Dietitian's Action in Emergency

Seminar Gizi Siaga Bencana FK UB - 26 September 2010 Presented by Nurul Muslihah, M.Kes

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EMERGENCY?
y Definisi Bencana (UU no 24 tahun 2007)

Peristiwa yang mengancam & mengganggu kehidupan & penghidupan masyarakat yang disebabkan baik oleh faktor alam, non alam, maupun manusia yang mengakibatkan timbulnya korban jiwa manusia (vulnerability), kerusakan lingkungan (hazard), kerugian harta benda, dampak psikologis
y Bencana : gangguan mengancam & merusak

(hazard) & kerentanan (vulnerability)

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EMERGENCY?
y Kategori Bencana (UU no 24 tahun 2007)

1. Bencana alam : gempa bumi, tsunami,

gunung meletus, banjir, kekeringan, angin topan, & tanah longsor 2. Bencana non alam : gagal tehnologi, gagal modernisasi, epidemi, dan wadah penyakit 3. Bencana sosial : konflik sosial dan teror

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Types of Emergencies
Rapid onset
earthquake volcano flood cyclone terrorist attack chemical plane crash spill epidemic war civil unrest

Slow onset

drought

famine

Natural

Manmade

Fase-fase Emergency
1. Fase Tanggap Darurat
(Tsunami Aceh : 26 Desember 2004 26 Maret 2005)

2. Fase Rehabilitasi dan rekonstruksi (Tsunami Aceh : 27 Maret 2005 akhir 2007)

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Emergency Indicators
IndicatorEmer Angka Kematian Status Gizi Anak Makanan Kuantitas Air Kualitas Air Emergency Level > 2 orang per 10.000 jiwa per hari > 10% anak BB/TB < 80% < 2.100 Kkal/orang /hari < 10 liter / orang / hari > 25 % menderita diare

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Indicators in Emergencies
1. Nutritional indicators: prevalence of wasting
y Weight for Height y Z scores (surveys) y MUAC (screening)

2. Mortality indicators
y Crude Mortality Rate (CMR) y Under 5 Mortality Rate (<5 MR)

Nutrition Indices Review Emergency Contexts

Stunting Underweight Wasting (Acute) (Chronic) (Both) Index H/A W/A < -2 SD W/H or MUAC < -2 SD, 70 - 80% Median, or MUAC 110 125* < - 3SD, <70% Median, or MUAC <110*, or Oedema

Moderate < -2 SD

Severe

< - 3 SD

< - 3SD

*Cut off points for MUAC have differed from agency to agency these cut offs are consistent with cluster guidance

Establish Public Health Priorities in the Emergency Phase

1. Initial Assessment
2. Measles Immunization 3. Water, Sanitation & Hygiene Promotion 4. Food & Nutrition including Infant Feeding in Emergencies 5. Shelter, Site Planning & Energy 6. Health Care in ER Phase - Minimum Initial Service Package (MISP) for Maternal and newborn health 7. Control of Communicable Disease & Epidemics 8. Public Health Surveillance 9. Human Resources & Training 10. Coordination/Camp Management

Emergency Response
y Operations in emergency response:

1. Commodity services & education 2. Population estimation & register 3. Site selection, planning & shelter 4. Commodity distribution 5. Health 6. Food and Nutrition 7. Water 8. Environment sanitation 9. Supplies and transport

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Role of Dietetians during emergencies

1. Rapid Assessment 2. Food Aid  Perencanaan  Pengembangan program  Monitoring & evaluasi program  Advocacy

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Rapid Assessments

Rapid Health Assessment Data Needs in the Emergency Phase

Background; social, political, economic data Background health data Affected population size and demographics Vital health information y Mortality rates y Top 5 causes of Morbidity y Risks for disease outbreaks y Measles vaccination coverage (>95% or <95%) y Acute malnutrition level y Access to health services (primary, referral, and secondary) human resources, medical supplies y Health practices (BF habit, delivery practice) 5. Environmental conditions water, shelter, sanitation
1. 2. 3. 4.

Rapid Assessment Data Needs in the Emergency Phase

Vital health information: Mortality rates y Crude Mortality Rate (CMR), Under 5 (U5MR) y Deaths per 10,000 persons per day y When stable, deaths per 1,000 persons per month y Age/Sex specific mortality rates y Cause specific mortality rates y Case fatality rates: measles, cholera y Access to health services

Rapid Assessment Data Needs in the Emergency Phase

Environment: Water
y y y y y

Quantity of water Quality of water Accessibility Sanitation Number of persons per latrine Accessibility and acceptability

Team composition
3 6 persons, including national health authorities and affected pop representatives, partner UN agencies, NGOs Multidisciplinary team with skills in: Logistics Water and sanitation Nutrition Health care Education Epidemiology Security Other expertise depending on situation

Rapid Assessment in Emergencies

Key elements of a good rapid assessment output:  Timely  Clear recommendations stating:
y Who should do what, when

 State limitations of the data  Include a plan for surveys and surveillance

Rapid Health Assessment Summary

Must be timely Multi organizational and multi disciplined Address basic needs:
 Food  Water  Shelter  Health  Sanitation

Set immediate program priorities Examine in some degree the health and nutrition status of the affected

population

Summary of Assessment Results

y Health y Water and Sanitation y Food Security and Distribution y Shelter and resettlement plans y Non-food items y Livelihood y Logistics

RAPID HEALTH ASSESSMENT IN NUTRITIONAL EMERGENCIES

confirming the first information

identifying the main causes

rapid assessment

assessing the severity of the problem identifyin measures to minimize or prevent the emergency ensuring monitoring & surveillance

RAPID HEALTH ASSESSMENT IN NUTRITIONAL EMERGENCIES

surveys : planning and implementing

1. 2. 3. 4. 5. 6. 7. 8. 9.

which population is to be assessed what is the smallest unit to be assessed is there any need to analyze subgroups which sampling methods will be used which age groups what will be the sample size which indicators will be used what persons, equipment, transport resources workload : how many children/ cluster per day

RAPID HEALTH ASSESSMENT IN NUTRITIONAL EMERGENCIES

surveys : planning and implementing

10. 11. 12. 13. 14. 15.

Training schedule: who, where.. who will supervise teams during survey data analysis who is responsible for logistics report : what, who.. who is responsible for taking action on reports findings

Contoh Kuesioner Rapid Assessment

1. 2. 3. 4. 5.

CAMP Shelter Medical Service Rumah Tangga Kesehatan

Contoh Kuesioner Rapid Assessment Tsunami ACEH

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FOOD and NUTRITION Needs in Emergencies

1/31/2012

Food and Nutrition Emergency

y Everyone has the right to a standard of living adequate for the health & well-

being of himself & of his family, including food (Universal Declaration of Human Right/UDHR, article 25-1)
y In Emergency situation:

a. Everyone to have access to adequate & safe food b. Food assistance : - cover the overall nutritional needs of all population group (quantity, quality & safety) - meets the populations minimum energy, protein & fat requirements for survival & light physical activity - nutritionally balanced - diversified, culturally acceptable, fit for human consumption, and suitable for all sub groups of the population
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Emergency Phases & Planning

y Phase 1 of the emergency
(From the outset & during initial stages of the emergency i.e during initial rapid assessment) a. Adopt 2,100 kcal/person as a reference figure b. Adjust the 2,100 kcal based on information available immediately using the factors environmental temperature, health & nutritional status, demographic characteristic, and physical activity level c. Ensure that food ration is adequate to address the protein, fat and micronutrient requirements of the population d. Consider food management issues and conditions e. Establish a monitoring system to ensure adequacy of the ration

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Emergency Phases & Planning

y Phase 2 of the emergency
(Situation stabilized) a. Adopt 2,100 kcal/person as a reference figure b. Adjust the 2,100 kcal based on information available immediately using the factors environmental temperature, health & nutritional status, demographic characteristic, and physical activity level c. Ensure that food ration is adequate to address the protein, fat and micronutrient requirements of the population d. Consider food management issues and conditions e. Establish a monitoring system to ensure adequacy of the ration

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Planning A Food Ration (Ransum makanan/bantuan pangan)

1. Calculate Nutrition Requirement
a. The initial planning for energy requirement :2,100 kcal/person/day
b. Adjust based on the following issues: * Temperature : add 100 kcal/day for every 5oC if daily temperature below 20oC (i.e +100 kcal at 15oC, +200 kcal at 10oC, +300 kcal at 5oC, +400kcal at 0oC) * Physical Activity Level : add 140 kcal/day for moderate activity, 350 kcal/day for heavy activity * Age/sex distribution : if adult males > 50% from all population, requirement are increased and if women & children > 50%, requirement are reduced (adjustment plus/minus 5%)
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Planning A Food Ration (Ransum makanan/bantuan pangan)

1. Calculate Nutrition Requirement
c. Protein : 10-12% of energy in diet should be in the form protein (i.e 52-63 gram protein) Fat/oil : at least 17% of energy in diet should be in the form fat (i.e 40 gram of fat)
Micronutrients : a range of vitamins & minerals are required for survival and good health

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Planning A Food Ration (Ransum makanan/bantuan pangan)

2. Choosing commodities
a. The mix commodities must meet the energy, protein, fat, and micronutrient requirements of the population b. Local food habits c. Prepare easily digestible energy-dense foods for young children & easily chewed and digestible food for elderly people d. Ease of storage & use

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Sample daily rations for food aid reliant populations ITEMS Cereal flour/rice/bulgur Pulses Oil (Vit A fortified) Fish/meat Fortified blended food *) Sugar Iodized salt Fresh vegetables-fruits Spices Total (gram/day) RATIONS (gram)
TYPE 1 TYPE 2 TYPE 3 TYPE 4 TYPE 5

400 60 25 50 15 5 555

420 50 25 20 40 5 560

350 100 25 50 20 5 550

420 60 30 30 20 5 565

450 50 25 20 5 100 5 655

2,113 2,106 2,087 2,092 2,116 Energy (kcal) Protein (gram & % kcal) 58g,11% 60g,11% 73g,14% 45g,9% 51g,10% 43g,18% 47g,20% 43g,18% 38g,16% 41g,17% Fat (gram & % kcal)
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Commonly used Food Aid Commodities

1. Cereals : wheat, rice, sorghum/millet, maize 2. Processed cereals : maize meal, wheat
flour, bulgur wheat

3. Blended Foods :
- Corn soya blend (CSB) - Corn soya milk (CSM) - Wheat soya blend (WSB) - Soya fortified bulgur wheat - Soya fortified maizena meal - Soya fortified wheat flour - Soya fortified sorghum grits
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Commonly used Food Aid Commodities

4. Dairy Product : Dried skim milk (DSM), Dried whole milk (DWM), Canned cheese, Therapeutic milk (TM) 5. Meat & fish : canned meat, dried salted fish, canned fish 6. Oil & Fat : vegetable oil, butter oil 7. Pulses : beans, peas, lentils 8. Miscellaneous : sugar, dried fruit, iodized salt

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Blended foods
Blended foods are a mixture of milled cereals & other ingredients such as pulses, dried skimmed milk, sugar, oil, vitamin/mineral premix Blended foods should meet the following
a. Palatability & taste : have a pleasant smell and be food that children enjoy b. Shelf life : retain above qualities for 6 months from date of manufacture c. Preparation : be easily prepared by adding boiling water and cooked in 5-10 minutes d. Have moisture content < 10% and fibre < 5% e. Nutritional value per 100 g are 400 kcal, 15% energy from protein & 6% from fat

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Blended foods
Corn-soya blend (CSB) from USA maize, soya flour, soya oil, vitamin/mineral premix Indiamix (India) 75% wheat & 25% soya or 55% wheat, 25% soya, 20% sugar Famix (Ethiopia) Maize pre cooked, soya flour, sugar, vitamin/mineral premix Tenamix (Tanzania) Pre-cooked maize, soya, chikpea, sugar, vitamin/mineral premix

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Ready to eat meals

y Keuntungan

a. Cepat dan mudah didistribusikan

b. Solusi tepat ketika fasilitas memasak tidak ada c. Daya simpan lama d. Tinggi energi dan difortifikasi dengan vitamin & mineral (biskuit)

* Kelemahan a. Umumnya bukan makanan yang biasa dikonsumsi b. Mahal c. Tidak cocol untuk theurapic feeding programme (High protein & sodium)
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The nutritional needs for infant & young children

1. Guiding principles for feeding infants (0-6 months) during emergencies
a. All infants should be exclusively breast fed for the first six months - initiate breastfeeding within one hour of birth - give a colostrums for baby - breastfeed exclusively for six months b. The quantity, distribution, and use of breast substitute (infant formula) at emergency should be strictly controlled

2. Complementary feeding for 6-36 months old

- 30-40% of energy from fat and 12% of energy from protein - Source food from basic food commodities and locally available food - Blended food (CSB, WSB)
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Nutritional relief : Selective feeding programs

 Provides additional food to specific groups  Supplementary feeding & Therapeutic feeding program  Findings

a. Food available at household level < 2,100 kcal/person/day * Improve general rations b. Malnutrition rate 15% or 10-14% with general food ration below the mean energy requirement or crude mortality rate > 1 per 10.000 per day or high incidence respiratory or diarrhea disease * General ration plus * Supplementary feeding general for all members of vulnerable group (children, pregnant & lactating women) * Therapeutic feeding program for severely malnourished individuals
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Basic emergency complementary feeding support:

y y

y y

Fortified blended foods (e.g. CSB/WSB) in general ration Addition of inexpensive locally available foods to the general ration Addition of micronutrient rich foods to SFP rations Sprinkles/micronutrients

Tantangan ke depan
Mampu membuat perencanaan dan analisa Rapid Assessment 2. Mampu merancang dan M & E suatu program Gizi 3. Mengembangan Ready Eat to Meal untuk keadaan emergency
1.

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Helen Keller International Tsunami

Tsunami Relief Initiatives
* SUM (Supplementation with Vitamins and Minerals * PEC (Primary Eye Care)

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Vitamin & Mineral yang disediakan:

y Kapsul Vitamin A y Tablet Zinc untuk pengobatan

diare y Multivitamin sprinkles (Vitalita) y Kecap manis difortifikasi zat besi (IFSS)

Pentingnya dan Keuntungan Vitamin dan Mineral

y Dampak yang besar. Vitamin A dan Zinc dapat menurunkan mortalitas dan morbiditas

pada anak. Zat gizi mikro lainnya seperti zat besi dan yodium juga sangat penting bagi perkembangan anak dan menurunkan morbiditas serta mortalitas.
y Biaya murah termasuk transport dan distribusi y Ruang penyimpanan yang sederhana. Tahan lama, dan membutuhkan tempat yang

sedikit
y Membutuhkan sedikit atau bahkan tanpa persiapan. y Mudah dibawa y Menjadi jalan bagi upaya kesehatan dan bantuan lainnya.

Responding to Crisis Screening New Approach

Acute Malnutrition
Without Complications

>80% of severes can be treated as outpatients

With Complications

70 - 80% WHM, Moderates MUAC <125mm

<70% WHM, MUAC <110mm OR Severes oedema

Oedema (+++) OR Severes (and Marasmic-Kwashiorker OR WHM <80% OR MUAC moderates) with <125mm OR oedema complications AND illness*

Supplementary Feeding

Outpatient Therapeutic Care

Inpatient Care

*Anorexia, LRI, High fever, Severe dehydration, anemia, not alert, hypolglycaemia, or hypothermia

Responding to Crisis Supplementary Feeding

Acute Malnutrition
Without Complications With Complications

80% WHM, MUAC Moderates <125mm

70% WHM, MUAC <110mm SeveresOR oedema

Oedema (+++) OR Severes (and Marasmic-Kwashiorker OR WHM <80% OR moderates) with MUAC <125mm OR oedema complications AND illness*

Supplementary Feeding

Outpatient Therapeutic Care

Inpatient Care

*Anorexia, LRI, High fever, Severe dehydration, anemia, not alert, hypolglycaemia, or hypothermia

Responding to Crisis Supplementary Feeding

y Blanket y Prevent malnutrition by providing a food

supplement to all members of vulnerable groups such as children <5 and pregnant and lactating women (alluded to earlier)
y Targeted y Prevent moderately malnourished women and

children from becoming severely malnourished by providing a food supplement to malnourished individuals