Leisel Talley

Lessons learned from complex emergencies over past decade

Major advances have been made during the past decade in the way the international community responds to the health and nutrition consequences of complex emergencies. The public health and clinical response to diseases of acute epidemic potential has improved, especially in camps. Case-fatality rates for severely malnourished children have plummeted because of better protocols and products. Renewed focus is required on the major causes of death in conflict-affected societies--particularly acute respiratory infections, diarrhoea, malaria, measles, neonatal causes, and malnutrition--outside camps and often across regions and even political boundaries. In emergencies in sub-Saharan Africa, particularly southern Africa, HIV/AIDS is also an important cause of morbidity and mortality. Stronger coordination, increased accountability, and a more strategic positioning of non-governmental organisations and UN agencies are crucial to achieving lower maternal and child morbidity and mortality rates in complex emergencies and therefore for reaching the UNs Millennium Development Goals.

Evaluation of the effectiveness of stainless steel cooking pots in reducing iron-deficiency anaemia in food aid-dependent populations

OBJECTIVE To evaluate the effectiveness of stainless steel (Fe alloy) cooking pots in reducing Fe-deficiency anaemia in food aid-dependent populations. DESIGN Repeated cross-sectional surveys. Between December 2001 and January 2003, three surveys among children aged 6-59 months and their mothers were conducted in 110 households randomly selected from each camp. The primary outcomes were changes in Hb concentration and Fe status. SETTING Two long-term refugee camps in western Tanzania. SUBJECTS Children (6-59 months) and their mothers were surveyed at 0, 6 and 12 months post-intervention. Stainless steel pots were distributed to all households in Nduta camp (intervention); households in Mtendeli camp (control) continued to cook with aluminium or clay pots. RESULTS Among children, there was no change in Hb concentration at 1 year; however, Fe status was lower in the intervention camp than the control camp (serum transferrin receptor (sTfR) concentration: 6.8 v. 5.9 microg/ml; P < 0.001). There was no change in Hb concentration among non-pregnant mothers at 1 year. Subjects in the intervention camp had lower Fe status than those in the control camp (sTfR concentration: 5.8 v. 4.7 microg/ml; P = 0.003). CONCLUSIONS Distribution of stainless steel pots did not increase Hb concentration or improve Fe status in children or their mothers. The use of stainless steel prevents rusting but may not provide sufficient amounts of Fe and strong educational campaigns may be required to maximize use. The distribution of stainless steel pots in refugee contexts is not recommended as a strategy to control Fe deficiency.

Acceptability and use of iron and iron-alloy cooking pots: implications for anaemia control programmes

OBJECTIVE To evaluate the acceptability of iron and iron-alloy cooking pots prior to an intervention trial and to investigate factors affecting retention and use. DESIGN Pre-trial research was conducted on five types of iron and iron-alloy pots using focus group discussions and a laboratory evaluation of Fe transfer during cooking was undertaken. Usage and retention during the subsequent intervention trial were investigated using focus group discussions and market monitoring. SETTING Three refugee camps in western Tanzania. SUBJECTS Refugee health workers were selected for pre-trial research. Mothers of children aged 6-59 months participated in the investigation of retention and use. RESULTS Pre-trial research indicated that the stainless steel pot would be the only acceptable type for use in this population due to excessive rusting and/or the high weight of other types. Cooking three typical refugee dishes in stainless steel pots led to an increase in Fe content of 3.2 to 17.1 mg/100 g food (P < 0.001). During the trial, the acceptability of the stainless steel pots was lower than expected owing to difficulties with using, cleaning and their utility for other purposes. Households also continued to use their pre-existing pots, and stainless steel pots were sold to increase household income. CONCLUSIONS Pre-trial research led to the selection of a stainless steel pot that met basic acceptability criteria. The relatively low usage reported during the trial highlights the limitations of using high-value iron-alloy cooking pots as an intervention in populations where poverty and the availability of other pots may lead to selling.

Retrospective determination of whether famine existed in Niger, 2005: two stage cluster survey

Objective To apply the famine scale by Howe and Devereux to the situation in Niger, west Africa, in 2005 to retrospectively determine whether famine existed. Design Two stage cluster survey. Setting Survey of households in each of Niger’s eight regions. Participants 4003 households. Main outcome measures Crude mortality, mortality in children under 5, and the proportion of caregivers both nationally and regionally adopting coping strategies to deal with insufficient food needs. Results The estimated national crude mortality rate was 0.4 (0.4 to 0.5) deaths per 10 000 per day and under 5 mortality rate was 1.7 (1.4 to 1.9) deaths per 10 000 per day. Nationally, 22.3% (95% confidence interval 19.9% to 24.8%) of caregivers of under 5s did not resort to any coping strategies to deal with insufficient food needs. Reversible coping strategies were, however, used by 5.8% (4.7% to 7.0%) of caregivers, whereas 49.4% (46.9% to 51.8%) relied on irreversible coping strategies and 22.6% (20.0% to 25.4%) on survival strategies. Conclusion On the basis of the famine scale proposed by Howe and Devereux, most regions in Niger experienced food crisis conditions and some areas approached famine proportions.

Suspected Outbreak of Riboflavin Deficiency among Populations Reliant on Food Assistance: A Case Study of Drought-Stricken Karamoja, Uganda, 2009–2010

Background In 2009, a humanitarian response was launched to address a food security and livelihoods crisis in Karamoja, Uganda. During a polio immunization campaign in mid-August 2009, health workers in Nakapiripit District reported a concern about an increase in mouth sores, or angular stomatitis (AS) and gum ulcerations, among children in one village, and an investigation was launched. Objective This article describes the investigation, lessons learned, and provides guidance for monitoring micronutrient deficiencies among populations receiving food assistance. Design An investigation into a suspected outbreak of riboflavin (vitamin B2) deficiency was initiated, including a rapid assessment, mass screening, a convenience sample collection of blood specimens (n = 58 symptomatic cases and n = 18 asymptomatic individuals), and analysis of the general food ration (70% ration). Results Findings showed signs of AS in only 399 (0.2%) of 179,172 screened individuals, including adults and children. Biochemical analysis confirmed riboflavin deficiency in 84.5% of specimens from symptomatic individuals and 94.4% of specimens from asymptomatic individuals. Ration distribution data showed that 55% of distributions provided less than half the riboflavin RDA. Conclusion Evidence was insufficient to confirm an actual outbreak of riboflavin deficiency, though the present investigation adds further documentation that micronutrient deficiencies continue to persist among populations in emergency settings. This article describes challenges, lessons learned, and guidance for monitoring micronutrient deficiencies among food assistance recipients, including: ongoing nutrition monitoring and surveillance; training and sensitization about micronutrient deficiencies, sensitization of the population about locally-available food, and identifying ways to improve micronutrient interventions.

Challenges to the Programmatic Implementation of Ready to Use Infant Formula in the Post-Earthquake Response, Haiti, 2010: A Program Review

Background and Objectives Following the 2010 earthquake in Haiti, infant and young child feeding was identified as a priority nutrition intervention. A new approach to support breastfeeding mothers and distribute ready-to-use infant formula (RUIF) to infants unable to breastfeed was established. The objective of the evaluation was to assess the implementation of infant feeding programs using RUIF in displaced persons camps in Port-au-Prince, Haiti during the humanitarian response. Methods A retrospective record review was conducted from April–July, 2010 to obtain data on infants receiving RUIF in 30 baby tents. A standardized data collection form was created based on data collected across baby tents and included: basic demographics, admission criteria, primary caretaker, feeding practices, and admission and follow-up anthropometrics. Main Findings Orphans and abandoned infants were the most frequent enrollees (41%) in the program. While the program targeted these groups, it is unlikely that this is a true reflection of population demographics. Despite programmatic guidance, admission criteria were not consistently applied across programs. Thirty-four percent of infants were undernourished (weight for age Z score <−2) at the time of admission. Defaulting accounted for 50% of all program exits and there was no follow-up of these children. Low data quality was a significant barrier. Conclusions The design, implementation and magnitude of the ‘baby tents’ using RUIF was novel in response to infant and young child feeding (IYCF) in emergencies and presented multiple challenges that should not be overlooked, including adherence to protocols and the adaption of emergency programs to existing programs. The implementation of IYCF programs should be closely monitored to ensure that they achieve the objectives set by the humanitarian community and national government. IYCF is an often overlooked component of emergency preparedness; however to improve response, generic protocols and pre-emergency training and preparedness should be established for humanitarian agencies.

Centers for Disease Control and Prevention Public Health Response to Humanitarian Emergencies, 2007–2016

Humanitarian emergencies, including complex emergencies associated with fragile states or areas of conflict, affect millions of persons worldwide. Such emergencies threaten global health security and have complicated but predictable effects on public health. The Centers for Disease Control and Prevention (CDC) Emergency Response and Recovery Branch (ERRB) (Division of Global Health Protection, Center for Global Health) contributes to public health emergency responses by providing epidemiologic support for humanitarian health interventions. To capture the extent of this emergency response work for the past decade, we conducted a retrospective review of ERRB’s responses during 2007–2016. Responses were conducted across the world and in collaboration with national and international partners. Lessons from this work include the need to develop epidemiologic tools for use in resource-limited contexts, build local capacity for response and health systems recovery, and adapt responses to changing public health threats in fragile states. Through ERRB’s multisector expertise and ability to respond quickly, CDC guides humanitarian response to protect emergency-affected populations.