74304 -1- -2- How to Protect and Promote the Nutrition of Mothers and Children: Policy Guidance: Priority Nutrition Interventions and Cross-Cutting Approaches in Latin America and the Caribbean Table of Contents Policy Guidance: Priority Nutrition Interventions and Cross-Cutting Approaches 1 Summary of Policy Guidance Recommendations for 2 Priority Nutrition Interventions Priority Nutrition Intervention 1: Assuring Maternal, Infant, 6 and Young Child Nutrition Priority Nutrition Intervention 2: Promoting Healthy Growth 16 Priority Nutrition Intervention 3: Preventing and Treating 20 Micronutrient Deficiencies Priority Nutrition Intervention 4: Preventing and Treating 29 Infectious Diseases Priority Nutrition Intervention 5: Promoting Healthy Motherhood 35 Priority Nutrition Intervention 6: Ensuring Food Security 41 Summary of Policy Guidance Recommendations for 48 Cross-Cutting Approaches Cross-Cutting Approach 1: Targeting 52 Cross-Cutting Approach 2: Multisectoral Coordination 54 Cross-Cutting Approach 3: Policy Making and Planning 56 Cross-Cutting Approach 4: Emergency Communication 60 Cross-Cutting Approach 5: Human Resources and Training 62 Cross-Cutting Approach 6: Water, Sanitation, and Hygiene 64 Cross-Cutting Approach 7: Monitoring and Evaluation 67 Policy Guidance: Priority Nutrition Interventions and Cross-Cutting Approaches This section describes the priority nutrition interven- 2. Crisis settings during which the efficient implemen- tions and cross-cutting approaches that are essen- tation of interventions begun during stable times tial to promote and protect the nutritional status of helps to further build resilience against shocks. mothers and children as well as a country’s human These interventions should be part of national de- capital in the short-, medium-, and long-terms. The velopment policies. During a crisis (such as a food main thrust of the guidance is that: (1) policies give or economic crisis) or emergency (such as an earth- special attention to the critical “window of oppor- quake), these interventions can be rapidly scaled tunity� represented by the first 1,000 days of life; up and extended to affected populations, thereby (2) policies are aligned with the latest international ensuring that the most vulnerable are protected recommendations in nutrition; (3) policies and inter- from the immediate- and long-term effects of a ventions of key sectors are coordinated to provide shock. These interventions should be integrated synergy of action; and (4) resources allocated for di- in crisis-preparedness plans, and their implemen- saster prevention and emergency management are tation should be adapted to respond to a popula- invested in the most cost-effective way. tion’s needs in case of a shock. As shown in Figure 2 of the Methodology1 for Develop- 3. Emergency settings in which short-term interven- ment of the Toolkit, three settings can be the iden- tions must be put in place when populations are tified in which these interventions and approaches faced with an unexpected shock. It is important variously apply: that these interventions be taken into account in crisis- and emergency-preparedness plans and 1. Stable settings that enable interventions that can that they be rapidly rolled out during a crisis, serve as the foundation for building long-term re- emergency, or sudden shock. silience to shocks among vulnerable populations. These interventions should be designed and im- This policy guidance provides recommendations on plemented as routine and sustainable develop- how priority nutrition interventions and cross-cutting ment programs, well ahead of a potential crisis or approaches should be implemented in stable, crisis, emergency. and emergency situations. Some additional resources on how to address nutrition in the first 1,000 days dur- ing emergencies and crises: • The Sphere Project. Humanitarian Charter Minimum Standards in Humanitarian Response. • UNHCR. Handbook for emergencies. • Global Nutrition Cluster. A toolkit for addressing nutrition in emergency situations. • International Committee of the Red Cross. Nutrition manual for humanitarian action. 1 The methodology is located in the book named Purpose of the toolkit -1- Priority Nutrition Interventions IN STABLE TIMES Summary of Policy Guidance Recommendations for Priority Nutrition Interventions Priority Nutrition Interventions Assuring Maternal, • Promote optimal breastfeeding practices: initiation of exclusive breastfeeding within one Infant, and Young hour of birth, exclusive breastfeeding until 6 months of age, and after 6 months sustained Child Nutrition breastfeeding with appropriate complementary foods until 2 years of age and beyond. • Encourage appropriate complementary feeding practices starting at 6 months of age. Appropriate complementary foods should be adapted to the development of the child, nutrient-dense, of the appropriate consistency, fed frequently, varied, easy to chew and digest, appealing to children, help children transition to the family diet, prepared and fed in hygienic conditions, and fed responsively with patience and encouragement. • Ensure the International Code of Marketing of Breast-milk Substitutes is in place and com- plied with at all times. • Implement community-based nutrition programs that promote and support optimal mater- nal, infant, and young child feeding practices. Promoting Healthy • Implement growth monitoring and promotion (GMP) activities to prevent undernutrition by Growth detecting growth faltering and improving household practices or seeking care for illness. • Integrate a referral system for cases of acute malnutrition detected through GMP and ensure that protocols for management of acute malnutrition are up-to-date with the latest recom- mendations. • If rates of acute malnutrition are above 5%, implement community-based management of acute malnutrition (CMAM) programs for children with acute malnutrition without complica- tions, providing ready-to-use therapeutic food. • Ensure that GMP and CMAM programs integrate the most cost-effective interventions and products. Preventing and • Promote consumption of a diverse diet rich in micronutrients. Treating • As needed, establish micronutrient supplementation programs for common deficiencies as a Micronutrient short-term strategy for eliminating micronutrient deficiencies: Deficiencies For children < 5 years, • vitamin A when vitamin A deficiency prevalence > 20% • iron when anemia prevalence is > 40% For females of reproductive age, iron-folic acid when anemia prevalence is > 20%. • Establish food fortification programs, including universal salt iodization and fortification of complementary foods, as a long-term strategy for eliminating micronutrient deficiencies. • Promote optimal breastfeeding practices. • Provide all pregnant women with daily iron-folic acid supplements for at least six months. • Provide daily iron-folic acid supplements to mothers for three months after delivery where anemia prevalence is ≥ 40%. • Provide deworming treatment to pregnant women, preschool-aged children, and school-aged children in areas where hookworms or soil-transmitted helminthes are prevalent. -2- Preventing and • Set up infrastructures that ensure access to safe water and hygienic environments. Treating Infectious • Decide whether health services should counsel HIV infected mothers to either breastfeed Diseases and receive ARV drugs or avoid all breastfeeding. • Promote replacement feeding only if it is acceptable, feasible, affordable, sustainable, and safe. • Recommend, in countries that choose to promote breastfeeding with ARV interventions and where ARV drugs are available or are planned to be, that mothers known to be HIV-infected exclusively breastfeed for six months and then continue breastfeeding with complementary foods at least until their children reach 12 months of age. • Use oral rehydration salts (ORS) and daily zinc supplements for the clinical management of acute diarrhea, as per WHO and UNICEF recommendation. • Implement robust malaria and dengue control programs that reduce vector breeding sites by encouraging clean environments and, where relevant, sleeping under bed nets, especially for pregnant women and young children. • Promote and protect breastfeeding, especially exclusive breastfeeding for the first six months of life. Promoting Healthy • Follow WHO guidelines for antenatal and postpartum package of services. Motherhood • Promote good nutrition for all girls and women of reproductive age, and adequate weight gain during pregnancy. • Discuss birth plans with all pregnant women, and provide each with a safe delivery kit. • Ensure the availability of skilled professionals and essential equipment. • Use infection prevention measures when caring for women and infants immediately after birth. • Ensure a sufficient number of delivery kits for the estimated number of deliveries in each area. • Integrate safe motherhood interventions into emergency plans. Ensuring Food • Establish strong links between agricultural, food security, social protection and nutrition Security policies that can be used to inform a robust communication program regarding maternal diet and critical infant and young child feeding practices. • Support diversified agricultural production to increase availability of nutrient-dense foods, particularly those of animal sources. • Target the most vulnerable geographic areas and, within them, the most vulnerable house- holds: poor/food insecure households and smallholder farmers. • Prioritize the needs of pregnant and lactating women (adolescent girls if appropriate), and infants and children <2 years of age. • Encourage procurement and use of locally produced products when possible. • Provide cash, vouchers, food, or in-kind transfers to food-insecure individuals. • Ensure that, when foods products are offered, they are adapted to the nutritional needs of women and young children. • Preposition food and logistics in hard-to-reach areas. -3- IN CRISIS Summary of Policy Guidance Recommendations for Priority Nutrition Interventions Priority Nutrition Interventions Assuring Maternal, Infant, • Intensify and scale up programs that educate, encourage, and support mothers and Young Child Nutrition and families to practice optimal infant-feeding practices, including sustained breastfeeding. • For households with pregnant women or children <2 years of age, consider income support in response to constrained access to affordable nutritious foods or specialized complementary food provision in response to constrained availability for those at risk of falling into poverty. Promoting Healthy Growth • Scale up and strengthen GMP programs to ensure coverage and more frequent monitoring of young children with enhanced vulnerability. GMP programs may be a good platform to scale up other health and social service programs. • Use an early warning surveillance system to target and monitor rates of acute malnutrition. • Use GMP as a platform to offer essential nutrition, health, and social protection interventions. • Strengthen referral networks or initiate CMAM programs to include acutely malnourished children and those with increased vulnerability, for example those who are losing weight. • Make sure a supply chain for CMAM supplies is in place. • Provide supplementary food rations to young children with moderate acute malnutrition. • If the crisis is prolonged screen pregnant and post-partum women for undernutrition and refer to supplementary feeding program as needed. Preventing and Treating • Scale up and strengthen programs to prevent, screen, and treat micronutrient defi- Micronutrient Deficiencies ciencies, paying attention to women and children whose diet quality or health care access may be limited. • Monitor prevalence of micronutrient deficiencies in vulnerable populations to see if the supplementation protocol should be modified. • Provide deworming treatment to pregnant women, preschool-aged children, and school-aged children in areas where hookworms or soil-transmitted helminthes are prevalent. Preventing and Treating • Expand and strengthen infectious disease control programs, especially in vulnerable Infectious Diseases populations. • Intensify the promotion and protection of optimal breastfeeding practices. • Ensure that emergency preparedness plans take into account appropriate management of infectious diseases including the provision of ART, ARV drugs, breast-milk substitutes (for those countries that recommend that HIV-infected mothers avoid all breastfeeding), and condoms. • Enhance the surveillance of infectious diseases and scale up programs where prevalence increases. Promoting Healthy • Identify women who are in advanced stages of pregnancy and discuss birth plans, Motherhood providing each with a safe delivery kit. • Consider cash transfers or vouchers for households in which pregnant mothers are unable to afford adequate services or diets. • Provide food transfers when affordable nutritious foods are not available. Ensuring Food Security • Scale up income support via cash transfers, vouchers or food transfers to allow house- holds to procure a sufficient food basket. • Scale up the provision of micronutrient supplements to pregnant/lactating women and young children in households that may be suffering from reduced dietary diversity and/or vulnerable to micronutrient deficiencies. -4- IN EMERGENCY Summary of Policy Guidance Recommendations for Priority Nutrition Interventions Priority Nutrition Interventions Assuring Maternal, Infant, • Ensure that mothers and families receive adequate support, including provision of and Young Child Nutrition ongoing information and of a safe environment, to practice optimal infant feeding, including sustained breastfeeding. • Provide, in situations where children cannot be breastfed, artificial feeding in the form of ready-to-use infant formula, following WHO recommendations. • Ensure availability of safe havens where mothers can breastfeed. • Ensure that pregnant and lactating women receive adequate fluids and food to main- tain hydration and sustain breastfeeding in order to support the additional nutritional requirements of pregnancy and lactation. • Provide specialized complementary foods to children 6-24 months of age. Promoting Healthy Growth • Intensify GMP and, where it does not exist, put in place rapid screening for acute child malnutrition and undernutrition in pregnant and post-partum women; target especially women and children in shelters. • Scale up CMAM or referral for acute malnutrition, ensuring the supply of ready-to-use foods to prevent and treat malnutrition. • Use information from GMP programs or the early warning surveillance system to inform nutrition-program decisions over time following the emergency; closely monitor rates of moderate and severe acute malnutrition, particularly among the poorest indivi- duals. Preventing and Treating • As needed, provide fortified food rations, including iodized salt. Micronutrient Deficiencies • Provide pregnant and lactating women with a daily multiple micronutrient supplements; continue provision of iron-folic acid supplements. • Provide children 6-59 months of age with a daily dose of multiple micronutrient supplements when fortified rations are not being given; when fortified rations are being given, children in this age group should receive two doses per week. • Continue semi-annual vitamin A supplementation. Preventing and Treating • Ensure supplies of ART, ARV drugs, breast-milk substitutes (if applicable), and condoms Infectious Diseases are included in emergency response kits and that health workers maintain blood safety and infection control procedures; provide ARV as soon as feasible. • In emergency settings, recommend breastfeeding for all mothers. • Guarantee adequate access to potable water and safe foods, prioritizing mothers and young children. • Have soap readily available in the toilet areas of shelters and promote regular hand washing with soap. • Encourage hygienic food preparation and closely monitor food safety in shelters. • Intensify vector control measures and follow WHO recommendations on diagnosis and treatment of infectious diseases. Promoting Healthy • Link with other sectors to provide “safe havens� for pregnant and lactating women. Motherhood • Ensure that pregnant and lactating women receive additional rations of food and safe drinking water. • Provide pregnant women with additional warm clothes, based on the climate. Provide baby clothes and blankets for infants. • Follow WHO recommendations for healthy childbirth during an emergency, including ensuring the presence of female health workers and adequate security at the delivery site. • Ensure that an evacuation plan is in place for women and newborns with pregnancy and health complications. Ensuring Food Security • Provide cash, vouchers, fee waivers, food rations, to individuals in distress rapidly to enable them to meet their daily nutritional needs. • Provide safe water and address specifically the need to continue breastfeeding with specific instructions about use of formula and artificial milk. • Make certain that adequate and hygienic cooking facilities are available to families who have lost access to their homes. -5- Priority Nutrition Intervention 1: Assuring Maternal, Infant, and Young Child Nutrition Assuring Maternal, Infant, and Young Child Nutrition Summary of Recommendations In stable times b Promote optimal breastfeeding practices: initiation of exclusive breastfeeding within one hour of birth, exclusive breastfeeding until 6 months of age, and after 6 months sustained breastfeeding with appropriate complementary foods until 2 years of age and beyond. b Encourage appropriate complementary feeding practices starting at 6 months of age. Appropriate comple- mentary foods should be adapted to the development of the child, nutrient-dense, of the appropriate consistency, fed frequently, varied, easy to chew and digest, appealing to children, help children transition to the family diet, prepared and fed in hygienic conditions, and fed responsively with patience and encour- agement. b Ensure the International Code of Marketing of Breast-milk Substitutes is in place and complied with at all times. b Implement community-based nutrition programs that promote and support optimal maternal, infant, and young child feeding practices. In crisis b Intensify and scale up programs that educate, encourage, and support mothers and families to practice op- timal infant-feeding practices, including sustained breastfeeding. b For households with pregnant women or children <2 years of age, consider income support in response to constrained access to affordable nutritious foods or specialized complementary food provision in response to constrained availability for those at risk of falling into poverty. In emergency b Ensure that mothers and families receive adequate support, including provision of ongoing information and of a safe environment, to practice optimal infant feeding, including sustained breastfeeding. b Provide, in situations where children cannot be breastfed, artificial feeding in the form of ready-to-use in- fant formula, following WHO recommendations. b Ensure availability of safe havens where mothers can breastfeed. b Ensure that pregnant and lactating women receive adequate fluids and food to maintain hydration and sus- tain breastfeeding in order to support the additional nutritional requirements of pregnancy and lactation. b Provide specialized complementary foods to children 6-24 months of age. -6- While optimal maternal, infant, and young child long-term risks for the fetus. Children born to obese feeding (MIYCF) practices during crises and emer- mothers are twice as likely to be obese and to de- gencies are essentially the same as those recom- velop type 2 diabetes later in life. Lastly, a woman’s mended in more stable conditions, the challenging micronutrient status before pregnancy is also impor- circumstances faced by mothers and children during tant, as adequate iron stores can reduce the risk of unstable times can make it difficult to initiate and anemia during pregnancy, and folic-acid deficiency sustain these practices. The poor nutritional, men- during the early weeks of pregnancy is associated tal, or physical health of caregivers, resulting from with neural tube defects. emergency-related trauma, can disrupt patterns of effective parenting and mother-child interactions, During pregnancy and lactation, women’s nutrient which may in turn impact MIYCF practices or reduce needs increase. These increased needs encompass the psychosocial stimulation that supports a child’s energy, protein, vitamins (e.g., vitamin A, folic acid), healthy growth and development (1). Thus, addition- minerals (e.g., iodine, iron), and water. As recent- al supportive interventions are called for to minimize ly underscored in the WHO e-Library of Evidence for the irreversible effects that a crisis may have on the Nutrition Actions (eLENA), the nutritional status of mother-child relationship. women prior to and during pregnancy plays a key role in fetal growth and development. A Cochrane review WHO and the Emergency Nutrition Network have of the most recent evidence concluded that giving published detailed guidelines and principles that nutritional advice and balanced energy and protein encompass technical aspects of the interventions, supplements to pregnant women can improve fetal implementation advice, and resources for monitoring growth and may reduce the risk of fetal and neonatal and evaluating child nutrition during emergencies (2, death (3). 3). These are critical resources for developing MIYCN strategies and integrating them into national plans Good nutritional status during pregnancy will give a and policies for emergencies. WHO stresses, how- woman the necessary energy and nutrients to allow ever, the importance of tailoring these interventions her baby to develop well in the womb and enough to the local context and applying them flexibly, since strength to go through delivery, enable breastfeed- MIYCN during emergencies is only one element of a ing, and thus ensure that her baby gets the best start broader array of survival strategies (2). in life. If a pregnant woman does not consume all the nutrients she needs, her body’s reserves will be There is increasing evidence that a woman’s age, used to meet the needs of her growing baby, leav- weight, and micronutrient status before she becomes ing her own body weakened. Poor maternal nutrition pregnant are strong determinants of pregnancy out- can lead to undesirable consequences for both the comes, and the stress of crisis or emergency can ex- mother and her offspring, including pregnancy com- acerbate their effect. Teenage pregnancy, a preoc- plications, anemia, birth defects, brain damage, low cupying problem in a number of countries in Latin birth weight, and increased risk of maternal and child America and the Caribbean, should also be addressed death. in national policies, as it is associated with adverse birth outcomes such as pre-term delivery, low birth Lactation also places high demands on maternal weight, and neonatal mortality (4). Women’s weight stores of energy, fat, protein, and other nutrients. can also significantly influence both her health and Therefore, lactating mothers, like pregnant women, the health of her child: pre-pregnancy underweight need to pay attention to consuming extra energy, is associated with low birth weight, while maternal vitamins, minerals, and water to reduce the risk of obesity during pregnancy is associated with great- maternal depletion. It is particularly important that er use of health care services and longer hospital women consume enough liquid to maintain good hy- stays (5), cesarean delivery, oversized fetus, gesta- dration (7). tional hypertension, diabetes, as well as birth and heart defects (6). Maternal obesity also increases the In stable times, the two main goals of maternal nu- -7- trition programming are establishing appropriate nu- ing number of households may be unable to meet the tritional status for girls and women of reproductive nutritional needs of women of reproductive age and age and meeting the additional nutritional require- young children. Expansion of existing platforms for ments of women who are pregnant or lactating. In health, nutrition, and social programs, including food this regard, nutrition education and promotion are and/or cash transfer is crucial to support the increas- a primary concern, but social change often is neces- ing numbers of affected households. sary as well to promote nutritionally sound diets and gender-equitable distribution of food (and nutrients) In the case of emergency, food support is necessary within households. Appropriate policy and investment for households whose access to food is compromised. priorities must be established to promote availability The highest priority should be given to children 6-24 of affordable nutritious foods, and interventions may months, to currently pregnant/lactating women, and be required in areas where nutritious foods are not then to women of reproductive age. Households with available at an affordable price. Cash transfer inter- pregnant or lactating women will require supplemen- ventions may be necessary for individual households tary rations that reflect the additional nutritional that lack purchasing power. needs of pregnancy and lactation. Food rations should not be withdrawn until food markets are functional In times of crisis (e.g., market failure, food price and households have access to resources and have re- fluctuation, high unemployment, etc.), an increas- sumed livelihood activities. 1.1 Promotion of optimal breastfeeding practices Breast milk is the ideal source of nutrition for infants Global recommendations for optimal breastfeeding and young children, provides protection from infec- include the following (2): tions, and is free and readily available—tremendous 1. Initiation of exclusive breastfeeding within one advantages that have significant life-saving conse- hour of birth; quences in crisis and emergency settings. 2. Exclusive breastfeeding for 6 months; and 3. Continued breastfeeding (along with age-appro- priate, nutrient-dense complementary foods) un- til 2 years of age and beyond. From the field: El Salvador During emergencies, clear norms state that the dona- tion of artificial infant formula is forbidden. A medi- cal prescription is needed by the caregiver in order to receive infant formula. -8- Basic interventions to facilitate these practices in- breastfeeding during emergencies. clude national policies that promote and protect breastfeeding, such as the creation of baby-friend- • Technique. In emergencies, women may be sep- ly hospitals, adoption of the International Code arated from family or friends who would normally for Marketing of Breast-milk Substitutes (http:// provide support and guidance; therefore, expert www.who.int/nutrition/publications/infantfeed- help should be offered at health facilities or by ing/9241541601/en/), and establishment of traditional birth attendants. breastfeeding-friendly workplace laws. The “Ten Steps to Successful Breastfeeding� emphasizes • Confidence. Only in extremely severe cases will the need to help mothers initiate breastfeeding a mother’s health or nutritional status impair her within one hour of birth and to show mothers how ability to produce adequate amounts of nutrition- to breastfeed. In times of crisis and emergency, ally complete milk; however, a woman’s percep- promoting and protecting breastfeeding requires tion of reduced milk volume may cause her to prioritizing mothers with young children for shel- introduce other liquids or foods into her child’s ter, food, security, water and sanitation; enabling diet prematurely. Mothers need support and re- mother-to-mother support; providing appropriate assurance that with continued suckling, milk pro- space for skilled breastfeeding counseling; and giv- duction will function normally. ing support to maintain or re-establish lactation. • Frequency. The circumstances of emergencies Many infants and young children stop breastfeeding may alter a woman’s normal role and responsi- prematurely in times of crisis and emergency. Possi- bilities, subsequently interfering with her abili- ble reasons include illness or death of their mothers, ty to breastfeed as she chooses. Relief activities separation from their mothers, and detrimental cul- should consider the impact of an emergency on tural practices. Premature cessation can have del- lactating women. Strategies should be imple- eterious consequences; therefore, it is important to mented to reduce the workload of lactating wom- recognize and promote factors that encourage suc- en, provide them with income-earning opportuni- cessful breastfeeding. These include (2): ties at home, and generally support frequent and sustained breastfeeding. • Attitude. Education and practical support should be provided to guarantee successful initiation. Information regarding breastfeeding in the context of Continued encouragement is needed to sustain HIV/AIDS can be found in section 4.1. -9- 1.2 Provision of ready-to-use breast-milk substitutes when necessary The use of breast-milk substitutes in an emergen- is scarce and because mothers often use less pow- cy carries high risks of undernutrition, illness, and dered milk than recommended, resulting in a diluted death, and should only be considered as a last re- mix that is not sufficiently nourishing. Maximizing sort when safer options have first been fully explored exclusive breastfeeding and minimizing the use of (7). Supporting breastfeeding is important not just breast-milk substitutes is required to protect infants for the duration of an emergency; it can also have in emergencies (9). Provision of adequate fluids and lifelong impacts on a child’s health and on a woman’s food for mothers must be a priority, as doing so will future feeding decisions (8). If supplies of infant for- help protect their health and well-being and that of mula or powdered milk are widely available, moth- their young children. ers who would otherwise breastfeed might needlessly start giving artificial feeds. Introducing artificial for- Nevertheless, if breast-milk substitutes are required, mula can also impair breastfeeding, as it will reduce the preferred type is ready-to-use formula, to avoid a mother’s breast-milk production, increasing the any risk linked to inadequate preparation of the pow- risk of breastfeeding failure and cessation. dered form, such as use of unsafe water, unclean bottles, or over- and underdilution of the powdered Feeding with artificial milk formula exposes infants product—all factors that could lead to harmful condi- and young children to increased risk of disease and tions such as diarrhea and/or malnutrition. death, especially from diarrhea when clean water From the field: Haiti After the 2010 earthquake and during the subsequent cholera crisis, optimal breastfeeding practices were widely promoted and supported. After careful assessment, ready-to-use infant formula (RUIF) was fed to 8,787 orphans or children whose mothers could not breastfeed after the earthquake. Procurement of the formula was centralized, its distribution followed strict criteria, and the Nutrition Cluster co-chaired by the Ministry of Health and UNICEF monitored the operation. Caretakers of infants eligible to receive RUIF were taught how to feed them safely. During the cholera outbreak, breastfeeding promotion was stepped up through individual counseling and mass media campaigns. (Ref: Case Study: Humanitarian nutrition response to the earthquake addresses child malnutrition) - 10 - Offers of well-intentioned but ill-advised donations of the International Code of Marketing of Breast- of “baby foods� and feeding bottles should be re- milk Substitutes (12). Any provision of breast-milk fused. If donations arrive, they should be collected substitutes for feeding infants and young children by a designated agency, preferably from point of should be based on careful assessment of needs and entry into the emergency area, under the guidance should be used only under strict medical control and of the infant feeding in emergency (IFE) coordinat- monitoring and in hygienic conditions, in accordance ing body. Dried milk products should be distributed with the International Code and subsequent relevant only when pre-mixed with a milled staple food and World Health Assembly resolutions, as well as with should not be distributed as a single commodity (10, the policies and guidelines of humanitarian agencies. 11). To hold those who make donations accountable, There should be no general distribution of breast- it is important to monitor and report any violation milk substitutes (12). WHO recommendations for the use of breast-milk substitutes during an emergency (2): • The quantity, distribution, and use of breast-milk substitutes at emergency sites should be strictly controlled. • A nutritionally adequate breast-milk substitute should be available, and fed by cup, only to those infants who have to be fed breast-milk substitutes. • Generally speaking, only limited quantities of a nutritionally adequate breast-milk substitute are required for infants – the target group should be those <6 months of age who do not have access to breast milk. • Those responsible for feeding a breast-milk substitute should be adequately informed and equipped to ensure its safe preparation and use. • Feeding a breast-milk substitute to a minority of children should not interfere with protecting and promoting breastfeeding for the majority. • Caregivers of infants who have to be fed a breast-milk substitute should receive instructions indi- vidually on appropriate use and safe feeding. This should not be done, however, in the presence of breastfeeding mothers and children. - 11 - 1.3 Provision of complementary food or supplements After 6 months of age, breast milk is no longer suffi- knowledge of complementary food preparation and cient to meet all of an infant’s nutritional needs and feeding practices (e.g., frequency, amount, feeding to promote optimal growth and development. Thus, approach, etc.), with sufficient time for caregivers from 6 months onwards, children require hygienical- to implement it, and a social environment that facil- ly prepared, easy-to-eat and -digest foods that nu- itates it. Ensuring availability and access to appro- tritionally complement breast milk. PAHO has pub- priate foods is a matter government policy, and may lished Guiding principles for complementary feeding require interventions, of such as cash or food trans- of the breastfed child (13), which provides detailed fers to sustain it. In crisis and emergency settings, it guidance on healthy feeding behaviors; safe prepara- may be difficult for caregivers to offer complemen- tion and storage methods; the appropriate amount, tary foods using locally available ingredients that are consistency, nutrient content, and density of comple- sufficient in terms of nutrient quality and quantity. mentary foods at different ages; feeding frequency; When appropriate foods are available but households feeding approach; and feeding during and after an cannot afford them, cash transfers should be consid- illness. This guidance is relevant in all conditions. ered to facilitate their access to these foods. When the foods themselves are unavailable, specially for- Achieving optimal complementary feeding in sta- mulated supplements or rations should therefore be ble times requires uninterrupted local availabili- considered. ty of nutritious foods at affordable cost, adequate Appropriate options may include (8): • Basic food-aid commodities from general rations with supplements of inexpensive locally available foods; • Micronutrient-fortified cereal-legume blended foods offered as part of a general ration or supple- mentary feeding program; • Lipid-based nutrient supplements (LNS)/ready-to-use supplementary foods (RUSF); • Additional nutrient-rich foods in supplementary feeding programs; and • Micronutrient supplements (as discussed in Section 3.5.). - 12 - From the field: Haiti During the earthquake, ready-to-use therapeutic and supplementary foods (RUTF and RUSF) were distributed to prevent and treat malnutrition. Almost 200,000 children aged 6-59 months received blanket supplemen- tary feeding for prevention of malnutrition. RUTF and RUSF are produced by local organizations at a cost of approximately $0.10 per dose. Initial findings from an ongoing study suggest that using RUSF in Haiti lowers micronutrient deficiencies in young children and improves their nutritional status, which ultimately will boost child development milestones. (Ref: Case Study: Tackling Malnutrition with Innovative Ready-to-use Local Food Products) Since young children need to eat frequently, special accommodations may be necessary in times of emergency, including (2): • Increasing fuel availability and conservation; • Providing caregivers with cooking utensils; • Making snacks available that require little or no cooking; • Encouraging income-generating preparation and sale of snack foods; and • Encouraging caregivers to group themselves for food preparation. - 13 - 1.4 Information, education, and communication on optimal feeding practices Promotion of complementary feeding is unique implemented successfully in emergency settings, among public health interventions in that effective- an effective system for interacting with caregivers ness requires supporting individual caregivers be- about feeding issues must be in place. Though the yond general recommendations. All young children tendency in emergency settings may be to focus on may need the same immunizations or antibiotics for attending to medical emergencies, these offer an pneumonia, but feeding recommendations depend on opportunity to provide preventive public health ad- how foods are prepared as well as the child’s taste vice to an information-seeking audience, especially preferences and appetite. For example, a blanket when mothers and children are concentrated in shel- recommendation to feed three daily meals is of little ters. Information on optimal IYCF practices should benefit for a mother who feeds watery, nutrient-poor be shared with mothers, caregivers, and other fam- foods at each of those meals. Promotion of infant and ily members as well as with health care personnel, young child feeding (IYCF) requires a system for as- international and governmental agencies, NGOs and sessing how a caregiver feeds and providing recom- relief organizations, community and religious lead- mendations that address the problems s/he is facing. ers. It is important to seek input from the community Many approaches are possible for achieving this, in- to set priorities, identify potential barriers, and plan cluding counseling during a child’s health center vis- effective delivery strategies for IYCF interventions. its, community-based programs, support groups, and Clear and frequent communication between service others (see Section 2, “Promoting Healthy Growth�). providers and caregivers is important. In order for all IYCF practices to be promoted and From the field: Panama The Ministry of Health implements programs to support breastfeeding and provide “Nutricereal� to children 6-24 months of age. In 2009 the government reported a 30% increase in exclusive breastfeeding of children under 6 months of age. (Ref: Benchmarking exercise) - 14 - For more information on how to integrate and implement MIYCN interventions: • PAHO. Guiding principles for feeding infants and young children during emergencies, 2003. • IASC Global Nutrition Cluster. Toolkit for addressing nutrition in emergency situation, 2008. • UNICEF. Course on Nutrition in Emergency, 2010. (http://www.unicef.org/nutrition/training/index.html) • International Committee of the Red Cross. Nutrition manual for humanitarian action. - 15 - Priority Nutrition Intervention 2: Promoting Healthy Growth Promoting Healthy Growth - Summary of Recommendations In stable times b Implement growth monitoring and promotion (GMP) activities to prevent undernutrition by detecting growth faltering and improving household practices or seeking care for illness. b Integrate a referral system for cases of acute malnutrition detected through GMP and ensure that protocols for management of acute malnutrition are up-to-date with the latest recommendations. b If rates of acute malnutrition are above 5%, implement community-based management of acute malnutri- tion (CMAM) programs for children with acute malnutrition without complications, providing ready-to-use therapeutic food. b Ensure that GMP and CMAM programs integrate the most cost-effective interventions and products. In crisis b Scale up and strengthen GMP programs to ensure coverage and more frequent monitoring of young children with enhanced vulnerability. GMP programs may be a good platform to scale up other health and social service programs. b Use an early warning surveillance system to target and monitor rates of acute malnutrition. b Use GMP as a platform to offer essential nutrition, health, and social protection interventions. bStrengthen referral networks or initiate CMAM programs to include acutely malnourished children and those with increased vulnerability, for example those who are losing weight. b Make sure a supply chain for CMAM supplies is in place. b Provide supplementary food rations to young children with moderate acute malnutrition. bIf the crisis is prolonged screen pregnant and post-partum women for undernutrition and refer to supplemen- tary feeding program as needed. In emergency b Intensify GMP and, where it does not exist, put in place rapid screening for acute child malnutrition and undernutrition in pregnant and post-partum women; target especially women and children in shelters. b Scale up CMAM or referral for acute malnutrition, ensuring the supply of ready-to-use foods to prevent and treat malnutrition. b Use information from GMP programs or the early warning surveillance system to inform nutrition-program decisions over time following the emergency; closely monitor rates of moderate and severe acute malnutri- tion, particularly among the poorest individuals. - 16 - 2.1 Management of acute malnutrition A rise in rates of child undernutrition, and of acute approach is usually expensive, inefficient, and inef- malnutrition in particular, is one of the landmark signs fective. Over the past decade, an approach called of a crisis or an emergency. Acute malnutrition (wast- “community-based management of acute malnutri- ing) reflects recent nutritional inadequacies, there- tion� (CMAM) has been introduced. It is a comprehen- fore rates will increase when food security conditions sive strategy that encompasses community outreach, deteriorate and the prevalence of various infectious screening, referral, and treatment of acute malnu- diseases rises. Acute malnutrition is a major cause of trition (16, 17). It has moved the management of child mortality in some developing countries. Diag- acute malnutrition from the facility to the communi- nosing acute malnutrition can be done either through ty, enabling more children to be treated, while it has traditional growth monitoring and promotion where been shown to greatly reduce the cost and expand children are weighed and measured or it can be done the reach of treatment and to permit more timely using a color-coded middle-upper arm circumference identification and treatment of cases. CMAM can be (MUAC) measuring tape. Community members can be applied in crisis, emergency, and routine settings, trained to identify acute malnutrition for referral to where the prevalence of acute malnutrition warrants treatment. Internationally agreed-to cut-off points it. In a CMAM activity, health workers conduct regular have been established to determine moderate and screenings in the community, during which they mea- severe malnutrition in children 6-60 months of age sure the MUAC of all children. Children identified (14): as having MAM without medical complications can be treated in the community with dietary counseling • moderate acute malnutrition (MAM) is defined as a and ready-to-use supplementary foods (RUSF). Chil- weight-for-height Z score (WHZ) of ≥ -3 SD and <-2 dren identified as having MAM are referred to a com- SD and/or a MUAC of <12.5cm and ≥ 11.5cm; and munity health center where a trained health worker • severe acute malnutrition (SAM) is defined as a can assess for the presence of medical complications. weight-for-height Z (WHZ) score of <-3 SD and/or a If children have SAM without medical complications, MUAC of < 11.5cm. they can be treated as outpatients in the commu- nity using ready-to-use therapeutic foods (RUTF). If Undernutrition in adults is assessed through a body children have SAM with medical complications, they mass index (BMI) below 18.5kg/m2, but this measure are referred to an inpatient nutrition rehabilitation is not suitable for pregnant and lactating women. center for treatment, which initially uses therapeutic MUAC is the preferred nutritional index during preg- milks (e.g., F-100 or F-50). nancy and for up to 6 months postpartum. Though there are no clearly defined cut-offs, several orga- Currently, WHO has issued no recommendations on nizations, among them UNICEF, consider a MUAC of the composition of supplementary foods used to <23cm in pregnant women to be a risk for poor birth treat children with moderate acute malnutrition. A outcomes. The Sphere Minimum Standards recom- growing body of research (16, 17) is available, how- mend a cut-off point of 21cm for identification of nu- ever, on the efficacy and effectiveness of ready-to- tritional risk in pregnant women in emergencies (15). use therapeutic and supplementary foods (RUTF and In Latin America and the Caribbean, the treatment of RUSF), which are specially formulated energy-dense, SAM in children is mostly limited to the hospital set- micronutrient-fortified spreads or pastes that do not ting and the use of therapeutic milk formulas. This require any refrigeration or preparation and can be - 17 - consumed directly from the package. RUSF is similar not otherwise optimal. They can be produced locally to RUTF, but provides fewer calories and is intended using simple equipment with appropriate quality con- to act as a supplement to the child’s diet. Since nei- trols, although this activity would have to begin dur- ther product is water-based, bacteria cannot grow ing stable times or be done for a prolonged crisis. in them—making them safe, even in areas where re- frigeration is not available or hygiene conditions are From the field: Guatemala Acute malnutrition became an important problem in the country as a result of the drought caused by the climatic phenomenon known as El Niño. The main strategy to address the issue was to provide comprehensive care for the treatment of uncomplicated acute malnutrition at the community level, with the participation of a range of community actors. Complicated cases were treated in hospitals with therapeutic formulas. These were accompanied by media promotion of exclusive breastfeeding and adequate complementary feeding as well as cooking demonstrations on how to prepare nutritious porridge with local foods. (Ref: Case Study – Guatemala: Management of Emergencies) In the outpatient setting, a child is provided with a While a need exists for programs that manage and sufficient number of sachets of RUSF or RUTF for the treat acute malnutrition, if undernutrition is going week and is expected to return to the health center to be reduced in the region, long-term programs that for regular follow-up anthropometric measurements, focus on preventing undernutrition in young children medical assessment, counseling, and ultimately dis- must be established and supported to address the charge. Numerous countries in the world, including chronic malnutrition that prevails in most countries Haiti, have developed a national protocol for the even in stable times. Growth monitoring and promo- management of acute malnutrition. WHO, WFP, the tion in the community, discussed below, has served as UN Standing Committee on Nutrition, and UNICEF a critical platform for prevention for many countries have released a joint statement on community-based in Latin America and the Caribbean. management of severe acute malnutrition (18). 2.2 Growth monitoring and promotion GMP is defined as “a preventive and promotional ac- growth; (2) improved caring practices; (3) increased tivity that uses growth monitoring (i.e., measuring demand for other services, as needed� (19). The five and interpreting growth) to facilitate communication main activities linked to GMP are described by Ash- and interaction with the caregiver and to generate worth et al. (20). adequate action to promote child growth through: (1) increased caregiver’s awareness about a child’s - 18 - In routine settings, GMP programs can be used as a at the community level to improve the environment platform to rapidly provide or scale up essential nu- for healthy growth (20). While the focus of GMP is to trition, health, and social protection interventions. establish a healthy growth pattern, if cases of acute Programs are community-based and are implemented malnutrition (moderate or severe) are identified, re- by trained local community growth promoters (CGPs) ferral to a health facility or CMAM program must be on a monthly basis. CGPs may be community health immediate. The infrastructure established for GMP workers or respected parents within the community can be used during crises and emergencies to reach supervised by a health worker (21, 22). Local owner- the vulnerable households with pregnant and post- ship and responsibility, which are crucial to the suc- partum women and young children for treatment cess of GMP programs, encourage the maintenance (see Case Study of the AIN-C program in Honduras). of healthy growth patterns and support the develop- ment of corrective actions within the household and From the field: Nicaragua During emergencies, the nutritional status of children in shelters is rapidly and systematically assessed, tracked, and monitored by trained local health personnel. In routine settings, the same staff provide ongoing counseling to the residents of extremely poor communities through “PROCOSAN,� the community health and nutrition program. The program offers continuous growth monitoring, education on improving the feeding habits of pregnant women and children (with an emphasis on children <2 years of age), and promotion of the consumption of nutritious, culturally acceptable foods. (Ref: Benchmarking results and Nicaragua Country Scorecard) For more information on how to implement growth monitoring programs: • UNICEF. Experts’ consultation on growth monitoring and promotion strategies: program guidance for a way forward, 2008. • FAO. Protecting and promoting good nutrition in crisis and recovery, 2005. • World Bank. Promoción del crecimiento para prevenir la desnutrición crónica: estrategias con base comunitaria en Centro América, 2009. • World Bank. Promoting healthy child growth and development: advances and opportunities for community-based nutrition programs in Central America, 2009. - 19 - Priority Nutrition Intervention 3: Preventing and Treating Micronutrient Deficiencies Preventing and Treating Micronutrient Deficiencies Summary of Recommendations In stable times b Promote consumption of a diverse diet rich in micronutrients. b As needed, establish micronutrient supplementation programs for common deficiencies as a short-term strategy for eliminating micronutrient deficiencies: o For children < 5 years, • vitamin A when vitamin A deficiency prevalence > 20% • iron when anemia prevalence is > 40% o For females of reproductive age, iron-folic acid when anemia prevalence is > 20%. b Establish food fortification programs, including universal salt iodization and fortification of complementary foods, as a long-term strategy for eliminating micronutrient deficiencies. b Promote optimal breastfeeding practices. b Provide all pregnant women with daily iron-folic acid supplements for at least six months. b Provide daily iron-folic acid supplements to mothers for three months after delivery where anemia preva- lence is ≥ 40%. b Provide deworming treatment to pregnant women, preschool-aged children, and school-aged children in areas where hookworms or soil-transmitted helminthes are prevalent. In crisis bScale up and strengthen programs to prevent, screen, and treat micronutrient deficiencies, paying attention to women and children whose diet quality or health care access may be limited. b Monitor prevalence of micronutrient deficiencies in vulnerable populations to see if the supplementation protocol should be modified. In emergency bAs needed, provide fortified food rations, including iodized salt. b Provide pregnant and lactating women with a daily multiple micronutrient supplement; continue provision of iron-folic acid supplements. b Provide children 6-59 months of age with a daily dose of multiple micronutrient supplement when fortified rations are not being given; when fortified rations are being given, children in this age group should receive two doses per week. b Continue semi-annual vitamin A supplementation. - 20 - Pregnant and lactating women and young children are tries. Micronutrient deficiencies typically occur when the groups most vulnerable to micronutrient deficien- access to micronutrient-rich foods (e.g., fruits and cies in normal times as well as in crises and emergen- vegetables, fortified foods) is limited or infectious cies. During periods of rapid child growth and devel- diseases elevate nutrient requirements and increase opment, mothers and young children have increased losses. Thus, the risk of micronutrient deficiencies nutrient requirements and are more susceptible to increases during crises and emergencies when food the harmful consequences of deficiencies. Thus, a crops are lost, food delivery systems and supplies are critical category of interventions aims to prevent and interrupted, and livelihoods are threatened; and that treat deficiencies of important vitamins and minerals increase in turn intensifies the occurrence of infec- during the first 1,000 days of life. Some interventions tious diseases that cause micronutrient malabsorp- aimed at reducing micronutrient deficiencies, such as tion and further losses (23). salt iodization and deworming, can also benefit other segments of the population. Implementation of interventions aimed at preventing and reducing micronutrient deficiencies should be in- Deficiencies of iron, folic acid, vitamin A, iodine, and cluded in routine health and nutrition policies as well zinc—which play vital roles in promoting growth and as in crisis-preparedness plans. The combined actions cognitive development and in reducing the risk of will promote optimal nutritional status and build the infectious diseases—are the most common micronu- resilience of vulnerable groups in the population. trient deficiencies in low- and middle-income coun- - 21 - 3.1 Iron-folic acid supplementation The following guidance applies to routine programs (1) increase iron intake; (2) control infection includ- and also should be reinforced during times of emer- ing control programs for malaria; and (3) improve nu- gency or crisis. Supplementation with iron and folic tritional status by preventing and controlling other acid to ensure that a woman’s iron stores are replete nutritional deficiencies, such as vitamin B12, folic is particularly important, because neural tube de- acid, and vitamin A (23). Iron-folic acid supplements fects, which folic acid can prevent, occur during the should be integrated into the package of essential very first weeks of gestation. WHO has updated its medicines provided in an emergency for women and recommendation for iron supplementation in malar- children who have lost access to these supplements ia-endemic areas, and it now recommends a three- as a result of a shock. pronged approach to combat iron-deficiency anemia: Recommendations for iron-folic acid supplementation in women Pregnant women: Iron requirements are increased • In areas where the prevalence of anemia in preg- during pregnancy and are usually difficult to meet nancy is ≥40%, the same dose should be provided through diet alone; routine iron supplementation for six months during pregnancy and continued for pregnant women is therefore recommended in virtu- three months after delivery (postpartum). ally all contexts. The supplement should also include folic acid to reduce the infant’s risk of neural tube Women of reproductive age: WHO recently issued defects, which can develop in the first few weeks the following guidelines on weekly iron-folic acid of pregnancy if the woman is deficient in folic acid. supplementation (25): in population groups where Iron and folic acid supplementation should be initiat- the prevalence of anemia is >20% among women of ed as soon as pregnancy is suspected and continued reproductive age and mass fortification programs of throughout the pregnancy and beyond if necessary. staple foods with iron and folic acid are not in place WHO updated guidelines are in press. Current guide- and are unlikely to be implemented within 1-2 years, lines are as follows (24): women of reproductive age should be supplemented on a weekly basis with 60mg iron in the form of fer- • In areas where the prevalence of anemia in preg- rous sulphate and 2800μg folic acid. Including folic nancy is <40%, 60mg of iron + 400µg of folic acid acid in the supplement reduces the risk of neural should be provided daily for six months during tube defects developing in the fetus. pregnancy; and Recommendation for iron supplementation in children Where the diet does not include fortified foods or reports of stained teeth after iron supplementation the prevalence of anemia in children approximately 1 with some solutions; however, good oral hygiene and year of age is >40%, iron supplements should be pro- the use of ferrous carbonate, which is not soluble but vided to all children 6-23 months of age at a dosage present as a suspension or a solution of iron EDTA, of 2mg/kg body weight/day. There have been some can prevent this condition (26). - 22 - 3.2 Deworming Deworming is an important component of strategies tard both physical and cognitive development, even to reduce micronutrient deficiencies, particularly at low intensities of infection. Moreover, if mothers anemia. A large proportion of the world’s popula- are infected, worms contribute to their already pre- tion, notably children and pregnant women, suffers carious iron status. Deworming not only improves from worm infestation (24, 27); hookworms infect nutritional status, but may also improve response to approximately 1 billion people worldwide, approxi- vaccinations. The following deworming guidelines mately 44 million of whom are pregnant women. are recommended (27): Worms exacerbate anemia and stunting levels and re- Recommendations for pregnant women • Where the prevalence of hookworms is 20-30% or greater, give anthelminthic treatment once in the second trimester of pregnancy; and • Where the prevalence of hookworms is >50%, repeat anthelminthic treatment in the third trimes- ter of pregnancy. Recommendations for preschool and school-aged children • If the prevalence of soil-transmitted helminthes in school-aged children is ≥20%, all children (pre- schoolers and school-aged) should be treated once a year; if it is ≥50%, then treatment should be twice a year; • As no data are available on the use of anthelminthic drugs in children <12 months of age, they should not be treated (unless indicated by a physician in a clinical setting); • Albendazole and mebendazole are safe for administration to children aged ≥12 months; • For children <3 years of age, tablets should be broken and crushed between two spoons, then water added to help administer the tablets. A child should never be forced to take a deworming tablet; and • Only chewable deworming tablets should be given to children <5 years of age, and tablets that taste good should be chosen. From the field: Nicaragua Deworming medicine and vitamin A are given to children based on their health card record, and iron-folic acid supplements are given to pregnant women both at shelters during emergencies and during Child Health Days in more stable times. Also through these activities, the country aims to strengthen the education of caregivers so as to pre- vent children-to-adult worm transmission. (Ref: Benchmarking results and Nicaragua Country Scorecard) 3.3 Vitamin A supplementation Vitamin A plays an important role in vision, growth, risk of disease and death from severe infections. In physical development, and immune function. pregnant women VAD causes night blindness and may Vitamin A deficiency (VAD) is the leading cause of increase the risk of maternal mortality. preventable blindness in children and increases the From the field: tackling vitamin A deficiency Colombia, El Salvador, and Guatemala have so significantly reduced the prevalence of vitamin A deficiency in children <5 years of age that large-scale supplementation with mega- doses of vitamin A is no longer required. High coverage of routine supplementation with vitamin A capsules and vitamin A-fortified sugar have contributed to the success of these countries’ programs. (Ref: Benchmarking results and Country Scorecards) - 24 - WHO has issued the following guidelines regarding vi- tamin A supplementation in various subgroups: Recommendations for pregnant and postpartum women (28) • Vitamin A supplementation in pregnancy as part of routine antenatal care is not recommended. • In areas where vitamin A deficiency is a severe public health problem (i.e., the prevalence of night blindness is ≥5% in pregnant women or ≥5% or higher in children 24-59 months of age), up to 10,000 IU/day or up to 25,000 IU/week should be provided for a minimum of 12 weeks during pregnancy until delivery. • Vitamin A supplementation in postpartum women is not recommended as a public health interven- tion for the prevention of maternal morbidity and mortality. Recommendations for children <6 months of age (29, 30) • Infants are usually born with low body stores of vitamin A. The breast milk of well-nourished mothers is rich in vitamin A and is its best source for infants. Mothers are therefore encouraged to exclusively breastfeed for the first six months postpartum. The concentration of vitamin A in breast milk is highest in the first 21 days postpartum. • Vitamin A supplementation in neonates and infants 1-5 months of age is not recommended as a public health intervention for the prevention of infant morbidity and mortality. Recommendation for children 6-59 months of age (31): in settings where vitamin A deficiency is a public health problem— i.e., in populations where the prevalence of vitamin A deficiency (serum retinol 0.70 µmol/L or lower) is ≥20% in infants and children 6-59 months of age or where the prevalence of night blindness is ≥1% in children 24-59 months of age— vitamin A supple- mentation is recommended in infants and children 6-59 months of age as a public health interven- tion to reduce child morbidity and mortality. Infants aged 6-11 months should receive a single dose of 100,000 IU, and children 12-59 months of age should receive a 200,000 IU dose every four to six months. - 25 - 3.4 Salt iodization and iodine supplementation Iodine-deficiency disorder (IDD), which can start in ism, an irreversible form of mental retardation that utero, is the world’s most prevalent, yet easily pre- affects people living in iodine-deficient areas. Chil- ventable cause of mental retardation; it can also dren with IDD can grow up stunted, apathetic, men- jeopardize a child’s very survival. The most critical tally retarded, and incapable of normal movements, period to prevent IDD is from the second trimester of speech, or hearing. Of far greater significance, how- pregnancy to the third year after birth (32), although ever, is IDD’s less visible, yet pervasive, mental im- IDD is possible at any age. Serious iodine deficien- pairment, which reduces intellectual capacity at cy during pregnancy can result in miscarriages, still- home, in school, and at work. births, and congenital abnormalities such as cretin- From the field: iodized salt in food rations Dominica, Haiti, and Honduras distribute iodized salt as part of the food rations given to families affected by emergencies. (Ref: Benchmarking results and Country Scorecard) New evidence has revealed that pregnant and lactat- tainable strategy to ensure sufficient intake of iodine ing women as well as children <2 years of age—the by all individuals, especially in emergencies. If io- most vulnerable groups for iodine deficiency—may dized salt is not accessible in these situations, in- not be adequately covered by iodized salt where uni- creasing iodine intake through supplementation is re- versal salt iodization (USI) is not fully implemented. quired (33). The recommendations for pregnant and The WHO/UNICEF Joint Committee on Health Policy lactating women, women of reproductive age, and recommends USI as a safe, cost-effective, and sus- children 7-24 months of age are as shown in Table 1. Table 1: Iodine supplementation recommendations (32) Population  group   Daily  dose  of  iodine   Single  annual  dose  of  iodized  oil   supplement  (µg/d)   supplement  (mg/year)   Pregnant  women   250   400   Lactating  women   250   400   Women  of  reproductive  age     150   400   (15-­�49  years)   Children  7-­�24  months  of  age*   90   200            *  Where  complementary  food  fortified  with  iodine  is  not  available.   - 26 - 3.5 Multiple micronutrient supplements During a crisis or an emergency, micronutrient defi- groups during emergencies. Multiple micronutri- ciencies can easily develop or worsen if already pres- ent supplements are often provided in the form of a ent in the affected population. One way of meeting powder contained in an individual sachet, sometimes micronutrient needs is through the provision of ad- known as micronutrient powders (MNPs) or more pop- equate amounts of fortified food rations. These foods ularly known as “sprinkles,� and can be used in both may not entirely meet the needs of nutritionally vul- routine and emergency settings to prevent or reduce nerable subgroups, however: the distribution of food micronutrient deficiencies. MNPs can easily be added within a household may not benefit pregnant and lac- to home-prepared food prior to serving and are usu- tating women or young children, or children may not ally well accepted by beneficiaries, as they have no be able to consume a sufficient quantity of fortified taste and very few side-effects. These supplements foods to meet their micronutrient needs. should be provided according to the recommenda- tions and supplementation schedule that follow, until Thus, WHO, WFP, and UNICEF have developed a daily the emergency is over and access to micronutrient- multiple micronutrient formula to meet the recom- rich foods has been restored (23). mended nutrient intake (RNI) of these vulnerable Recommendations for pregnant and lactating women • Pregnant and lactating women should be given a supplement providing one RNI of micronutrients daily, whether they receive fortified rations or not; and • Iron-folic acid supplements, when already provided, should be continued. Recommendations for children aged 6-59 months of age • When fortified rations are not being given, children 6-59 months of age should be given one dose of micronutrient supplement daily. • When fortified rations are being given, children 6-59 months of age should be given two doses of micronutrient supplement weekly. • Mega-dose vitamin A supplements should continue to be given to children 6-59 months of age ev- ery six months. - 27 - From the field: Haiti “Bebe Vayan� – multi-micronutrient powder sachets— were widely distributed to children 6-59 months through the “baby-friendly centers� as well as with emergency food rations after the earthquake. The World Food Program includes the distribution of micronutrient powders as part of its maternal and child health program. For more information on how to implement micronutrient deficiency control programs: • WHO Nutrition website: http://www.who.int/nutrition/topics/micronutrients/en/index.html • WHO Vitamin and Mineral Nutrition Information System (VMNIS) http://www.who.int/vmnis/en/ index.html • UNSCN. Module 6 – Measuring malnutrition: individual assessment of acute malnutrition. http:// www.unscn.org/layout/modules/htp/pdf/mod6_measuring_malnutrition-fact_sheet.pdf • WHO, WFP, and UNICEF. Preventing and controlling micronutrient deficiencies in populations af- fected by an emergency: multiple vitamin and mineral supplements for pregnant and lactating women, and for children aged 6 to 59 months, 2007. - 28 - Priority Nutrition Intervention 4: Preventing and Treating Infectious Diseases Preventing and Treating Infectious Diseases Summary of Recommendations In stable times b Set up infrastructures that ensure access to safe water and hygienic environments. b Decide whether health services should counsel HIV-infected mothers to either breastfeed and receive ARV drugs or avoid all breastfeeding. b Promote replacement feeding only if it is acceptable, feasible, affordable, sustainable, and safe. b Recommend, in countries that choose to promote breastfeeding with ARV interventions and where ARV drugs are available or are planned to be, that mothers known to be HIV-infected exclusively breastfeed for six months and then continue breastfeeding with complementary foods at least until their children reach 12 months of age. b Use oral rehydration salts (ORS) and daily zinc supplements for the clinical management of acute diarrhea, as per WHO and UNICEF recommendation. b Implement robust malaria and dengue control programs that reduce vector breeding sites by encouraging clean environments and, where relevant, sleeping under bed nets, especially for pregnant women and young children. b Promote and protect breastfeeding, especially exclusive breastfeeding for the first six months of life. In crisis b Expand and strengthen infectious disease control programs, especially in vulnerable populations. b Intensify the promotion and protection of optimal breastfeeding practices. b Ensure that emergency preparedness plans take into account appropriate management of infectious diseases including the provision of ART, ARV drugs, breast-milk substitutes (for those countries that recommend that HIV-infected mothers avoid all breastfeeding), and condoms. b Enhance the surveillance of infectious diseases and scale up programs where prevalence increases. In emergency b Ensure supplies of ART, ARV drugs, breast-milk substitutes (if applicable), and condoms are included in emer- gency response kits and that health workers maintain blood safety and infection control procedures; provide ARV as soon as feasible. b In emergency settings, recommend breastfeeding for all mothers. b Guarantee adequate access to potable water and safe foods, prioritizing mothers and young children. b Have soap readily available in the toilet areas of shelters and promote regular hand washing with soap. b Encourage hygienic food preparation and closely monitor food safety in shelters. b Intensify vector control measures and follow WHO recommendations on diagnosis and treatment of infectious diseases. - 29 - The vicious cycle between infectious disease and pecially diarrhea and pneumonia. While breastfeed- malnutrition is well known: infectious disease predis- ing carries a risk of HIV infection for children of HIV- poses undernutrition, and undernutrition predisposes infected mothers, antiretroviral (ARV) interventions infectious disease. Protecting the nutrition of chil- (antiretroviral therapy for mothers needing ARV for dren in the first 1,000 days thus requires avoidance of their own health and prophylactic ARV for mothers infection as well as improved infant and young child and/or infants when the mothers do not require ART) feeding. Importantly, breastfeeding is the single most can reduce the risk of infection to less than 1%, cre- powerful preventive measure for children. Breastfed ating the possibility for HIV-exposed infants to enjoy children (exclusive breastfeeding for the first six the same life-saving benefits of breastfeeding that months, breastfeeding with complementary foods for non-exposed children do. months 6-23) are less likely to experience illness, es- 4.1 HIV/AIDS and preventing mother-to-child transmission Good nutrition is essential to the health and survival gions have higher HIV prevalence rates than South of people living with HIV/AIDS (PLWHA). They have America, with rates in countries such as the Bahamas, higher nutrient requirements, and frequent concomi- Belize, and Haiti as high as 3.1%, 2.3%, and 1.9%, re- tant infections, such as diarrhea and tuberculosis, spectively (36, 37). All Latin American and Caribbean put an additional strain on their nutritional status. countries have policies mandating free provision of In 2010, UNAIDS estimated that 1.86 million people antiretroviral therapy (ART) to those in need as a ba- were living with HIV/AIDS in Latin America and the sic human right, according to a 2012 PAHO study that Caribbean (34, 35), two-thirds of which reside in five found that 63% of PLWHA who require treatment are countries: Argentina, Colombia, Haiti, Mexico, and receiving it—giving the region the highest ART cover- Brazil. The Caribbean and Central American subre- age rate of any developing region in the world (38). From the field: Honduras During emergencies, HIV/AIDS prevention and care is of high importance: HIV-infected individuals are identi- fied for health services, condoms are included in personal hygiene kits, and health personnel receive training on how to provide counsel on preventing mother-to-child transmission of the virus. Of special relevance to efforts to protect the nutri- • The provision of antiretroviral therapy (ART) or tional status of pregnant and lactating women and antiretroviral (ARV) prophylaxis to mother and/or children <2 years of age in the context of HIV/AIDS child during pregnancy and breastfeeding to pre- are initiatives aimed at preventing mother-to-child vent MTCT; and transmission (PMTCT), which include: • Safe feeding practices for HIV-exposed infants. - 30 - Recommendations for HIV-infected mothers • In 2010, WHO published new PMTCT guidelines (39, 40) recommending that national authorities decide whether health services should counsel HIV infected mothers to either breastfeed and re- ceive ARV drugs or avoid all breastfeeding. • Where ARV drugs are available, in countries that decide to recommend breastfeeding with ARV in- terventions, health services should advise mothers known to be HIV-infected to exclusively breast- feed for the first six months and continue breastfeeding, with complementary foods, until their children reach 12 months of age. After 12 months the mother should discontinue breastfeeding gradually as soon as she is able to provide a safe and nutritionally adequate diet without the benefit of breast milk. When ARV are not (immediately) available, HIV-infected mothers should be counseled to exclusively breastfeed for the first six months of life and continue breastfeeding thereafter unless environmental and social circumstances are safe for, and supportive of, replace- ment feeding (41). • The recommendation remains that replacement feeding should not be used unless it is accept- able, feasible, affordable, sustainable, and safe (AFAS) (42). It is important that countries maintain interventions The national policy on infant feeding practices may to prevent and treat HIV/AIDS during an emergency also need to be reconsidered during an emergency or crisis, especially those with higher HIV/AIDS preva- when safe drinking water and sanitation are often un- lence rates. Ensuring supplies of ART, ARV drugs, milk available, making replacement feeding more danger- replacement, and condoms should be included in all ous. In those conditions, the benefits of breastfeed- emergency preparedness planning, which should also ing by HIV-infected mothers, even if no ARV drugs make provisions to ensure that health workers main- are available, may outweigh the risks (40). National tain normal blood safety and infection control pro- authorities should consider this scenario and include cedures. clear guidance to health staff on what to recommend to HIV-infected mothers during an emergency in train- ing and emergency-preparedness plans. They should also aim to provide ARV as soon as feasible (41). For more information on how to implement PMTCT and infant feeding in the context of HIV/AIDS Program, consult the following: • WHO. Guidelines on HIV and Infant Feeding, 2010. • PAHO. Regional Initiative for the Elimination of Mother-to-Child Transmission of HIV and Congenital Syphilis in Latin America and the Caribbean: Clinical Guidelines, 2010. - 31 - 4.2. Malaria and dengue Malaria and dengue are vector-borne diseases trans- from non-endemic to endemic areas, overcrowding, mitted via female mosquitoes. Dengue infection is and changes in the habitat that promote mosquito more commonly encountered in children <15 years breeding (landslides, deforestation, river damming, of age, but pregnant women can also be infected. and rerouting of water) can also increase the risk for The effect of dengue infection on pregnant women outbreaks. A pause in disease control activities or and their fetuses is unclear (43). Pregnant women are weakened public health infrastructure can further in- particularly susceptible to malaria, however, which crease morbidity and mortality associated with these increases their risk of severe anemia, spontaneous diseases during an emergency (44). It is therefore im- abortion, stillbirth, and premature delivery, as well portant for disaster preparedness teams to consider as their children’s low birth weight—a leading cause vector control measures when formulating emergen- of child malnutrition and mortality. cy water and sanitation plans and to include WHO recommendations on diagnosis and treatment in their Natural disasters, especially those involving large emergency medical planning (45). displacements of water such as heavy rains, flooding or hurricanes, can raise transmission of both dengue Preventing transmission of both malaria and dengue and malaria by increased availability of the vector’s depends on control of the mosquito vectors or inter- breeding sites (namely, standing water). Artificial ruption of human–vector contact through integrated containers used when basic water supply and waste vector management (IVM) (46, 47). Once infected, disposal services are disrupted can also serve as early symptom recognition, accurate diagnosis, and breeding sites. Other factors, such as increased expo- prompt treatment can substantially lower the risk of sure to mosquitoes while sleeping outside, movement developing severe disease and death. From the field: El Salvador Shelters are fumigated before they open. Every health center has a vector control program. Standardized protocols are in place and include effective training and communication programs set up by the Ministry of Health For more information on how to implement malaria and dengue prevention and treatment programs: • WHO Guidelines for the Treatment of Malaria, 2010. (includes evidence-based recommendations on case management including a section on complex emergencies and epidemics). • WHO. Dengue hemorrhagic fever: diagnosis, treatment, prevention, and control, 2009. • WHO. Planning social mobilization and communication for dengue fever prevention and control : a step-by-step guide (COMBI Strategy). - 32 - 4.3 Diarrhea Increased incidence of diarrhea may occur in emer- low-osmolarity oral rehydration solution with zinc gency situations as access to electricity, clean water, supplementation for the treatment of diarrhea among and sanitary facilities is limited. Hygiene practices children. Health service staff should be trained in the may also be disrupted, and health care-seeking be- ORS+zinc protocol and its promotion, and ORS and haviors may be altered. Infection is spread through zinc supplements should be available in all health contaminated food or drinking water, or from person centers as well as through private pharmaceutical to person as a result of poor hygiene. Severe diar- channels. rhea leads to fluid loss, and may be life-threatening. Diarrhea remains the leading cause of death among It is therefore crucial that preventive measures be infants and young children in low- and middle-income put in place to preclude diarrhea in precarious situ- countries (48) and can significantly affect nutritional ations. People affected by a crisis or an emergency status, especially in those who are already malnour- should have access to potable water and safe foods. ished or who have reduced immunity. Soap should be readily available in the toilet areas of shelters. Regular hand washing with soap, especially Programs for the control of diarrheal disease should after using the toilets, and changing young children be part of health services in any stable setting. before and after food preparation should be wide- Safe water, appropriate sanitation and hygiene, and ly promoted. As discussed in section 6.4, hygienic breastfeeding are proven measures for the preven- methods of food preparation should be encouraged tion of diarrhea, and WHO recommends the use of and closely monitored in a shelter environment. Recommendations for diarrhea Treatment WHO and UNICEF recommend two simple, effective treatments for the clinical management of acute diarrhea (49, 50): • Use of low-concentration oral rehydration salts (ORS); and • Daily zinc supplementation for 10–14 days, at a dosage of 10mg/day in children <6 months and 20mg/day for children ≥6 months of age. Oral rehydration is a well-known and relatively simple children with diarrhea, because it is a vital micro- treatment approach. Zinc supplementation has been nutrient essential for growth, immune function, and found to reduce the duration and severity of diarrhe- intestinal transport of water and electrolytes. Zinc al episodes, decrease the likelihood of subsequent in- is also important for normal growth and development fections for 2–3 months, and reduce diarrhea-related of children both with and without diarrhea. mortality by 23% (51). Supplementary zinc benefits - 33 - From the field: Haiti In 2010, zinc supplementation was added to the treatment of diarrhea as well as to the treatment of cases of cholera in children. Supplementary feeding is also provided to prevent malnutrition in children leaving cholera treatment centers. (Ref: Case Study: Humanitarian nutrition response to the earthquake was adequate to address child malnutrition) For more information on how to implement diarrhea prevention and control pro- grams: • WHO/UNICEF. Joint Statement on the Clinical Management of Acute Diarrhea, 2004. - 34 - Priority Nutrition Intervention 5: Promoting Healthy Motherhood Promoting Healthy Motherhood Summary of Recomendations In stable times b Follow WHO guidelines for antenatal and postpartum package of services. b Promote good nutrition for all girls and women of reproductive age, and adequate weight gain during preg- nancy. b Discuss birth plans with all pregnant women, and provide each with a safe delivery kit. b Ensure the availability of skilled professionals and essential equipment. b Use infection prevention measures when caring for women and infants immediately after birth. In crisis b Ensure a sufficient number of delivery kits for the estimated number of deliveries in each area. b Integrate safe motherhood interventions into emergency plans. bIdentify women who are in advanced stages of pregnancy and discuss birth plans, providing each with a safe delivery kit. b Consider cash transfers or vouchers for households in which pregnant mothers are unable to afford adequate services or diets. b Provide food transfers when affordable nutritious foods are not available. In emergency b Link with other sectors to provide “safe havens� for pregnant and lactating women. b Ensure that pregnant and lactating women receive additional rations of food and safe drinking water. b Provide pregnant women with additional warm clothes, based on the climate. Provide baby clothes and blankets for infants. b Follow WHO recommendations for healthy childbirth during an emergency, including ensuring the presence of female health workers and adequate security at the delivery site. b Ensure that an evacuation plan is in place for women and newborns with pregnancy and health complica- tions. - 35 - Malnutrition can be both a cause and an effect of ma- Implementing the full package of antenatal, deliv- ternal morbidity. A poorly nourished mother will im- ery, and postpartum services during an emergency pair fetal growth, which can lead to low birth weight or crisis can be challenging, however. Disruptions in babies (those born weighing <2.5kg), who are at great- the communication or transportation infrastructure er risk for many causes of infant mortality and mor- caused by bad weather, earthquakes, or other natu- bidity (52). Obstructed labor is common among young ral disasters can prevent women from reaching life- and malnourished girls whose pelvises are underde- saving emergency obstetric care, often resulting in veloped and among adult women of short stature as dire consequences for the mother and child. First a result of undernutrition during their childhood, as responders should be trained on how to manage ob- a small pelvis can block passage of the fetus. As dis- stetric emergencies during these events, including cussed above in section 3.1, iron-deficiency anemia evacuation to tertiary services equipped to handle is a highly prevalent problem among pregnant women emergencies requiring surgical intervention. that also contributes to obstetric hemorrhage. En- suring proper nutritional status among all girls and Governments should target pregnant women during women of reproductive age—which by definition re- times of stress and integrate safe motherhood prac- quires ensuring proper nutrition for girl children—and tices into their emergency planning. Mechanisms optimal nutrition in pregnancy are important aspects should be put in place to ensure that pregnant and of healthy motherhood in times of stability as well as postpartum women continue to have access to timely during a crisis or an emergency. services and that they can be easily referred to ad- equate health facilities in case of obstetric compli- UNFPA estimates that in an emergency or refugee sit- cations. WHO advises the following priority actions uation, one in five women of childbearing age is likely during an emergency: (1) essential supplies (in the to be pregnant (53). Women and their babies in these form of emergency kits) reach expectant mothers as situations are especially vulnerable as a result of re- quickly as possible; (2) skilled professionals with es- duced access to health services that may be com- sential equipment be available; and, (3) an evacua- bined with malnutrition, injury, disease, trauma, or tion plan be created for women and newborn infants exposure to violence. To avoid short-term problems with pregnancy and health complications (54). and potentially long-term perinatal complications, it 5.1 Antenatal is essential to make motherhood as safe as possible during crisis situations by providing antenatal, deliv- care ery, and postpartum care for mothers and newborns. Many health problems in pregnant women can be pre- causes of infant mortality and morbidity (52), while vented, detected, and treated during antenatal care excess weight gain during pregnancy increases the visits by trained health workers. WHO recommends risks of gestational diabetes, complications during a minimum of four antenatal visits and has pub- delivery, and excess weight postpartum. Recent rec- lished various standards and guidelines comprising ommendations for total weight gain during pregnancy key antenatal care interventions (55-58). Monitoring of the Food and Nutrition Board of the Institute of weight gain during pregnancy is important, because Medicine are as shown in Table 2 (59): undernutrition or overnutrition during pregnancy can negatively influence maternal and infant morbidity and mortality. Undernutrition before or during preg- nancy can lead to low birth weight babies (those born weighing <2.5kg), who are at greater risk for many - 36 - Table 2: Recommendations for total weight gain in pregnancy Pre-­�pregnancy  BMI   Total  Weight  Gain   2 (kg/m )   (kg)   Underweight   12.5–18 <18.5     Normal  weight 11.5–16 18.5–24.9   Overweight 7–11.5 25.0–29.9   Obese     5–9 ≥30.0   *  Calculations  assume  a  0.5–2kg  (1.1–  4.4lb)  weight  gain  in  the  first  trimester     (based  on  Siega-­�Riz  et  al.,  1994;  Abrams  et  al.,  1995;  Carmichael  et  al.,  1997)   WHO published the following guidance for antenatal care to ensure safe pregnancy during an emergency (54): • Ensure sufficient numbers of delivery kits for the estimated number of deliveries in each area. • Identify women who are in advanced stages of pregnancy and discuss birth plans—where to de- liver, how to recognize danger signs, and where to seek help; give each woman a delivery kit. • Maintain a register of pregnant women and estimated dates of delivery, births, and deaths; • Provide women information on where to find skilled attendants and on referral facilities; • Give tetanus toxoid (2 X) to all pregnant women; • Ensure that pregnant women receive additional warm clothes, depending on climate; provide baby clothes and blankets for babies; and • Ensure that pregnant and lactating women receive additional rations of food and drinking water; chemicals for water disinfection are safe for pregnant and lactating women, if used according to instructions. From the field: Nicaragua The “Programa Amor� offers a wide range of services to mothers through home visits that include education on healthy eating, evaluation of nutritional status, and voluntary HIV testing. Midwives monitor the progress of women’s pregnancies in “casas maternas� (maternal care homes). A birth plan is elaborated, and brigades transport pregnant women to the nearest hospital or health facility when complications arise. Ref: Benchmarking results - 37 - 5.2 Safe delivery Most of the above-cited guidelines also include guid- ean delivery), or if an appropriate health facility is ance on key interventions in the safe childbirth pack- not available nearby; age (55-58). An important innovation is a 29-item • Ensure that, during childbirth, the mother is pro- WHO Safe Childbirth Checklist that addresses the ma- vided with clean fluids and food (meat should be jor causes of maternal and neonatal mortality and is thoroughly cooked) and that she is not left alone at due for publication by year-end 2012. Some specific any time; WHO recommendations for healthy childbirth during • Reduce risks of infection by using infection-preven- an emergency include (54): tion measures while examining and caring for the • Ensure presence of female health workers and ad- woman during and immediately after childbirth; en- equate security for the delivery site; sure an adequate supply of clean water and gloves • Keep the place of delivery warm in cold weather for or disinfectants for hand-washing for delivery and the birth of the baby; cutting the cord; and • Organize referral to the appropriate level of care in • Use a clean (preferably sterile) instrument to cut case of known complications or where problems are the umbilical cord, and check frequently for bleed- highly likely (e.g., a woman with a previous cesar- ing. From the field: El Salvador The country passed a law that ensures access to assisted delivery. Moreover, hos- pitals instituted “salas de espera materna� (dedicated waiting rooms), where expectant mothers who live in remote areas can come in advance of their delivery date. 5.3 Postpartum care for mother and newborn WHO guidelines (55-58) also provide recommenda- • Promote, protect, and support early (initiation tions for a postpartum package of services for mother within the first hour of birth) and exclusive breast- and child under “normal� circumstances. In emer- feeding, day and night; and gency settings, WHO recommends that the following • Observe the mother and baby for problems for at interventions take place after childbirth, which are least 12 hours, especially the breathing of preterm the same as for normal circumstances (59): and small babies. • Keep the baby warm by keeping the baby dry, close to the mother’s body; - 38 - 5.4 Safe spaces Safe spaces are tents or special shelters in camps for lactation include prioritizing mothers with young chil- refugees or internally displaced people, where moth- dren for support and providing a specific space for ers with children <2 years of age can find a safe and skilled breastfeeding counseling. secure place to rest, eat, and receive support (60). The above-mentioned challenging and sometimes Disaster-affected populations returning to the site of traumatic circumstances faced by mothers and chil- their original homes or being hosted or accommodat- dren during emergencies can interfere with feeding ed in temporary communal settlements require safe, practices. Traumatized and depressed mothers may secure, and equitable access to essential services, have difficulty responding to their infants and require such as child-friendly spaces (61-62). special mental and emotional support. Basic interven- tions to facilitate breastfeeding and to re-establish From the field: Haiti After the 2010 earthquake, “baby friendly centers� were set up throughout the affected areas to provide a safe space for mothers to breastfeed, offer counseling on infant and young child feeding, and distribute artificial infant formula for young orphans and children whose mothers were unable to breastfeed. Almost 50,000 mothers received services in these centers, where exclusive breastfeeding for six months was practiced by 83% of the attended mothers. (Ref: Case Study: Humanitarian nutrition response to the earthquake was adequate to address child malnutrition) - 39 - Recommendations related to safe spaces In the first few days of an emergency, establish imme- eas where privacy, security, and shelter are provided diate links with other sectors, such as reproductive with access to water and food for pregnant and lac- health services, to provide safe spaces for pregnant tating women. Basic supportive care of breastfeed- and lactating women in the early days of an emergen- ing mothers and their infants should be offered and cy. These safe spaces should be easily accessible ar- peer-to-peer support nurtured (63). For more information on how to implement healthy motherhood programs: • Partnership for Maternal, Newborn, and Child Health, WHO and Aga Khan University. Essential interventions, commodities and guidelines for reproductive, maternal, newborn and child health: A global review of the key interventions related to reproductive, maternal, newborn and child health, 2011. • WHO. Pregnancy, childbirth, postpartum and newborn care: A guide for essential practice, 2006. • WHO. Key steps for maternal and newborn health in humanitarian crisis, n.d. - 40 - Priority Nutrition Intervention 6: Ensuring Food Security Ensuring Food Security Summary of Recommendations In stable times b Establish strong links between agricultural, food security, social protection and nutrition policies that can be used to inform a robust communication program regarding maternal diet and critical infant and young child feeding practices. b Support diversified agricultural production to increase availability of nutrient-dense foods, particularly those of animal sources. b Target the most vulnerable geographic areas and, within them, the most vulnerable households: poor/food insecure households and smallholder farmers. b Prioritize the needs of pregnant and lactating women (adolescent girls if appropriate), and infants and chil- dren <2 years of age. b Encourage procurement and use of locally produced products when possible. b Provide cash, vouchers, food, or in-kind transfers to food-insecure individuals. b Ensure that, when food products are offered, they are adapted to the nutritional needs of women and young children. b Preposition food and logistics in hard-to-reach areas. In crisis bScale up income support via cash transfers, vouchers or food transfers to allow households to procure a suf- ficient food basket. b Scale up the provision of micronutrient supplements to pregnant/lactating women and young children in households that may be suffering from reduced dietary diversity and/or vvulnerable to micronutient defi- ciencies. In emergency b Provide cash, vouchers, fee waivers, food rations, to individuals in distress rapidly to enable them to meet their daily nutritional needs. b Provide safe water and address specifically the need to continue breastfeeding with specific instructions about use of formula and artificial milk. b Make certain that adequate and hygienic cooking facilities are available to families who have lost access to their homes. - 41 - FAO defines “food security� as a situation in which When a crisis or emergency hits, people may lose or “all people at all times have access to sufficient, be forced to sell off assets, or they may lose their safe, and nutritious food to maintain a healthy and livelihoods— leaving them even more vulnerable to active life.� Food security is built on three pillars: subsequent shocks. As a result, families and individ- uals can be plunged further into poverty, reducing 1. Food availability: sufficient quantities of nutri- their capacity to return to productive activity once tious foods are available on a consistent basis; the crisis has passed. 2. Food access: individuals have sufficient resources to obtain culturally appropriate foods for a nutri- Depending on the circumstances and resources avail- tious diet; and able, ensuring food security may take the form of 3. Food use: foods are used appropriately based on distribution of cash, vouchers, food or other in-kind knowledge of basic nutrition and care, as well as transfers. The selected responses should aim to, at availability of adequate water and sanitation. minimum, meet short-term needs, do no harm, re- duce the need for the affected population to adopt Times of crisis put pressure on livelihoods and pur- potentially damaging coping strategies. Where pos- chasing power and may impair households’ access to sible they may contribute to restoring longer-term adequate and nutritious food. Emergencies disrupt food security and reduce vulnerability (60). even more severely livelihoods as well as markets and services. They may disrupt both access and availabil- ity of food. 6.1 Provision of transfers in crisis settings One of the fundamental hallmarks of crisis settings and can include direct transfers (e.g., cash transfers, is the pressure on purchasing power of wide swathes vouchers, and in-kind transfers such as food) and of the population. Transfers, established through indirect transfers (e.g., fee waivers and subsidies). social protection measures, can act directly to restore some of that purchasing power and protect Good social safety net programs take time to develop livelihoods. They can help individuals, households, and thus should be planned and implemented before and communities to: a crisis hits. The choice of program is context-specific and can include direct transfers (e.g., cash transfers, • Maintain their access to food and energy as well as vouchers, and in-kind transfers such as food) and to health and education services that are crucial to indirect transfers (e.g., fee waivers and subsidies). safeguarding human capital; • Avoid coping strategies with negative consequences; Transfers in cash, vouchers or in-kind can contribute • Maintain social equilibrium; and sometimes to restoring purchasing power. In settings where • Emerge from poverty and into productive food markets are functioning well, the provision of livelihoods. cash can be adequate to boost purchasing power and may have a side benefit of helping to sustain Good social safety net programs take time to develop local economy. Moreover, cash transfers have the and thus should be planned and implemented before advantages of the lowest administrative costs and a crisis hits. The choice of program is context-specific that they can be done with very good accountability. - 42 - There is a host of experience available to draw from in lead to reduced productivity in adult life. The the social protection sector on choice of instruments, recommendations regarding appropriate food and targeting methods, payment methods and the like. micronutrient supplementation is discussed in details Most middle income and an increasing number of low in Priority Nutrition Interventions 1, 2 and 3. income countries have one or more poverty-targeted cash transfer programs that can be used as a basis for Several useful resources and toolkits are available scaling up the level of benefit, the coverage, or both. to provide more guidance on social protection in normal times, crises and emergencies, such as those When households are under pressure to reduce produced by the World Bank and WFP. Moreover, expenditures on their food basket, the quality of the several countries in Latin America and the Caribbean, diet, more particularly dietary diversity and intake of including Mexico and Brazil, are at the forefront of vitamin and minerals (micronutrients) through food developing social safety net programs that have sources, may suffer. Thus in addition to transfers to proven successful in protecting the nutritional status support household purchasing power, it is desirable of mothers and young children (96-98). to concomitantly provide micronutrient supplements to individuals in the first 1,000 days of life to prevent deficiencies which can lead to increased morbidity, mortality and cognitive impairments which will For more information on how to implement social protection programs: • World Bank. Safety nets how-to: a toolkit for practitioners. www.worldbank.org/safetynets/howto • World Bank. For protection and promotion: the design and implementation of effective safety nets, 2008. • WFP. Nutritional dimension of the social safety nets in Central America and the Dominican Repub- lic, 2010. - 43 - 6.2 Provision of transfers in emergencies Depending on the circumstances and resources avail- often via vouchers or cash. As transport and markets able, ensuring food security during an emergency are re-established and people begin to move out of may take the form of distribution of cash, vouchers, camps back to private homes cash transfers to sup- food rations, or other in-kind transfers. The selected port food purchases may be useful for a period long responses should aim to meet short-term needs, do enough to allow livelihoods to be re-established. no harm, reduce the need for the affected popula- tion to adopt potentially damaging coping strategies, When food aid is provided, issues around food stor- and contribute to restoring longer-term food security age, distribution, handling, and preparation must (61). be considered, because the normal food systems are often disrupted and yet food must continue to Where markets are functioning and households are be delivered, prepared, and eaten. In an emergen- living independently, cash or vouchers may still be cy, food-borne illnesses are common due to inade- quite suitable instruments of transfer and there is quate hygiene and poor infrastructure. The link be- increasing use of them, with all payment modali- tween food safety and undernutrition is very clear, ties (cash distributed in envelopes, through bank with poor food handling leading to diarrhea and other accounts, mobile banking, etc.) When markets are gastrointestinal complaints (62). In emergencies, al- too disrupted, so food is in short supply, or when un- though the preference is for the distribution of dry related households are grouped together as in camp foods (which are taken home, stored, and prepared settings, provision of food in-kind can be called for. by the beneficiaries), distribution of cooked meals There may be a mix or transition process – e.g. with may be needed in exceptional circumstances (e.g., food and shelter provided in camps initially follow- when access to safe water or cooking fuel is extreme- ing a natural disaster, with support for repairing or ly limited or when the beneficiaries’ security is at rebuilding homes provided as soon after as feasible, risk) (63). From the field: Panama Rations of packaged dry staple foods are prepared and stocked for distribution to families. Mobile kitchens, water filters, and other supplies are also stocked in the capital to be ready for deployment when needed. (Ref: Benchmarking exercise) - 44 - Recommendations regarding the use of food rations in emergency settings • In situations where the nutritional needs of the general population cannot be met through more normal channels of markets and cash transfers, a general ration should be provided. The ration should be customized or additional supplementary foods should be provided to meet the height- ened nutrient needs of pregnant and lactating women. • For children 12-24 months of age, basic food-aid commodities, ideally locally available food, are suggested. Where malnutrition is already an underlying problem among the population, this food ration should also include special, nutrient-dense supplements. In all situations, attention should be given to the nutritional value of the food ration distributed to infants and young children whose particular nutritional requirements may not be covered by the general ration (8). • In situations where supplementary foods are available but sufficient food for a general food ration is not, consider pregnant and lactating women and young children as priority target groups, given their higher caloric and nutrient requirements, their increased susceptibility to undernutrition and the likelihood that undernutrition will lead to irreversible physical and cognitive damage. • Food rations should be balanced, palatable, and culturally acceptable. Provide familiar food items and maintain sound traditional food habits. Staple food should not be changed simply because unfamiliar substitutes are readily available (63). • The food basket should comprise a staple food source (cereals), an additional energy source (fats and oils), a protein source (legumes, blended foods, meat, and fish), iodized salt, and condiments (spices). When possible, fresh foods should be included in the food basket for essential micronu- trients (63). • The recommended general food ration in emergency situations is 2100 kcal/day, 10% of total en- ergy provided by protein and 17% provided by fat (62, 8); however, environmental temperature, nutritional status, demographic distribution, level of physical activity, and self-reliance oppor- tunities should be considered and may call for an increase in energy or nutrient content (63). If health or nutritional status of the population is extremely poor, energy requirements should be adjusted upwards by 100-200 kcal (62). - 45 - For more information on how to implement transfers in emergencies: • Harvey et al. Delivering Money – Cash Transfer Mechanisms in Emergencies. Save the Children Fund, 2010. http://policy-practice.oxfam.org.uk/publications/delivering-money-cash-transfer- mechanisms-in-emergencies-112500 • Pelham L., Clay, E., Braunholz, T. Natural Disasters: What is the Role for Social Safety Nets? The World Bank, February 2011. http://siteresources.worldbank.org/SOCIALPROTECTION/Resources/ SP-Discussion-papers/Safety-Nets-DP/1102.pdf 6.3 Prepositioning food and logistics Prepositioning of food is a key aspect to ensure timely delivery of foods and essential goods, such as hygiene kits, in an emergency. Food should be prepositioned near regions that are prone to emergencies to ensure that it can be provided to victims in times of need, even if the trans- portation infrastructure has been disrupted. From the field: St. Lucia St. Lucia has an interesting private-public partnership model for prepositioning food and sanitation kits: the government contracts a local company to store and supply essential goods in the event of an emergency. It is recommended that a food and nutrition coordi- beneficiaries, particularly women’s committees (63). nator (or coordinators) be appointed to manage the The food and nutrition coordinator should ensure logistics of procurement, storage, and distribution that food aid responses are coordinated with other of food aid during emergencies. Clear delivery and services and sectors and that feeding programs are distribution methods should be established to reduce effectively coordinated, monitored, and evaluated. the risk that food is diverted (60) and all arrange- Typically, WFP and UNHCR share responsibility to ments for the distribution of food to beneficiaries support countries in meeting the food and nutritional should be agreed upon jointly by the government, needs of populations affected by emergencies. other UN agencies, and NGOs in consultation with - 46 - 6.4 Cooking facilities People affected by emergencies that return to their ration. Proper containers or bags should also be pro- homes or are hosted or accommodated in temporary vided so that food rations can be stored safely and communal settlements require safe, secure, and eq- hygienically. uitable access to essential utensils and facilities for food preparation (61). Ensuring access not only to Food preparation time and environmental implica- food but also to nonfood items such as cooking fuel, tions should be considered when planning which foods utensils, transport, and food storage containers helps to include in rations. The type of foods included in maintain cultural preferences and independence of the rations, cooking facilities, and meal preparation households, thus promoting food security (63). Some methods in shelters should aim to save fuel and limit cooking supplies (e.g., individual kits, fuel-efficient the environmental impact of food preparation (62, stoves) have been developed or adapted specifical- 63). Consideration should also be given to providing ly for use in emergency situations, while other mea- fuel and managing and controlling the use of natural sures may be as simple as providing eating utensils or resources around shelter areas. access to communal basins or stoves for food prepa- For more information on how to implement food security programs in crises and emergencies: • The Sphere Project. Humanitarian Charter Minimum Standards in Humanitarian Response, 2011. • UNHCR. Handbook for Emergencies. Second Edition, 2007. • IASC Global Nutrition Cluster. A toolkit for addressing nutrition in emergency situations. Global Nutrition Cluster, UNICEF, New York, NY, 2008. • FAO. Guidelines for joint planning for nutrition, food security, and livelihoods: Agreeing on causes of malnutrition for joint action. • IFE Core Group. Infant and young child feeding in emergencies. Operational Guidance for Emer- gency Relief Staff and Programme Managers, 2007. - 47 - Cross-Cutting Approaches IN STABLE TIMES Summary of Policy Guidance Recommendations for Cross-Cutting Approaches Cross-Cutting Approaches Targeting • Identify and map pockets of vulnerability using a variety of criteria: poverty, disaster-prone, marginalized population, geographic isolation, etc. • Define target groups according to the different realms of interventions implemented. • Define targeting strategy including categories and criteria for inclusion, conditions, approaches, and appropriate targeting agents. • Establish a system at the community and agency level for identifying vulnerable families and actions to reduce their vulnerability. • Ensure that the targeting strategy does not add stigma to beneficiaries. Multisectoral • Establish a comprehensive humanitarian coordination mechanism that will lead the func- Coordination tions of preparedness, response, leadership, policy, advocacy, information management, and humanitarian financing. • Establish operational “clusters� or subcommittees by technical areas (such as health, nutri- tion, water, and sanitation) to avoid duplications and gaps and ensure coordination and clear leadership for each technical area. • Involve a wide range of organizations and actors in humanitarian coordination mechanisms, including governmental and non-governmental institutions, religious or humanitarian groups, and bilateral and multilateral partners. Policy Making and • Make fighting undernutrition a top priority, focusing on optimal nutrition during the first Planning 1,000 days through education of and advocacy among senior policy makers. • Enlist nutrition experts to review existing policies and plans to ensure that they are up-to- date with regard to international recommendations and best practices and that nutrition has been mainstreamed into preparedness planning. • Orient local first-responders to translate central plans into decentralized action that reaches those most in need. • Develop a graduation strategy or transition plan to assist individuals to return to stability after a shock and to build resilience. Emergency • Elaborate a comprehensive communication plan for crises and emergencies to efficiently Communication inform the public about the situation and what to do at both the central and decentralized levels and to provide accountability to the public. • Include, in planning, multiple channels of communication—hardwired and wireless networks, broadcast and satellite television, radio, mobile phone networks, Internet, social media, and interpersonal networks. Human Resources • Develop or adapt training strategy, curricula, and materials to ensure that they include pro- and Training tecting nutrition during the first 1,000 days, taking into account training resources that have been produced by UN agencies and other reputable organizations. • Integrate nutrition into crisis and emergency response training curricula for workers at all levels. • Ensure that key personnel undertake training courses on basic concepts of humanitarian aid, management of undernutrition and emergency response. - 48 - Water, Sanitation, • Invest resources in WASH infrastructures, especially in disaster-prone and peri-urban areas, and Hygiene to minimize the effects of poor hygienic conditions and to avoid population-wide epidemics. • Ensure that emergency and crisis plans include sections on WASH and comply with interna- tional best practices taken from WHO/WEDC guidelines. • Promote culturally-specific good WASH practices. • Maintain a store of clean water to meet basic needs for the initial phase of an emergency in more remote disaster-prone areas. Monitoring and • Develop early warning systems based on international best practices that enable the govern- Evaluation ment to predict crises and their associated effects. • Establish responses to be made when food security and nutritional status indicators fall be- low crisis and emergency cutoff values. • Develop a monitoring and evaluation system for crises and emergencies that can assess the effectiveness of the humanitarian response, enable learning, and promote accountability. • Link the monitoring and evaluation system to relevant government management information systems. - 49 - IN CRISIS Summary of Policy Guidance Recommendations for Cross- Cutting Approaches Cross-Cutting Approaches Targeting • Target based on nutritional needs, especially pregnant and lactating women and chil- dren <2 years of age, if resources are limited. • Prioritize other vulnerable groups, including children 2-5 years of age, people with disabilities, the elderly, and people living in hard-to-reach areas. Multisectoral Coordination • Intensify coordination mechanisms and ensure that core functions are operating well and are ready to be activated. • Enable coordination mechanisms to build shared situational awareness as well as com- mon strategy, approaches, and implementation plans. Policy Making and • Intensify links with existing social protection systems to address the food and nutrition Planning needs of the chronic and transient poor. • Expand systems and programs that address food and nutrition insecurity, with an em- phasis on meeting the needs of mothers and children. • Ensure that emergency response plans are up-to-date and that resources are available to be rolled out rapidly. Emergency • Implement communication plan, targeting the affected population, to provide infor- Communication mation on how to seek assistance and on what to do. • Monitor the situation and continually test the effectiveness of the communication system by regularly obtaining feedback from the field and collecting data. Human Resources and • Provide refresher training to crisis and emergency response personnel to assure that Training their skills and knowledge are up-to-date, notably in nutrition. • Have trained human resources assist in scaling up programs, implementing communica- tion and education campaigns, and participating in surveillance and monitoring activi- ties. Water, Sanitation, and • Strengthen WASH infrastructures in areas that are the most vulnerable to shocks and Hygiene where the population lives in conditions of extreme poverty, such as peri-urban and rural areas. • Scale up programs to educate the population on practices they need to follow to pre- vent water-borne diseases. • Promote exclusive breastfeeding and appropriate hygiene practices related to comple- mentary feeding. Monitoring and Evaluation • Activate early warning systems and intensify surveillance, especially in vulnerable areas. • Monitor closely the food security and nutrition situation in vulnerable areas (i.e. rural and peri-urban areas) among mothers and young children, and provide relevant assis- tance in accordance with the information collected. • Evaluate periodically the impact of these programs, informing planners of the results of evaluation, so that strategies can be improved. - 50 - IN EMERGENCY Summary of Policy Guidance Recommendations for Cross-Cutting Approaches Cross- Cutting Approaches Targeting • Establish an ongoing targeting process throughout the emergency that is clear and acceptable to those who are included. • Balance inclusion and exclusion errors to minimize harm to affected individuals. • Consider blanket distributions in sudden-onset disasters if all households have suffered similar losses or where targeting is not possible. Multisectoral Coordination • Activate coordination mechanisms to ensure efficient emergency response. • Ensure that these mechanisms perform their core functions, share information fluently, and implement the response cooperatively. Policy Making and • Follow-up the work of, and maintain communication with, local responders to adapt Planning the implementation of policies and plans according to the situation. • Evaluate the situation before closing a program or making the transition to a new phase, to provide evidence of improvement or identify suitable actors to take over the responsibility. • Communicate the exit strategy to affected populations during the early stages of pro- gram implementation to enhance sustained recovery. Emergency • Rapidly roll out emergency communication plan, maintain open communication with Communication the public to assure calm and order, and provide clear and practical information on what to do and how to seek assistance. • Ensure that the communication system accommodates two-way communication in order to collect and analyze information coming in from the field and to be responsive to it as the nature of the emergency changes. • Once the emergency is over, continue communication relevant to recovery and to pre- venting relapse. • Evaluate public communication strengths and weaknesses during and following events and adapt plan accordingly. Human Resources and • Provide continuous training, support, and supervision to response personnel during and Training after an emergency. • Take stock of strengths and skill gaps to adapt training after an emergency. Water, Sanitation, and • Promote exclusive breastfeeding for children <6 months of age and appropriate Hygiene hygiene practices related to complementary feeding. • Supply adequate levels of safe drinking water, prioritizing young children and pregnant and lactating women in light of their increased water needs. • If the local water supply is compromised, distribute water purification technologies or products. • Ensure that the population has access to adequate sanitation facilities and the ability to maintain good hygiene. • Monitor the incidence of water-borne diseases, particularly diarrhea and infectious diseases. Monitoring and Evaluation • Intensify surveillance of the situation through early warning and response (EWARN) systems to detect and respond rapidly to outbreaks of diseases and malnutrition. • Monitor and evaluate the emergency response, notably to assess the two most vital, basic public health indicators measuring severity of crisis: nutritional status of children <5 years of age and mortality rate of the population. • Ensure that key data from the field are inputted into government management infor- mation systems for easier analysis and communication. - 51 - Cross-Cutting Approach 1: Targeting Targeting Summary of Recommendations In stable times bIdentify and map pockets of vulnerability using a variety of criteria: poverty, disaster-prone, marginalized pop- ulation, geographic isolation, etc. b Define target groups according to the different realms of interventions implemented. b Define targeting strategy including categories and criteria for inclusion, conditions, approaches, and appropri- ate targeting agents. b Establish a system at the community and agency level for identifying vulnerable families and actions to reduce their vulnerability. b Ensure that the targeting strategy does not add stigma to beneficiaries. In crisis b Target based on nutritional needs, especially pregnant and lactating women and children <2 years of age, if resources are limited. b Prioritize other vulnerable groups, including children 2-5 years of age, people with disabilities, the elderly, and people living in hard-to-reach areas. In emergency bEstablish an ongoing targeting process throughout the emergency that is clear and acceptable to those who are included. b Balance inclusion and exclusion errors to minimize harm to affected individuals. b Consider blanket distributions in sudden-onset disasters if all households have suffered similar losses or where targeting is not possible. When resources are limited within a program, tar- can also be rapidly used as a platform for rapid scale geting may be required to maximize effectiveness. up of interventions during crisis and emergencies, This is relevant in all three settings, i.e. stable times, though in emergencies the targeting criteria may crisis and emergency, though the nuances may vary change, to take into account that the emergency it- somewhat. In stable times, programs can focus re- self has changed the situation of many people, and sources on the poor and the most vulnerable. Design- that those who formerly did not need assistance may ing targeting systems can be complex but cost-effec- be greatly affected and also in need of assistance. tive nonetheless, especially when the same targeting system can be used by multiple programs. Both in- Programs should define target groups according to the clusion and exclusion errors should be factored in the different realms of interventions implemented. For design and implementation. Targeting system should example, nutrition and health interventions may spe- be dynamic, allowing new or newly poor households cifically target individuals in the 1,000 days window to access programs and moving out households that of opportunity; social protection and income support are no longer eligible (96). Some targeting systems may be focused on those with incomes insufficient to - 52 - provide food security; whereas WASH interventions Targeting should be an ongoing process, not some- may target those with poor access to WASH services thing that is done merely during the initial phase of such as peri-urban areas. In some instances, target an emergency. Finding the right balance between groups may overlap significantly. Thus, there could excluding some people (exclusion errors can be be significant efficiency gained in conceiving a single life-threatening) and including too many people (in- operational mechanism that could be used for multi- clusion errors are potentially disruptive or wasteful) ple interventions. is complex (61); moreover, efforts to reduce errors normally increase costs. In acute emergencies, inclu- Emergency response should seek to protect all affect- sion errors may be more acceptable than exclusion ed populations. If resources are limited, it is recom- errors. Blanket distributions may be appropriate in mended that targeting be based on nutritional needs, sudden-onset disasters, where all households have which this toolkit posits means focusing on pregnant suffered similar losses or where a detailed targeting and lactating mothers and children <2 years of age. assessment is not possible due to lack of access. But children <5 years of age, people with disabilities, the elderly, and people living in hard-to-reach areas The selection of people who will make targeting deci- also represent vulnerable groups in times of emer- sions should be based on their impartiality, capacity, gency or crisis. Natural disasters also tend to dispro- and accountability. “Targeting agents� may include portionately affect the poor. Catastrophes are most local elders, locally elected relief committees, civil deadly to the poor who live in high-risk zones, occu- society organizations, local NGOs, local governmen- py structurally unsound housing, and cultivate their tal institutions, or international NGOs. The selection crops on steep slopes and in riverbeds. Vulnerability of female targeting agents is strongly encouraged in is a major component of their poverty (66). It is es- light of potential security issues. Targeting approach- sential to understand the political and socioeconomic es need to be clear, and the people who will make determinants of vulnerability and to design methods the decisions accepted by recipients (68). to reach the most vulnerable populations (67). Tar- geting should, however, not add to any stigma that vulnerable people already experience. From the field: Honduras In the aftermath of Hurricane Mitch, community volunteers called “monitoras� in the AIN-C program proved useful for efficient targeting since they knew who the neediest families were. (Ref: Case Study on Honduras) For more information on how to target the most vulnerable during stable times, crises and emergencies: • Grosh M. et al. For Protection and Promotion – the Design and Implementation of Effective Safety Nets. The World Bank, 2008. • The Sphere Project. Humanitarian Charter Minimum Standards in Humanitarian Response, 2011. - 53 - Cross-Cutting Approach 2: Multisectoral Coordination Multisectoral Coordination Summary of Recommendations In stable times b Establish a comprehensive humanitarian coordination mechanism that will lead the functions of prepared- ness, response, leadership, policy, advocacy, information management, and humanitarian financing. b Establish operational “clusters� or subcommittees by technical areas (such as health, nutrition, water, and sanitation) to avoid duplications and gaps and ensure coordination and clear leadership for each technical area. b Involve a wide range of organizations and actors in humanitarian coordination mechanisms, including gov- ernmental and non-governmental institutions, religious or humanitarian groups, and bilateral and multilat- eral partners. In crisis b Intensify coordination mechanisms and ensure that core functions are operating well and are ready to be activated. b Enable coordination mechanisms to build shared situational awareness as well as common strategy, ap- proaches, and implementation plans. In emergency bActivate coordination mechanisms to ensure efficient emergency response. b Ensure that these mechanisms perform their core functions, share information fluently, and implement the response cooperatively. From the field: Guatemala In 2009 “El Niño� caused a prolonged dry season, which as a result led to food insecurity and an increase in cases of acute malnutrition. In response, the Government formed the “Humanitarian Network� with UN agencies and NGOs. The Network rapidly put in place mechanisms to deploy over 200 health and nutrition professionals, identify cases of acute malnutrition in children, procure supplies to treat those children, provide education to families and—on detection of danger signs— promote optimal breastfeeding and comple- mentary feeding practices . As a result, 1,000 children with severe acute malnutrition were treated and the lives of at least 4,000 children <5 years of age were saved. (Ref: Case Study: Management of Emergencies) - 54 - Multisectoral coordination seeks to improve the ef- through situation reports and maps. fectiveness of humanitarian response by ensuring • Building common approaches: getting agreement greater predictability, accountability, and partner- among the key operational actors on policy di- ship. Response to humanitarian emergencies may lemmas, such as how best to support vulnerable come from a range of organizations and actors, in- groups, or whether and how to coordinate with lo- cluding governments, the United Nations system, in- cal or international military actors. ternational and local nongovernmental organizations • Building a common strategy and implementation (NGOs), the Red Cross/Red Crescent movement, as plan: ensuring that resource mobilization and fi- well as specialists in the different aspects of human- nancing are handled in a common way. This also itarian response, such as search-and-rescue opera- means seeing that appropriate coordination mech- tions. anisms are established. Those mechanisms include the “cluster approach,� which groups agencies Core functions of comprehensive coordination mech- with a shared operational interest such as health, anisms include: preparedness, response, and lead- water, and sanitation. This approach helps to avoid ership as well as policy, advocacy, information man- gaps and duplications and to ensure that there is agement, and humanitarian financing (63). These a clear lead organization in each sector in each functions contribute to the following: country, with corresponding responsibility and ac- • Building a shared situational awareness: en- countability that can serve as a reliable partner suring that needs assessments are coordinated, with governments. consolidated, analyzed, and communicated—e.g., GLOBAL NUTRITION CLUSTER In a humanitarian crisis, when the capacities of countries do not suffice to fully respond to the popu- lation’s needs, governments can request assistance from the United Nations. The UN has set up sec- tor-specific “clusters� to coordinate the activities of agencies and organizations engaged in humanitar- ian support. Each cluster has a designated lead agency at the global level, which in turn can delegate country-level coordination to another agency. UNICEF is the lead agency for the Global Nutrition Cluster. (See http://oneresponse.info/globalclusters/ nutrition/Pages/default.aspx and http://www.unicef.org/emerg/index_33296.html .) The remit of the Global Nutrition Cluster is to cover contingency planning, strategy development, coordination mecha- nisms, needs assessment, resource mobilization, inclusion of cross-cutting issues (e.g., age, diversity, gender, etc.), adherence to technical standards and policy guidelines, monitoring and communication, training and skill development. For more information on how to coordinate multisectoral actions during crises and emergencies: • The Sphere Project. Humanitarian Charter Minimum Standards in Humanitarian Response, 2011. • United Nations Disaster Assessment and Coordination (UNDAC) Handbook. • UN Office for the Coordination of Humanitarian Affairs (OCHA) website: http://www.unocha.org/ what-we-do/coordination/response/overview - 55 - Cross-Cutting Approach 3: Policy Making and Planning Policy Making and Planning Summary of Recommendations In stable times b Make fighting undernutrition a top priority, focusing on optimal nutrition during the first 1,000 days through education of and advocacy among senior policy makers. b Enlist nutrition experts to review existing policies and plans to ensure that they are up-to-date with regard to international recommendations and best practices and that nutrition has been mainstreamed into preparedness planning. b Orient local first-responders to translate central plans into decentralized action that reaches those most in need. b Develop a graduation strategy or transition plan to assist individuals to return to stability after a shock and to build resilience. In crisis b Intensify links with existing social protection systems to address the food and nutrition needs of the chronic and transient poor. b Expand systems and programs that address food and nutrition insecurity, with an emphasis on meeting the needs of mothers and children. b Ensure that emergency response plans are up-to-date and that resources are available to be rolled out rapidly. In emergency b Follow-up the work of, and maintain communication with, local responders to adapt the implementation of policies and plans according to the situation. b Evaluate the situation before closing a program or making the transition to a new phase, to provide evidence of improvement or identify suitable actors to take over the responsibility. b Communicate the exit strategy to affected populations during the early stages of program implementation to enhance sustained recovery. - 56 - 3.1 Mainstreaming nutrition into emergency preparedness planning Fighting undernutrition should be the top priority for Notwithstanding the available programmatic and policy makers and donors, according to a recent re- technical guidance, the challenge for emergency port of the Copenhagen Consensus (69). Several hand- management policy makers remains how to integrate books, plans, and guidelines have been designed to nutrition—traditionally a vertical program within the ensure that nutrition remains a central focus in plans health or social protection ministry—into their poli- to prepare for emergencies, manage humanitarian cies and plans. The first step is to include more nu- crises, and recover from disasters and emergencies. trition specialists on emergency planning staffs and Existing resources by groups such as the Sphere Proj- planning committees. A process of review of existing ect (61), UNHCR (63), Save the Children (70), UNICEF plans and policies should also be undertaken by nutri- (71), and others provide enormously useful guidance; tion experts to ensure they reflect the most current they do not, however, focus on nutrition during the best practices. Proposed changes will likely have first 1,000 days as a period now understood to re- budgetary implications and require support from se- quire special attention. Infant and Young Child Feed- nior policy makers, which will necessitate ongoing ing Practices in Emergencies is an operational guide advocacy and education as to the importance of fo- for emergency relief staff and program managers de- cusing on nutrition during the 1,000-day window and veloped by the IFE Core Group (UNICEF, WHO, UN- the specific benefits of targeting this group, including HCR, WFP, IBFAN-GIFA, CARE USA, Fondation Terre economic benefits, during and after emergencies. It des hommes, and the Emergency Nutrition Network) is also critical to orient local first-responders, so that that comes closer to providing concise, practical, central-level policies are translated into decentral- nontechnical guidance on how to ensure appropriate ized action that reaches those most in need. infant and young child feeding in emergencies (8). 3.2 Exit strategy planning During emergencies and, to a lesser extent, crises, affected and that may need additional, longer-term governments and donors generally have preparedness support following the immediate response. When a plans for providing food and supplements to affected crisis situation provokes a family’s loss of housing, populations for a set post-emergency period. They livelihood, or a relative who may have died or been tend to be less prepared, however, with plans for how forced to migrate to another location in search of to transition affected populations in the post-emer- work, that family will require longer-term assistance. gency period. They do not always provide transient support to populations that have been profoundly - 57 - From the field: Colombia The new presidential-level program “Cero a Siempre� gives priority to the first 1,000 days of life. Health, nutrition, education, sports, and culture are inte- grated under one all-encompassing policy. It is important to develop a plan of graduation or grams may end when external support is no longer transition that maps out a path to a return to normal, needed, when local communities or national institu- independent subsistence as in pre-emergency times tions assume responsibility for providing the services, and builds the resilience of individuals and families or when multi-year development assistance programs to potential recurrent shocks. Exit and transition can be implemented to provide continued support strategies should be considered from the outset, par- for recovery. Benchmarks are needed for determin- ticularly where the response has long-term implica- ing when exit criteria have been reached and regular tions—e.g., the provision of goods or services. The monitoring of progress towards benchmarks conduct- exit plan will vary depending on factors such as the ed. In the case of food, cash, and voucher transfers, duration of the emergency program, the nature of it may mean linking with existing social protection the emergency or crisis, how the assistance program or long-term safety-net systems or advocating with was implemented, what the pre-emergency condi- governments and donors to establish systems that ad- tions were, and the like. dress chronic food insecurity (61). Finally, a strategy for sustainability of impacts and responsible parties Before closing a program or making the transition to after exit should be in place (62). a new phase, an evaluation should be conducted to provide evidence of improvement or to indicate that better-placed actors can assume responsibility. Pro- - 58 - Recommendations regarding exit strategies • Consider, from the start, the exit strategy for the program and a plan for longer-term support beyond the emergency. An exit strategy should be planned with key stakeholders from design onwards. Planning, implementation, and monitoring should involve local stakeholders such as governments, local authorities, communities, and beneficiaries. Such involvement will help ensure relevance and sustainability. • Include important components of an exit strategy such as exit timeline, activities required, monitoring and evaluation, and sustainability strategies. Graduation criteria determine when individuals and communities are transitioned out of the program and may include age, physiological condition, and nutritional status. • Communicate the exit strategy to affected populations during the early stages of program implementation to enhance sustained recovery. The entry/exit criteria and the performance indicators related to children and pregnant and lactating women should be clearly established and communicated to beneficiaries. • Close down a targeted supplementary feeding program when the following criteria are satisfied (73): bGeneral food distribution is adequate (meets planned nutritional requirements). bPrevalence of acute malnutrition is <10% without aggravating factors. bControl measures for infectious diseases are effective. bDeterioration in nutritional status (e.g., seasonal deterioration) is not anticipated. bInterpretation of any improvement in nutritional data (e.g., decrease in prevalence of acute malnutrition) is made in the context of food-security information. An improvement in nutritional status may indicate an effective food or health intervention; however, it does not necessarily mean that the population has access to food from its own production (74). bTransitory food insecurity in urban emergency food assistance programs is addressed within a short (i.e., within one-year) timeframe. Capacity strengthening of a range of stakeholders is ter members should be gradually reduced, as the required for sustainability. Working with and through government takes on increased responsibility for im- local institutions is essential for impact and sustain- plementing and coordinating the program (75). ability. All activities conducted by international clus- For more information on how to develop and update crisis and emer- gency policies and plans: • UNHCR/UNICEF/UNICEF/WHO. Food and nutrition needs in emergencies, 2003. • The Sphere Project. Humanitarian Charter Minimum Standards in Humanitarian Response, 2011. • Save the Children. Child Care Toolkit for Emergency and Post Emergency Response, 2009. • IASC Global Nutrition Cluster. A toolkit for addressing nutrition in emergency situations, 2008. - 59 - Cross-Cutting Approach 4: Emergency Communication Emergency Communication Summary of Recommendations In stable times b Elaborate a comprehensive communication plan for crises and emergencies to efficiently inform the public about the situation and what to do at both the central and decentralized levels and to provide accountability to the public. b Include, in planning, multiple channels of communication—hardwired and wireless networks, broadcast and satellite television, radio, mobile phone networks, Internet, social media, and interpersonal networks. In crisis b Implement communication plan, targeting the affected population, to provide information on how to seek assistance and on what to do. b Monitor the situation and continually test the effectiveness of the communication system by regularly obtain- ing feedback from the field and collecting data. In emergency bRapidly roll out emergency communication plan, maintain open communication with the public to assure calm and order, and provide clear and practical information on what to do and how to seek assistance. b Ensure that the communication system accommodates two-way communication in order to collect and analyze information coming in from the field and to be responsive to it as the nature of the emergency changes. b Once the emergency is over, continue communication relevant to recovery and to preventing relapse. b Evaluate public communication strengths and weaknesses during and following events and adapt plan accord- ingly. Maintaining open communication with the public populations have used social media and mobile com- during a crisis or emergency is essential to assuring munication during recent disasters (e.g., the 2010 calm and order and mitigating problems that could earthquake in Haiti) underscore the public’s need arise from people not knowing what to do or where for timely information. Channels of communication to get help. Efficiently collecting and analyzing infor- that should be a part of a crisis or emergency com- mation coming in from the field and being responsive munication plan include hardwired and wireless net- to it is critical. The public requires clear, practical works, broadcast and satellite television, radio, mo- information on steps they can take to protect them- bile phone networks, and increasingly the Internet. selves and on how to seek assistance. Open commu- However, established networks of health providers, nication enables affected people to define and de- particularly those at the community level, should not mand accountability based on their own expectations be forgotten. and standards (76, 77). The ways in which affected - 60 - From the field: St. Lucia The island currently uses the Disaster Information Kit for the Media produced in 2005 by the Caribbean Disaster Emergency Response Agency. The country has a National Telecommunications Plan that focuses on the various responsibilities of key agencies and the importance of ensuring timely and accurate dissemination of information to the general public. (Ref: Benchmarking results) WHO has published best practices for communicat- ongoing release of information in the event of a ing with the public during a health emergency (e.g., verified or suspected emergency. a disease outbreak) primarily through the mass me- 4. Listening during an outbreak: develop a sys- dia, which would also apply to communication about tem for ongoing information-gathering during an health and nutrition during other emergencies or cri- outbreak about public knowledge, attitudes, and ses. Five essential best practices for effective disease behaviors related to infectious disease risks, in- outbreak communication are: build trust, announce terventions, and involved organizations. early, be transparent, respect public concerns, and 5. Communication evaluation: ensure there is an plan in advance (76-78). These practices are ex- evaluation mechanism to identify public commu- panded upon in the WHO Outbreak Communication nication strengths and weaknesses during and fol- Planning Guide, intended for national authorities lowing infectious disease events. to strengthen their planning and preparation activi- 6. Constructing an emergency communication ties, which recommends the following seven planning plan: on the basis of the previous steps, develop steps (77): a written outbreak or emergency communication 1. Assessment: assess existing public communica- plan. tion capacity and available research on the com- 7. Training: ensure readiness by establishing a risk munity, including demographics, literacy levels, communications training program, including sim- language spoken, as well as socioeconomic and ulations and exercises to test the emergency pub- cultural backgrounds. lic communication plan and its components. 2. Coordination: identify likely public communica- tion partners and develop a communication coor- A similar, but even more-detailed description, is dination mechanism. provided in PAHO’s step-by-step risk communication 3. Transparency: put in place a national level pol- strategy to help planners prepare for health emer- icy or guideline on public announcements and gencies (79). For more information on how to plan and roll out communication during crises and emergencies • PAHO. Field guide for developing a risk communication strategy: from theory to action, 2011. • WHO. Effective media communication during public health emergencies: a WHO handbook, 2005. - 61 - Cross-Cutting Approach 5: Human Resources and Training Human Resources Summary of Recommendations In stable times b Develop or adapt training strategy, curricula, and materials to ensure that they include protecting nutrition during the first 1,000 days, taking into account training resources that have been produced by UN agencies and other reputable organizations. b Integrate nutrition into crisis and emergency response training curricula for workers at all levels. b Ensure that key personnel undertake training courses on basic concepts of humanitarian aid, management of undernutrition and emergency response. In crisis b Provide refresher training to crisis and emergency response personnel to assure that their skills and knowl- edge are up-to-date, notably in nutrition. b Have trained human resources assist in scaling up programs, implementing communication and education campaigns, and participating in surveillance and monitoring activities. In emergency b Provide continuous training, support, and supervision to response personnel during and after an emergency. b Take stock of strengths and skill gaps to adapt training after an emergency. Human resources are possibly the most critical input The Emergency Nutrition Network (ENN) collaborates for emergency preparedness. Having the right people with other agencies to facilitate meetings and training with the right training available during and immedi- courses to contribute to lesson learning and capacity ately after an emergency can mean the difference development of individuals and agencies working in between life and death. But emergency personnel emergency nutrition and food security. ENN is also are rarely oriented or trained on the importance of partnering with Nutrition Works to develop in-service protecting the nutritional status of the most vulner- and pre-service training at the national level, funded able. To address that lack of resource development by the US Office for Foreign Disaster Assistance and, in this critical area, a number of organizations have with the support of the University College London’s prepared training materials as described below. Centre for International Health and Development, to provide regional professional training, with sup- The Institute of Nutrition in Central America and Pan- port from the OFDA (81, 82). ENN has also developed ama and UNICEF have prepared a five-month virtual training courses on nutrition interventions during cri- course in nutrition and health in emergencies, which ses (83). is offered to professionals and technicians who play important roles in emergency situations (80). - 62 - UNICEF offers online training courses that cover ba- Organizations such as the International Committee of sic concepts of humanitarian aid, undernutrition, the Red Cross (ICRC) (85) and the United Nations Of- and response in emergencies, including nutritional fice for Coordination of Humanitarian Affairs (OCHA) assessment and micronutrients. The aim is to in- (86) have significant experience training profession- crease access to information within key modules of als and volunteers worldwide in topics such as how the Harmonized Training Package: Resource Material to cope with emergencies, international humanitar- for Training on Nutrition in Emergencies (the HTP) ian laws, and first aid. The ICRC has a manual in nu- to strengthen the technical knowledge of individuals trition for all humanitarian workers involved in the working in, or aspiring to work in, emergency nutri- field of nutrition (87). The Sphere Project also has tion (84). a training course for the training of trainers (61). From the field: Panama and El Salvador Panama through its organization, SINAPROC, has international exper- tise in rapid response mechanisms, especially in emergencies. It has supported other countries in need, including Haiti, the Dominican Re- public, and Costa Rica. El Salvador has set up training centers within the Ministry of Civil Pro- tection. In coordination with OCHA, training is provided to key stake- holders at central, regional, and municipal levels. (Ref: Benchmarking results) - 63 - Cross-Cutting Approach 6: Water, Sanitation, and Hygiene Water, Sanitation, and Hygiene Summary of Recommendations In stable times b Invest resources in WASH infrastructures, especially in disaster-prone and peri-urban areas, to minimize the effects of poor hygienic conditions and to avoid population-wide epidemics. b Ensure that emergency and crisis plans include sections on WASH and comply with international best practices taken from WHO/WEDC guidelines. b Promote culturally-specific good WASH practices. b Maintain a store of clean water to meet basic needs for the initial phase of an emergency in more remote disaster-prone areas. In crisis b Strengthen WASH infrastructures in areas that are the most vulnerable to shocks and where the population lives in conditions of extreme poverty, such as peri-urban and rural areas. b Scale up programs to educate the population on practices they need to follow to prevent water-borne diseas- es. b Promote exclusive breastfeeding and appropriate hygiene practices related to complementary feeding. In emergency b Promote exclusive breastfeeding for children <6 months of age and appropriate hygiene practices related to complementary feeding. b Supply adequate levels of safe drinking water, prioritizing young children and pregnant and lactating women in light of their increased water needs. b If the local water supply is compromised, distribute water purification technologies or products. b Ensure that the population has access to adequate sanitation facilities and the ability to maintain good hy- giene. b Monitor the incidence of water-borne diseases, particularly diarrhea and infectious diseases. Providing adequate safe water together with appro- man development perspectives. Inadequate access to priate sanitation and hygiene recommendations and safe water and proper sanitation facilities and poor facilities comprise a critical foundation that commu- hygiene practices can have a myriad of ill effects that nities need to diminish their vulnerability to health stem primarily from increased prevalence of diseas- and nutrition problems in stable times and to endure es that prevent children, particularly girls, from ac- crises and emergencies without increased dire conse- cessing their right to education; reduce productivity; quences. Promoting and providing proper WASH infra- and impede the development of national economies, structures and practices are essential for sustainable which suffer as a result of the increased burden on development and make sense from economic and hu- health systems. - 64 - The population groups suffering from the poorest ac- situation, particularly in light of current projections. cess to WASH infrastructure are often also those most According to FAO, one-third of the population world- vulnerable to crises: those living in extreme conditions wide lives in countries where there is insufficient wa- of poverty in developing countries such as peri-urban ter or its quality has been compromised; by 2025, this dwellers and rural inhabitants. It is important to un- proportion is expected to rise to two-thirds (88). dertake measures in times of stability to correct this From the field: Panama The country’s current WASH strategy in emergencies is based on inter- national best practices as outlined in the Sphere Project Guidelines. Among notable features of the strategy is promotion of the use of indi- vidual water pumps in emergencies. (Ref: Benchmarking results) Water and sanitation are critical determinants for ticularly for children who are more vulnerable to survival during a prolonged crisis that may be related water-borne diseases and for pregnant and lactating to, for example, a drought and during the initial stag- women who have increased water needs. Although es of an emergency when all access to water and san- specific guidelines as to water requirements for preg- itation facilities may be cut off. Poor or inadequate nant and lactating women and young children in the access to water and sanitation facilities and the in- context of emergency settings do not exist, the Insti- ability to maintain good hygiene leaves people sus- tute of Medicine (89) specifies the following recom- ceptible to water-borne diseases—most significantly mendations for water intake under normal circum- diarrhea and infectious diseases (61). Providing peo- stances: ple with a variety of ways to make available water sources safe for drinking—through filtration, chlori- • Children 6-12 months: 0.8 L per day; nation, solar water disinfection (SODIS), or boiling—is • Children >12-24 months: 1.3 L per day; fundamental. Other WASH measures will depend on • Pregnant women: 3 L per day; and the circumstances of the crisis or emergency. • Lactating women: 3.8 L per day. In extreme emergency situations, there may not be sufficient water available to meet basic needs. In such cases, supplying a minimum level of safe drink- ing water for survival is of critical importance, par- - 65 - WHO/WEDC guidelines on drinking water, sanitation, and hygiene in emergencies (90) indicate: •The amount of water required depends on factors such as climate, individual physiology, sociocultural norms, and food type. As a general guideline, the Sphere Project recommends a total of 5.5-9.0 L: • Basic survival: 2.5-3.0 L of water per person per day; • Basic hygiene practices: 2.0-6.0 L of water per person per day; and • Basic cooking: 3.0-6.0 L per person per day. •The type of sanitation provided has a big impact on water requirements. Water-borne types of sanitation, such as flush toilets, require a large volume of water (up to 7 L per person per use) (90). •The minimum provision of domestic water containers suggested is two 10-20 L vessels for collecting water plus one 20 L vessel for water storage per five-person household (90). For more information on how to implement WASH interventions: • WHO Water Sanitation Health website: http://www.who.int/water_sanitation_health/en/ • The Sphere Project. Humanitarian Charter and Minimum Standards in Humanitarian Response, 2011. • WHO/Water, Engineering, and Development Center. Technical notes on drinking water, sanitation and hygiene in emergencies. How much water is needed in emergencies? 2011. - 66 - Cross-Cutting Approach 7: Monitoring and Evaluation Monitoring and Evaluation Summary of Recommendations In stable times b Develop early warning systems based on international best practices that enable the government to predict crises and their associated effects. b Establish responses to be made when food security and nutritional status indicators fall below crisis and emergency cutoff values. b Develop a monitoring and evaluation system for crises and emergencies that can assess the effectiveness of the humanitarian response, enable learning, and promote accountability. b Link the monitoring and evaluation system to relevant government management information systems. In crisis b Activate early warning systems and intensify surveillance, especially in vulnerable areas. b Monitor closely the food security and nutrition situation in vulnerable areas (i.e. rural and peri-urban areas) among mothers and young children, and provide relevant assistance in accordance with the information collected. b Evaluate periodically the impact of these programs, informing planners of the results of evaluation, so that strategies can be improved. In emergency b Intensify surveillance of the situation through early warning and response (EWARN) systems to detect and respond rapidly to outbreaks of diseases and malnutrition. b Monitor and evaluate the emergency response, notably to assess the two most vital, basic public health indicators measuring severity of crisis: nutritional status of children <5 years of age and mortality rate of the population. b Ensure that key data from the field are inputted into government management information systems for easier analysis and communication. - 67 - 7.1 Surveillance and early warning systems Surveillance systems that aim to predict the timing, ing food security issues worldwide. It analyzes data magnitude, and severity of crises and emergencies on weather conditions, climate change, agriculture, and are linked to pre-determined responses are a markets, trade systems, and food prices to identify critical part of preparedness planning. Several or- potential threats to food security conditions. Simi- ganizations and agencies have developed systems to larly, the global information early warning system track conditions that are associated with the onset of (GIEWS) on food and agriculture (92), an effort sup- disasters or crises. The famine early warning systems ported by FAO, monitors the world food supply-and- network (FEWSNET) (91) is an initiative that col- demand situation on a continuous basis and issues re- laborates with international, regional, and national ports such as Food Outlook, Crop Prospects, and Food partners to provide timely and rigorous early warning Situation, as well as individual country briefs. and vulnerability information on emerging and evolv- From the field: Panama As part of its surveillance system, the national civil protection system (SINAPROC) uses an international platform that produces maps of the zones at greatest risk. A simple monitoring system is used to inform decisions as to when to stop emergency assistance. (Ref: Benchmarking results) Early warning and response (EWARN) systems are also vent morbidity and mortality rates from escalating. commonly set up in the acute phase of an emergency In 2009, WHO hosted a technical workshop and pub- to detect and respond rapidly to outbreaks of dis- lished a report that concludes with recommendations ease among the affected population, in order to pre- for EWARN systems (93). - 68 - 7.2 Monitoring and evaluation Monitoring is a continuous process of collecting and implementation, both with the power to significantly analyzing information to better understand how well influence decision making (93). Programs with strong a program is operating against expected outputs and monitoring and evaluation systems benefit from feed- to allow remedial intervention to correct failures. back that allows for improving program productivity, Situation monitoring measures the change, or lack of effectiveness, and impact. Unfortunately, few crisis change, in a condition or a set of conditions and in- and emergency response programs in Latin Ameri- cludes monitoring of the wider context. Performance ca and the Caribbean include strong monitoring and monitoring, on the other hand, measures progress in evaluation components. achieving specific results in relation to an implemen- tation plan. Several tools and methodologies have been developed to facilitate monitoring and evaluation in emergency Evaluation is a systematic and objective assessment settings. The method for standardized monitoring that attempts to determine the worth or significance and assessment of relief and transitions (SMART ) (94) of an intervention, strategy, or policy. It is used to is based on the two most vital, basic public health in- appraise the effectiveness of an intervention to de- dicators to assess the severity of a crisis: nutritional termine if it meets its goals, to estimate its results or status of children <5 years of age and the mortality impact, and to identify its costs vs. its benefits. rate of the population. The method simplifies the collection and reporting of high quality data with In addition to systems that predict crises and their only one manual and accompanying software; all its associated effects, monitoring and evaluating the materials, including software and training programs, status of a crisis or emergency situation and the ef- are available for free download from the SMART web- fectiveness of humanitarian response efforts is essen- site. WFP has also developed comprehensive guide- tial. Learning and accountability are the two main lines, which comprise 14 modules and provide clear objectives of monitoring and evaluation, which are advice on the design, implementation, and evalua- individually distinct aspects of program planning and tion on monitoring and evaluation (95). For more information on how to design and implement monitoring and evaluation systems for crisis and emergencies • Famine Early Warning Systems Network (FEWSNET) website: www.fews.net • WHO. Early warning surveillance and response in emergencies, 2009. • CDC. Survey toolkit for nutritional assessment, 2012. http://www.micronutrient.org/nutrition- toolkit/index.htm. • Standardized Monitoring and Assessment of Relief and Transitions. http://www.smartmethodol- ogy.org. • WFP. Monitoring and evaluation (M&E) guidelines. http://www.wfp.org/content/monitoring-and- evaluation-guidelines. - 69 - - 70 - - 71 - - 72 -