Priority Health interventions which impact Nutrition in Emergencies Module 15 This presentation is approximately 45 minutes

Learning objectives Understand how nutrition and health status is related to extreme poverty and vulnerability, how these are exacerbated by natural hazards Be aware of the interventions required from other sectors to ensure optimal health and nutritional status in an emergency Understand the importance of planning for host populations as well as emergency affected populations Understand the importance of coordination between health and nutrition programme staff and how to better coordinate and/or integrate health and nutrition interventions Understand how to plan for high impact nutrition and health interventions. 1

Globally >35% of under-five deaths are attributable to undernutrition Causes of Neonatal Deaths >35% attributable to undernutrition Other – 7% Tetanus – 1% Diarrhoea – 1% Sepsis – 17% Asphyxia – 23% Congenital – 12% Preterm – 38% 1

Framework of the causes of maternal and child under nutrition and its short-term consequences Source: Lancet series on Maternal and Child Undernutrition 2008 – adapted from Conceptual framework for analysing the causes of malnutrition, UNICEF, 1997 1

Reproductive Health and Undernutrition Poor intra-uterine growth, low birth weight and subsequent suboptimal child growth and development are consequences of: Poor maternal health Inadequate diet (quantity & quality) before and during pregnancy Lack of micronutrient supplementation Multiple pregnancies, especially in quick succession Early childbirth (<18 years) & older mothers (>35 years) are risk factors for both mother and child 1

Consequences of Maternal Undernutrition   Maternal consequences Child consequences Increased risk of maternal death Increased infections Anaemia Compromised immune functions Lethargy and weakness Lower productivity Lactational failure Increased risk of foetal and neonatal deaths Intrauterine growth retardation Low birth weight Pre-term birth Birth defects Cretinism and reduced IQ Source: UNICEF, 2006 1

Mother-to-child transmission of HIV Pregnant and lactating HIV +ve women require supplemental food and micronutrients plus an additional 10% to maintain their health and nutritional status Current recommendations encourage HIV+ women to exclusively breastfeed in the first six months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS) If replacement feeding is still not AFASS after 6 months: continuation of breastfeeding with additional complementary foods is recommended all breastfeeding should stop once a nutritionally adequate and safe diet without breast milk can be provided 1

Link between Undernutrition and HIV Humanitarian crises (displacement, food insecurity, poverty) increase vulnerability to HIV and negatively affect the lives of people living with HIV Services may be disrupted resulting in lack of access to VCT, condoms, PMTCT, treatment of opportunistic infections and ART as well as nutritional support The impact of an emergency on mothers and other carers living with HIV may impact their ability to provide optimal nutrition and care for children and subsequently affect the nutritional status of those children. 1

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Major causes of morbidity and mortality in emergencies Major causes of excess morbidity and mortality in emergencies are: acute respiratory infections, diarrhoeal diseases, malaria (where prevalent), measles and undernutrition Meningococcal meningitis and typhoid may cause large scale epidemics in emergencies Tuberculosis is also often critical in long term emergencies Poor reproductive health, gender based violence (GBV) and its consequences, including HIV, are also a major concern Trauma/injury, mental health and psychosocial issues also contribute to excess morbidity and mortality in emergencies. 1

Develop a story on the link between health and undernutrition and the role the health system plays using these photos 1

Child and Maternal Health in Emergencies Emergencies exacerbate the severity and magnitude of childhood diseases. Children under-5 have the highest mortality rates in refugee populations In 1991 at the Turkey - Iraq border 63% of deaths of Kurdish refugees were in children In 1992 during the famine in Somalia over 74% of <5 years died in IDP camps Among Rwandan and Burundian refugees in DRC in 1996, 54% of all deaths were among children < 5 Maternal health may also be negatively affected by a poor health environment, while maternal nutrition may be very seriously affected by inadequate quality and quantity of food. 1

Mental Health in Emergencies Mental health and psychosocial issues in emergencies include: Pre-existing social problems (e.g. extreme poverty, discrimination against or marginalisation of particular groups) Emergency-induced social problems (e.g. family separation, disruption of social networks and/or community structures) Humanitarian-induced social problems (e.g. undermining community structures or traditional support mechanisms) Pre-existing psychological problems (e.g. mental disorders, alcohol abuse) Emergency-induced psychological problems (e.g. grief, depression, anxiety including post traumatic stress disorder) Humanitarian aid related problems (e.g. anxiety due to lack of information about food distribution ) 1

Health of the Elderly in Emergencies The health and nutritional status of the elderly population is also affected in emergencies by issues such as: loss, grief and depression, exhaustion and poor diet, exacerbating poverty, and chronic disease Lack of access to appropriate medical treatment Inadequate and inappropriate diet Inability to cook 1

Health programming in emergencies and links to Nutrition Health system should: Provide equitable optimal access to health care Ensure minimum level of care (quantity and quality) Include components of health promotion from early stages involving communities (both males and females) Consider needs for outreach activities (mobile clinics, particularly in case of outbreaks) Integrate community participation and potential outreach community staff in planning, management, implementation , M&E of services. 1

Health programming in emergencies and links to Nutrition Essential health services Communicable diseases: their control requires a systematic approach and cooperation from various sectors (WASH, Food, Nutrition, Health, Shelter) Malaria or tuberculosis are also diseases that have impact on nutrition and require multi-sector preventative measures For all diseases, standards for case fatality rates are determined and should be maintained. 1

Case fatality rates Disease Case fatality rate (CFR) Cholera 1% or lower Shigella dysentery Typhoid Meningococcal meningitis Varies between 5-15% Malaria <5% in severely ill malaria patients Measles <5% * *CFR as high as 21% have been reported in some conflict settings If CFRs exceed these levels an immediate evaluation of control measures should be undertaken and corrective steps taken to ensure CFRs are reduced to and maintained at acceptable levels 1

This is the same Yemeni child being admitted with SAM, in the hospital being treated for SAM with complications and walking out of the hospital cured. Demonstrates the role the health system played in saving his life. However should not have been there in the first place – the role of prevention 1

Health programming in emergencies and links to Nutrition Child health is divided into: Care of newborns (care at birth, early initiation of breastfeeding, health and immunization after birth, education and support for mothers) Care of children (in line with WHO IMCI guidelines) which include: Assess nutrition and immunisation status and potential feeding problems at the outpatient health facility level 1

Health programming in emergencies and links to Nutrition Establishment of child-focused health interventions which address the major causes of excess morbidity and mortality Where measles vaccination coverage is <90% or is unknown: Mass measles vaccination campaign should be conducted for children 6 months to 15 years Vit. A should be administered to children 6-59 months A system should be set up to ensure that any newcomers to the area are vaccinated

Health programming in emergencies and links to Nutrition Diarrhoeal diseases are a major cause of morbidity and mortality in emergency situations often accounting for over 40% of deaths in an acute phase of an emergency with 80% of these deaths occurring among children under 2 years of age Prevention of outbreaks of Cholera and Shigella dysentery are of particular concern in emergencies they are highly infectious diseases if poorly managed can result in extremely high case fatality rates Risk factors for diarrhoea include overcrowding, inadequate quantity and quality of water, poor personal hygiene, poor washing facilities, poor sanitation, poor cooking facilities and lack of soap 1

Health programming in emergencies and links to Nutrition Diarrhoea control interventions in emergencies include: provision of adequate quantities of safe drinking water provision of facilities for safe disposal of human excreta provision of adequate storage for cooked and uncooked food appropriate cooking utensils and fuel for cooking provision of soap for handwashing promotion of optimal breastfeeding practices provision of information on all of the above activities for prevention Prompt diagnosis and appropriate treatment according to protocols and guidelines is essential to reduce and prevent excess mortality in emergencies. 1

Health programming in emergencies and links to Nutrition Sexual and reproductive health should encompass: A Minimum Initial Services Package (MISP), Prevent, and manage the consequences of sexual violence Support mothers breastfeed Reduce the transmission of HIV Prevent maternal and newborn morbidity and mortality Begin planning for comprehensive RH services. Then Adolescent Reproductive Health Family Planning Maternal and Newborn Care including postpartum vitamin A supplementation Gender Based Violence (protection and care) STI Care HIV Care. 1

Health programming in emergencies and links to Nutrition Recommended intervention pyramid for mental health Specialized services Focused non specialized support Strengthening community and family support Social considerations in basic services and security Mental health care by mental health specialists Basic mental health care by PHC doctors. Basic emotional and practical support by community workers Activating social networks communal traditional supports Supportive age-friendly spaces Advocacy for basic services that are safe, socially appropriate and that protect dignity Examples: 1

Key messages Emergencies exacerbate severity and magnitude of childhood diseases and mortality rates are highest in children under five The health and nutritional status of pregnant women significantly impact the health, well-being and nutritional status of their infants The child is more likely to be born premature, with LBW and more vulnerable to illness and undernutrition if the mother is sick and undernourished or has multiparity Humanitarian crises, increase vulnerability to HIV and negatively affect the lives of those people living with HIV The role of operational health agencies in emergencies is to provide essential services that effectively reduce health risks. 1

Key messages Establishment of good quality control of communicable diseases interventions has significant impact on health and nutritional status of an emergency-affected population Implementation of key priority reproductive health interventions has a positive affect on the health, well-being and nutritional status of both infants and mothers Provision of quality basic child health care at first line health facilities, supported by promotion of key infant and young child feeding and care practices will have a positive impact on the health and nutritional status of young children. 1