn48 - Hygiene in the meals preparation and distrib ution

5. Registration

- Register the patients and fill in their individual monitoring card (nof identification, date of

entry, first name, name of the parents, full address15, age, sex, nationality and date ofarrival on the camp/site + anthropometrics measurements).

- Put an identification bracelet for each new patient: note his identification nand the name(or symbol) of the centre

- Give mosquito net,blanket, soap, cup and spoon to the in-patients- Explain to the accompanying care givers the operation of the centre, the medical and

nutritional taking care in detail but also for which tasks their participation is requested(assign a member of the staff specifically for this task!)It is essential that s/he understands andagrees on the importance of the treatment adherence until it is completed.

Sheets n49 Standard Register TFCn50 Individual monitoring card ITFC and ATFC

6. Psycho-Social Follow-Up

- As soon as possible, it will be necessary to associate the medical and nutritional treatmentto session of psychosocial stimulation, which supports the recovery of the child.

- Thus recruit an animator who will be responsible for organizing these sessions of animation(games in group, songs, music, stories...) to which the mothers will be encouraged to takepart.

14Ready to Use Therapeutic Food (Plumpynut, BP100)

15Note at which place of the camp (or site) the patient lives (section, nof the shelter) and this, in order to be able to

easily find the defaulters


19/27


7. Medical and Nutritional Follow-Up

Phase 1 Each day Phase 2

- Weight measurement- Oedema assessment- Clinical examination

- Diet control

- Ttwice

- Weight measurement 1day/2 or 2x/weekif workload +++

- Clinical examination 1day/2 or 3 days

- Height 1/month

- Tif necessary

ATFC 1x/week (see point 6 SFC)

8. Discharge

- Measure the MUAC, the height, the weight, calculation of index W/H and check that thechild fits the discharge criteria.

- Fill in the individual monitoring card of the patient and the register (N.B. The individual cardremains in the TFC).

- Fill the health book and check that the vaccine against measles (and eventually others) wasmade and correctly noted in the health book and give instructions to mother for completionof EPI calendar if not completed yet.

Sheets n51 Discharge criteria TFC

ORGANIZATION OF A SFC

1. Waiting Area

- Pass regularly in the lines and make a regular triage of the patients who wait in order todetect the most serious cases and to treat them in priority (Be careful for dehydration in thequeue : foresee a place protected from the bad weather and drinking water!)

Sheet n39 - The triage

2. Admission

- Take the anthropometric measurements : MUAC, oedema16, weight and height- Calculate the W/H index in Zscores and note the target weight17- Admit the new patients according to the admission criteria ; refer those who do not meet the

criteria to the appropriate place (TFC, health structure)- Regularly verify that the admission criteria are strictly respected and that the

anthropometric measurements noted on the card correspond well to the patient (Indeed,some cheating can happen: exchange of bracelets, falsification of anthropometric measurements...be thus vigilant!)

Sheets n40 Measurement of the weightn41 Measurement of the heightn42 Reference Tables Weight/Heightn53 Admission criteria SFC

16Attention, if the child has oedema, you have to refer him immediately to the TFC

17The target weight is the weight that the child must reach at his discharge: it corresponds to W/H> -2 z-score.


20/27


3. Registration

- Register the patients and fill in their individual monitoring card (nof identification, date ofentry, first names, name of the parents, full address18, age, sex, nationality and date ofarrival on the camp/site + anthropometric measurements).

- Put an identification bracelet on each new patient: note his identification nand the name(or symbol) of the centre and the day of distribution

- Explain to the accompanying care givers the operation of the centre and the medical and

nutritional follow-up in detail

Sheets n54 Standard Register SFCn55 Individual monitoring card SFC Dry Ration

4. Medical Treatment

- Make a complete clinical examination: medical history + physical examination- In the areas where malaria is endemic, systematically do a rapid test malaria (Paracheck)- Vaccinate the child against measles (non discriminating approach)- Prescribe the systematic treatment and give it without delay- If the patient has medical condition that cant be treated in ambulatory, refer him/her to the

ITFC; if no ITFC, to a doctor or an appropriate health structure- If possible, refer the pregnant women to an ante-natal consultation

Sheets n46 How to do a complete clinical examin ation in a malnourished childn56 Systematic Treatment SFC

5. Nutritional Treatment

- Distribute the weekly ration to the child and explain well to the mother how to prepare it andgive it

- The patient then returns home; if your circuit is well organized, the patient will not haveremained more than 2 hours in the centre

-

The individual monitoring card of each patient must remain in the centre and be broughtback to the person of the registration for the following week- After each distribution, identify the defaulters and organize the visits at home

Sheets n16 Dietary Protocol SFC

6. Medical and Nutritional Follow-Up

- A regular monitoring of the patient and a rigorous follow-up of the medical and nutritionaltreatment are essential

- Ensure that all information, including the prescriptions, is each time recorded on theindividual monitoring card of the patient.

- To ensure the best follow-up, staff must know the expected progress for the patient (weightgain, improvement of the general state...)

- If the health of the child is degrading, a transfer to the ITFC or in a hospital must beorganized

Weight

- Take the weight of the patient each visit- If the patient does not gain weight, it is necessary to try to understand what is the problem

(disease, insufficient food, etc.) and to take the appropriate measures

18Note at which place of the camp (or site) the patient lives (section, nof the shelter) and this, in order to be able to

easily find the defaulters


21/27


- Indicate the target weight on the individual monitoring card and recalculate it each monthat the time of the update of the height

Height

- Measure the height of the patient once per month

Bilateral Oedema

-

Check the possible presence of oedema at each visit. If +, transfer the child to the TFC

MUAC

Check MUAC at each visit. If < 115 mm, transfer the child to the TFC

Medical Follow-up

- Do a complete clinical examination each week and give a weekly dose of iron + folic acid(not when RUTF is used)

7. Discharge

- Measure the MUAC, the height, the weight, calculation of index W/H and check that thechild fulfils well the exit criteria

- Fill in the individual monitoring card of the patient and the register- Fill in the health book and check that the vaccine against measles (and eventually others)

was done and correctly noted in the health book and give instructions to mother forcompletion of EPI calendar if not completed yet.

Sheets n58 Discharge Criteria SFCn59 Referral Card

EVALUATION OF

THE NUTRITIONAL PROGRAMMES

1. Objectives

- To evaluate the functioning, quality, coverage, acceptability, accessibility and effectivenessof the programmes to make fast improvements if necessary

- To follow the trends of the nutritional situation and to adapt the activities of the programmesaccordingly

- To provide data for testimony, lobbying and public information

2. Means

The data collectionwill relate mainly to :

- The number of admissions (type & age groups) and discharges (discharge, death,default, transfer, non respondent) of the programmes

- Causes of the deaths- Average weight gain & length of stay- The vaccine coverage


22/27


- The follow-up of the diseases with epidemic potential

Analysis of these data and the report :

- Without the analysis (which must be done in the field) and especially without theimplementation of the actions which result from this, to collect data is useless!

- Standard forms of evaluation were worked out for an easy and practical use in thefield but also to facilitate the comparison of the nutritional programmes in time... use

them instead of re-inventing the wheel...!

Sheets n60 Principal indicators of the nutritio nal programmesn61 Data Collection Form Feeding Centres

61 a How to fill selective feeding centres data reporting forms61 b Printable data collection forms

61 c- Therapeutic feeding program summary sheet61 d Supplementary feeding program summary sheet

Observation and supervision :

- To supervise in an effective way, it will be necessary for you to ensure an almostpermanent presence in your structures and to acquire a global vision of the functioning

of the programme and the nutritional situation in general. (Attention: to supervise does notmean to say "To do all, all alone", nor "to cross the arms by looking at the others working! "but"To work well shoulder to shoulder with the staff")

- Discuss the result of your observations (negative AND positive) and the analysis of thedata with the staff during regular meetings is essential to involve them more in theimprovement of the quality of the taking care of your patients

Sheet n62 Grid of evaluation of a nutritional centre


23/27


REFERENCES

General

NUTRITION GUIDELINESMSF 2007 Draft

MSFOCB NUTRITION E-LEARNING

MSF 2011

MSFOCB Standard_Nut_Protocol_ITFC_2010_finalMSF 2010

MSFOCB_ATFC Protocol V3_Jan 2011MSF 2011

REFUGEE HEALTHAn approach to emergency situationsMSF - 1997

LA MALNUTRITION EN SITUATION DE CRISE

Manuel de prise en charge thrapeutique et de planification dun programme nutritionnelACF 2001

Evaluation of the nutritional situation

RAPID HEALTH ASSESSMENT OF REFUGEE OR DISPLACED POPULATIONSMSF 1999

EMERGENCY NUTRITION ASSESSMENTGuidelines for field workersSAVE THE CHILDREN 2004

ASSESSMENT AND TREATMENT OF MALNUTRITION IN EMERGENCY SITUATIONS ACF

2002

RAPID NUTRITIONAL AND MORTALITY SURVEYS. STEP BY STEP MSF 2002 revised 2011

Food Logistic

GUIDELINE LOGISTIQUE ALIMENTAIREMSF 2010

GUIDE OF KITS Medical and logisticI. KMED p. 115 to 125 : Kits nutritionMSF 2010

MEDICAL CATALOGUE Volume 1XI. SFOS Specialized foodMSF 2010

Installation of a nutritional centre

AIDE A LA MISE EN PLACE DE CENTRES NUTRITIONNELS THERAPEUTIQUES ETSUPPLEMENTAIRES. En situation dUrgence.MSFF Document interne 2001-rvision 2010


24/27


MISE EN PLACE DUN CENTRE NUTRITIONNEL THERAPEUTIQUE EN URGENCE :COMMENT ABORDER LE RECRUTEMENT, LORGANISATION PRATIQUE DU TRAVAIL ET LAFORMATION ?MSFF Draft 2001


25/27


Construction

LOGISTIC CATALOGUEV. CBUI ConstructionVI. CSEM Semi-permanent structuresVII. Shelter CSHETENH82- Tent 82 mMSF 2006

TEMPORARY & SEMI-PERMANENT BUILDINGS FOR HEALTH STRUCTURES IN REFUGEESCAMPSMSF 1998

Water, Hygiene, Sanitation

PUBLIC HEALTH TECHNICIAN IN PRECARIOUS SITUATIONMSF 1994 New version to be published in 2007 !?

ESSENTIAL WATER AND SANITATION REQUIREMENTS IN HEALTH STRUCTURES WHSUnit, Medical department, MSFB - 2006

Medical

CLINICAL GUIDELINES DIAGNOSIS AND TREATMENT MANUALMSF 2010

MEDICAL CATALOGUE Volume 1Drugs and Medical MaterialMSF 2010


26/27


LIST OF THE TECHNICAL SHEETS ON THE CD

Generalities1. Theoretical concepts on malnutrition

Evaluation of the nutritional situation

2. Rapid MUAC assessment in practice3. Job descriptions4. Measurement of the MUAC5. Bilateral oedema assessment6. Tally sheet

Strategies and specifics approaches7. Decision-making flow chart for the nutritional interventions8. Automatic calculation worksheet of the nutritional value of a ration (COMPONUT)9. targeted Food Distribution10. Diagram and practical organization of a distribution11. Malnutrition in infants12. Malnutrition in teenagers and adults

13. Definitions, advantages and disadvantages of the various types of approach for the nutritionalprogrammes

Food14. Specialized food15. Dietary protocols TFC16. Dietary protocols SFC17. Meals for accompanying care givers18. Automatic calculation Worksheet for food order (SIMUFOOD)19. Standard Order Sheet WFP20. Management and Quality Control of Food21. How to store Food ?22. Stock Card

Material23. Kits Nutrition24. Logistic Material needed to open an ITFC25. Logistic Material needed to open a ATFC/SFC26. TFC : Needs in Drugs and Medical Material27. SFC : Needs in Drugs and Medical Material

Human Resources28. Needs in staff by type of nutritional centre29. Job Description ITFC30. Job Description ATFC/SFC31. Flow chart ITFC

32. Flow chart ATFC/SFC33. Example of work schedule34. Job interview35. Plan of training

Logistic and WHS36. Plan ITFC and ATFC and standards to follow37. Plan SFC and standards to follow38. Water, Hygiene and Sanitation in a nutritional centre


27/27

TFC39. The triage40. Measurement of the weight41. Measurement of the height42. Reference Tables Weight/Height43. Admission criteria TFC

44. How to do a complete clinical examination in a malnourished child ?45. Systematic Treatment TFC46. Oral Re-hydration for severely malnourished children

47. Milk Card48. Hygiene in the meals preparation and distribution49. Standard register TFC50. Individual monitoring card ITFC and ATFC

51. Discharge criteria TFC

SFC53. Admission criteria SFC

54. Standard register SFC55. Individual monitoring card SFC Dry ration56. Systematic Treatment SFC58. Discharge criteria SFC59. Referral card

Evaluation of the nutritional programmes60. Principal indicators of the nutritional programmes61. Data collection forms feeding centres

61 a How to fill selective feeding centres data reporting forms61 b Printable data collection forms61 c - Therapeutic feeding program - summary sheet61 d Supplementary feeding program - summary sheet

62. Evaluation scale of a nutritional centre

NUTRITION Memento Draft Version

Documents

Transcript of NUTRITION Memento Draft Version