The Institute of Child Health (ICH) is currently nearing completion of a project with considerable relevance to the findings of the WHO review.
The project, which is funded by UNHCR, Geneva, has sought to address key aspects in improving awareness, detection, and interventions for micronutrient malnutrition in refugee and emergency affected populations.
The five main activities being implemented are:
Building capacity for field-based detection and quantification of micronutrient deficiencies
This has involved raising awareness of micronutrient malnutrition in field staff. The experience from training workshops with survey teams in five different African countries has been used to produce a training pack which will be made available next year. This will focus on imparting basic knowledge of deficiencies and encouraging accurate recognition of clinical signs through the use of photo-cards.
As indicated in the WHO review difficulties arise when clinical signs do not fall within the classic text book images. One approach to dealing with uncertain 'cases' or outbreaks is the use of biochemical tests. In view of the difficulties in conducting biochemical testing for deficiencies in the field, ICH have undertaken development work on nutrient analysis from dried blood spots and improving the taking of peripheral blood samples during surveys. Surprisingly, some of the standard laboratory assays also required development work. Although manuals published by WHO and others describe biochemical methods for the assessment of conditions such as pellagra, scurvy and beriberi, some of these are, in practice, difficult to set up and tend to produce results which may be open to interpretation. This became apparent when setting up a method for measuring niacin status in response to a suspected outbreak of pellagra in Tanzania in 2001. ICH have subsequently invested time investigating alternative, reliable and valid methods for laboratory analysis.
Micronutrient malnutrition needs assessment surveys in refugee situations
ICRC have completed surveys in Kenya, Uganda, Ethiopia, Tanzania and Algeria. These surveys have attempted to adopt a holistic approach to the causes of deficiencies and have, for example, included measurements of the major parasitic causes of anaemia such as malaria and intestinal helminths as well as looking at dietary intake. These data provide a valuable overview of the status of micronutrient malnutrition in a range of refugee operations and may well prove useful in formulating strategies and policies to improve operations at headquarters level. They have also been used to advocate for improvements in programmes to tackle identified problems in the field, e.g. strengthening of malaria programmes and increased supply of blended food in Uganda, and improved coverage of vitamin A capsule distribution in Kenya.
Evaluation of the effectiveness of iron cooking pot provision as a strategy to reduce anaemia
In collaboration with CDC, Atlanta, an intervention trial is ongoing in Burundian refugee camps in Tanzania on the effectiveness of stainless steel1 cooking pot distribution in reducing iron-deficiency anaemia. This project is funded mainly by WFP and is an innovative approach to improving the dietary intake of iron in refugee situations. The end point evaluation is scheduled for early in 2003.
Trial of multiple-micronutrient supplementation for pregnant women
A large-scale supplementation trial of multiplemicronutrient supplements for pregnant women in a refugee setting is reaching completion in the Dadaab camps in Kenya. This effectiveness trial, undertaken in close cooperation with MSFBelgium, seeks to address the question of whether a multiple micronutrient tablet can be more effective than the established iron and folate regimen in controlling anaemia and other deficiencies during pregnancy. Issues of compliance with supplementation are receiving special attention as these are often neglected and can be major causes of programme ineffectiveness.
Development of nutrient calculation software
One crucial tool in combating micronutrient malnutrition is the ability to monitor the micronutrient content of food aid distributions. This, of course, requires good records of distribution and, in some cases, on-site distribution monitoring as well as knowledge of the micronutrient content of the commodities. There are a number of software applications that can be used to calculate the nutrient content of food aid. NutCalc, NutVal and Food Basket Calculator are three examples of software developed especially for this purpose. All of these have disadvantages and advantages. NutVal was originally developed by UNHCR and is a relatively simple Excel application that can run on most computers with minimal set up or technical expertise. However, it was in need of an update. A modified version of the NutVal spreadsheet application has been produced and following field-testing is being further modified before production of the final version later this year.
It is hoped to publish the findings of these trials and studies as they are finalised in subsequent issues of Field Exchange.
For further information contact: Andy Seal, Institute of Child Health, London, UK tel: 0044 (0)20 7905 2233. email: A.Seal@ich.ucl.ac.uk
1 Stainless steel is a metal alloy that contains iron. Studies conducted by ICH have shown that the iron content of typical refugee foods is increased if they are cooked in stainless steel cooking pots.