Nutrition Guidelines (MSF, 1995, 191 p.) Annexes Annex 1: Rapid assessment of the state of health of displaced populations or refugees (A.Moren - Medical News, No. 1) Annex 2: Mid - Upper Arm Circumference (MUAC) Annex 3: Nutritional status assessment in adults and adolescents Annex 4: Agencies involved in food relief Annex 5: Food composition table Annex 6: GENERAL RATION: How to calculate the energetic value Annex 7: Micronutrient deficiencies Annex 8: Food basket monitoring methodology Annex 9: Analyzing nutritional survey data Annex 10: Drawing of a random number Annex 11: Standardization of anthropometric measuring techniques Annex 12: Data collection forms Annex 13: W/H Reference tables Annex 14: Selection of food items for selective feeding programmes Annex 15: Oral rehydration for severely malnourished children Annex 16a: Preparation of High Energy Milk Annex 16b: Recipes for porridge for use in therapeutic and wet supplementary feeding programmes Annex 16c: Recipes for premix for dry ration supplementary feeding programmes Annex 17a:Example of a Therapeutic feeding centre Annex 17b: example of layouth of a <<wet>> supplementary feeding centre Annex 17c: Example of a DRY SFP Annex 18a: Example of an Attendance register (tfp or SFP) Annex 18b: Example of a Nutritional Status Monitoring (SFP) Annex 19a: TFP individual monitoring card Annex 19b: SFP individual monitoring card Annex 19c: Individual card for Supplementary feeding centre Annex 19d: Example of an individual card for dry blanket SFC Annex 20: Feeding programme indicator graphs Annex 22: MSF nutrition kits

Nutrition Guidelines (MSF, 1995, 191 p.)

Annexes

Annex 1: Rapid assessment of the state of health of displaced populations or refugees (A.Moren - Medical News, No. 1)

GENERAL

The main objective when assisting displaced populations or refugees is quickly to reduce excess mortality ever present in these situations(10). During the first few weeks or the first few months following population displacement (Figure la), the death rate observed is often high. It rapidly goes down when intervention becomes organized and coordinated.

FIG1a:

- East Ethiopia 88 - 89 - Somalia N - W 80 - 81 - Thailand 79-80 - Sudan 85.

Intervention priorities have long since been properly defined and procedures standardized. They may be summarized in ten points:

1) Mass immunization against measles
2) A rapid initial evaluation
3) Water supply
4) Food supply
5) Shelter
6) Organize a programme to control diarrhoeal diseases
7) Setting up an epidemiological surveillance system
8) Training community health workers
9) Setting up a curative care unit based on a list of essential drugs and the application of standardized therapeutic protocols
10) Coordinating the various operational partners.

The first four interventions can, and must, be carried out simultaneously (6). This is all the more easy as such activities are conducted by groups of different specialists (health care staff, epidemiologists and logistics experts).

METHOD

If an intervention is to be fast, effective and properly suited to the situation, it must be based on an initial evaluation which has to be conducted in the early days after the displaced populations have arrived or are taken charge of. The preliminary results from such an evaluation have to be available in the week following the start of the evaluation.

The data to be collected relate to: the background to the displacement, security conditions, site mapping, demography, mortality, nutrition, priority pathologies, water and food resources, housing, sanitation, climate, the road network and available resources.

There are three ways in which these data may be gathered:

· Mapping It is important to count the number of people quickly and ascertain the structure of the population. A rough map of the site can be drawn rapidly by squaring out the camp and making measurements on foot or in a car. Using squared paper, the sections or zones making up the camp may be drawn (Fig. 1b).

Once the map has been produced, a 100m - by - 100m grid is superimposed. Each of the squares is then classified as a low - medium - or high density population square. Then two or three squares are drawn by lots from each category of zone density. Each of the selected squares is then visited to make a population count. This gives an average number of refugees per low, medium and high density population zone of refugees. The number of people in the low density squares is multiplied by the number of such low density squares. The same operation is repeated for each of the other density categories (Fig. 1b). This method makes it possible to produce an estimate of the aggregate number of refugees on the site.

FIG. 1b:

The number of litres of water available per person and per day can be assessed on the basis of the number of watersupply points and measurements of their respective capacities(3). This is an operation that can be carried out as the map is being drawn.

· Sample survey

The following information may then be obtained using a sampling technique within the population. A simple random type of sampling can be used if the households are numbered (drawing lots); the systematic type if the households are organized into rows or properly ordered geographical zones; or the two stage cluster sampling survey type if the site is not organized geographically (2). The size of the sample is a compromise between the urgency of the expected result and the desired accuracy. It is advisable to take at least 200 households.

In each household selected, the number of individuals is recorded, together with the age and sex of each one. For children aged 6 to 59 months old, their weight, height and mid - upper - arm circumference are measured(2). Each head of household is questioned about the number of deaths in the household over the previous months. Using a verbal autopsy questionnaire, the causes of death are determined(9).

The type of dwelling (huts, tents, permanent housing, open air) is noted. Food stores are estimated by weighing the food available on the day of the enquiry. The food intake of the previous day may be measured by using a 24 hour food intake summary (the quantity of food eaten the previous day by the individuals in the sample is estimated for each type of food and the calorie intake is established using food tables - Annex 5).

The date of the last food distribution operation is also noted. The existence of latrines, the distance to the nearest water supply point and its type will be noted (3).

· Interviews with the leaders of organizations present and those of the various communities

Human resources are to be determined (numbers of doctors, nurses, water, hygiene, sanitation specialists, logisticians and available community health care workers).

The total number is expressed as a ratio of the aggregate population and is compared to advocated staff levels (6, 10).

Interviews with the host country authorities provide information on the background to the displacement and security conditions. In the same way, information is gathered on the date(s) of the rainy season(s), the possibility of roads and expected temperatures (6).

Once these data have been collected, they are summarized in a preliminary report in the form of a table showing the main indicators (computed from the data as above) and the comparison thresholds. One page suffices to summarize the data. The purpose here is to be convincing by using the figures and to trigger the rapid adjustment of any assets made available.

Often the list of relevant information proves impossible to complete within a week. If a choice has to be made, priority is given to the collection of data on the number of refugees, the daily mortality, the food ration distributed and water supply.

This initial evaluation also serves to set up an epidemiological surveillance system (5). The most important indicator to be monitored is the daily mortality, expressed as a number of deaths per day per 10,000 people. The number of deaths may be obtained by making a daily count of the new graves on the site and by regularly questioning the community leaders.

The system may also be based on the work carried out by the community health care workers in each section in the camp as they record the number of deaths occurring in their section each day or each week. A simple weekly data collection sheet is used. A simple daily or weekly mortality graph also has to be filled in (Annex l c).

FIG. 1c:

Example of a of rapid assessment report:

Place: XXXX
Dates: 12110192 - 19110192
Person responsible: XX

Method:

1) Mapping/grid
2) Sampling (clusters), 200 households, N = 900
3)Other sources of information: WFP, UNHCR.

Results:

	Observed	Theoretical
Total number of refugees	55,423	-
% of children under the age of 5 years (if need be, age pyramid)	14.5%	20%
% 6 - 59 months with a MUAC < 12cm	15.5%	7%
Number of deaths per 10,000 people per day computed for the previous month.	6	< 1/0,000

Breakdown of causes of death

Measles	35%	-
Diarrhoea	25%	-
Malnutrition	22%	-
Acute respiratory infections	5%	-
Malaria	0%	-

Epidemic pathologies present

Cholera	NO
Meningitis	NO
Measles	YES
Available daily food ration	1500	2100 Kcal
Average number of litres of water available per person and per day	45	>20L
Number of people per latrine	50%	<20
% of people with a protected dwelling	100%
Number of doctors/I0,000 persons	0.5	1
Number of nurses/10,000	1	2
Number of logisticians	0.2	1
Number of sanitation workers/10,000	0.2	1
Number of city health workers/10,000	5	10

CONCLUSION

The purpose of a rapid evaluation is to provide guidance for setting up emergency operations in the shortest possible time. Methods will often be approximate and results will have to be corroborated with remote in depth studies. The initial evaluation report is an item of paramount importance. It needs to be brief, concise, precise, fast and it should provide only figures.

Alain Moren, Epicentre, October 1992

References

1. Famine Affected, refugee, and displaced populations: recommendations for public health issues. CDC. MMWR 1992; 41(No.RR13).

2. Enguetes anthropometriques au sein de populations en situation precaire., Coulombier D. EPICENTRE/MSF, 1991.

3. Technicien Sanitaire en Situation Precaire, MSF, 1992, Courvalet M., Delmas G.

4. Public health consequences of the civil war in Somalia, Manoncourt et al. LANCET (letter), 1992; 340:176177.

5. Epidemiological surveillance among Mozambican refugees in Malawi, Moren A. and al. DISASTER

6. Populations refugiees: Priorites et conduites a tenir. Cahiers Sante, Moren A, Rigal J. 1992; 2:13 - 21.

7. Public health consequences of acute displacement of Iraqi citizen, Pecoul B., Malfait Ph. Toole MJ, Waldman RJ. - March - May 1991. MMWR 1991; 40:4436

8. Refugee Community Health Care., Simonds S.et al. Oxford Medical Publication, 1983.

9. Methods For Field Trials Of Interventions Against Tropical Diseases, Smith PG, Morrow RH, Oxford Medical Publications. 1991; Ch 8:169175.

10. Prevention of excess mortality in refugee and displaced populations in developing countries, Toole MJ, Waldman RJ. JAMA 1990; 263: 3296302. Tableau I.

TABLE:

CUT - OFF POINTS FOR THE INTERPRETATION OF UNDER 5 MORTALITY RATES ARE APPROXIMATELY DOUBLE THOSE OF CMR CUT - OFFS.

Annex 2: Mid - Upper Arm Circumference (MUAC)

1. Taking the measurement

MUAC should be measured on the left arm, while the arm is hanging down the side of the body and is relaxed. The MUAC should be measured at the midpoint between the shoulder and the tip of the elbow.

The end of the tape is fed down through the first window and up through the third window, and the measurement is read from the middle (second) window.

FIGURE

2. Reading the measurement

MUAC can be recorded with a precision of 1 millimetre. Read the number in the box which is completely visible in the middle window.

FIGURE

3. Interpretation

Contrary to the weight for height indicator, there is not 1 set of universal cut - off points for interpreting MUAC. There is agreement between the different MSF sections and Epicentre to use the following cut - off points:

< 110 mm = Severe acute malnutrition

110 to 124 mm = Moderate acute malnutrition

At the population level, these cut - offs give broadly similar results to the estimate of the prevalence of acute malnutrition as accepted weight - for - height cut - off points. At the individual level MUAC and W/H are not comparable. For entry to nutrition programmes we use W/H, but as MUAC is faster to perform we can measure all children with MUAC and only refer those children

< 135 mm

to the second stage where they are measured for W/H to see if they can enter the programme.

4. Interpretation with colours

Colour bands are included on the tapes so that illiterate workers may use the tapes to classify children's nutritional status.

RED	= Severely acutely malnourished
ORANGE	= Moderately acutely malnourished
YELLOW	= To be referred for weighing and measuring
GREEN	= Normal

For mass screenings as long as the reading window is completely green, the children are not referred for further assessment (W/H).

For quick surveys, it is necessary to note down the proportion of children falling in the ORANGE and RED bands (but for a survey it is better to record actual measurements if possible).

Annex 3: Nutritional status assessment in adults and adolescents

The weight - for - height indicator can only be used to 137 cm (+/- 10 years). Furthermore, adults are less prone to malnutrition and the effects of malnutrition are less harmful in the short and longer term. Nevertheless, in severe nutritional emergencies adult malnutrition can be an important problem.

Body Mass Index (BMI) is used as an indicator for adult nutritional status. BMI is an indicator that is supposed to reflect thinness, by measuring weight and controlling for height. BMI is calculated as
weight / height²

WHO proposes the following BMI cut - off points:

16 - 18.5: AT RISK

<16: MALNOURISHED

These cut - off points were based on European populations and there are difficulties in using one set of cut - off points universally. Due to genetic and environmental factors, many African populations have, on average, a lower BMI than European populations, even during optimal nutritional status. This is mainly due to the fact that many African populations have a smaller body frame size and a longer relative leg - length.

More appropriate reference figures have been proposed, taking into account sex and frame size, but the BMI still depends on factors other than the nutritional status, such as height and relative leg - length. Therefore, BMI is usually used as a relative indicator, to indicate progress or deterioration in the population's nutritional status, over time.

For individual follow-up, weight gain or loss is the preferred indicator.

BMI can only be used in adults, having reached full maturity. The age of onset of maturity may be later in developing countries, so BMI must be used with caution when dealing with younger adults and avoided for use with adolescents.

The lack of clearly defined standards for assessing adult malnutrition is a cause of great concern. Of even greater difficulty is the assessment of adolescent malnutrition. Intervention in war situations inevitably leads to contact with broadly malnourished populations. Intervening in situations of mass adolescent and adult malnutrition is a major responsibility for which we are not well equipped.

Nutritional oedema in adults is rare and will only occur in severe famines. It should always be interpreted with caution, as other causes of oedema may occur.

FIGURE

Annex 4: Agencies involved in food relief

Although there are various agencies involved in relief food assistance, the U.N. agencies are most often present and have a constant mandate:

I / UNITED NATIONS AGENCIES:

1. World Food Programme (WFP/PAM)

The main agency concerned with food aid among the UN family - WFP has various sources under which it operates, depending on the situation:

- Special fund for food assistance to refugees and displaced persons.

- Fund for emergency operations: natural and man - made catastrophes, drought and harvest failure.

- Management of the International Emergency Food Reserve (IEFR).

WFP will donate food to NGOs for a variety of reasons. Food items that are a part of the general ration will be available to NGOs for feeding of in - patients at hospitals, feeding mothers accompanying children in the feeding centre and Food For Work (FFW) for staff. Other supplies (i.e. oil, sugar, CSB) can also be received for feeding programmes.

In some circumstances, WFP will pay an internal transport, storage and handling allowance. Check with the WFP country - office for available options.

WFP also has a large presence in development assistance.

2. United Nations High Commission for Refugees (UNHCR)

UNHCR is responsible for the coordination of relief assistance to international refugees and the protection of their rights.

The degree to which UNHCR is responsible for the actual food supply to the refugees depends on the situation - UNHCR is dependent on other organizations for supply of food aid (usually WFP) and brokers agency responsibilities in each different situation.

WFP usually has the responsibility for the supply of the general food ration and UNHCR might complement the food basket with additional food items (i.e. fish, meat, spices). The actual delivery of the food aid will be coordinated by one of the agencies, but its distribution is often subcontracted to other agencies (Care, Red Cross/Crescent, Oxfam, SCF, CARITAS, CRS, etc.). The supply and delivery of supplementary and therapeutic foods will usually be under the responsibility of UNHCR.

UNHCR also has a mandate to assist the displaced, but its resources and legal powers are limited and UNHCR does not play a lead role in this respect. For nonrefugees (e.g.displaced persons), WFP will often provide food assistance through other UN agencies (e.g.UNICEF) or even NGOs.

3. United Nations Children's Fund (UNICEF)

UNICEF focuses on the welfare of children. UNICEF is the UN agency with the greatest amount of autonomous resources and will often become involved with funding or coordinating special programmes to meet needs unmet by the other agencies.

Unicef can be requested to provide blended food (i.e. UNIMIX), material for feeding centres (balances, cooking utensils, essential drugs, etc.). The response will depend on the level of autonomy and the local policy of the country UNICEF office however, a well presented proposal has a good chance of funding. UNICEF also occasionally has funds for local purchase of food items and transport costs.

Investigate the current national policy on food assistance (sometimes agreements with WFP or other agencies) and what delays to expect.

II. OTHER AGENCIES:

· Bilateral donors, such as the EEC, USAID and others often provide food assistance of various kinds to developing countries.

The EEC food aid is essentially divided into two categories: - Fund for Food Aid (FAA) - Fund for Emergency Aid (FAU/ECHO)

FFA food destined for NGOs is channelled through Euronaid.

· Some NGOs also have special access to sources of food aid which they import independently, either received from bilateral donors, or purchased with their own funds (particularly CARITAS, CARE, CRS, ADRA, SCF, OXFAM, LWF, ICRC).

Annex 5: Food composition table

FIGURE

Annex 6: GENERAL RATION: How to calculate the energetic value

1. List the different items with Weir caloric value, fat and protein content.
2. Calculate the total number of calories and the protein content of the ration.
3. Calculate the relative percentage of calories provided by each item.

In order to make these calculations, we need information on the average caloric value and protein content of some common relief foods (see the food composition table in Annex 5).

FIGURE

1 GRAM OF PROTEIN = 4 Kcals

1 GRAM OF FAT = 9 Kcals

Proportion of Kcal provided by protein:

- Number of KCal: 59 x 4 = 236 KCal
- Proportion: (236/2024) x 100 = 11.7%

Proportion of Kcal provided by fat:

- Number of KCal: 77 x 9 = 693 KCal
- Proportion: (693/2024) x 100 = 34.2%

Annex 7: Micronutrient deficiencies

Protein-Energy Malnutrition is not the only form of malnutrition. Deficiencies in micronutrients can occur without signs of acute PEM, with important functional consequences and increased risk for the morbidity and even mortality of the population affected.

From an analysis of the composition of the food ration, it is possible to predict the presence of micronutrient deficiencies. One should not wait for clinical manifestations of micronutrient deficiencies to advocate more adequate food rations.

Certain food storage and preparation techniques may destroy or diminish the micronutrient content of food items. The treatment of food should also be considered when assessing micronutrient content of rations.

Before embarking on prevalence surveys of micronutrient diseases, consult the medical department at head quarters. There are many methodological problems with estimating prevalence of micronutrient deficiencies:

· A standard case definition is imperative.
· Estimation cannot be combined with anthropometric surveys.
· There is a need for a large sample size.

WHAT TO DO ABOUT MTCRONUTRIENT DEFICIENCIES?

- Provide individual treatment and secondary prevention for the identified cases.
- If deficiency diseases are prevalent on a large scale, use the population approach:

· advocate changes in general ration composition and quantities;
· consider technical possibilities and costs of food fortification;
· stimulate garden projects etc.;
· mass supplementation of the population with vitamin tablets;
· vitamin supplementation outreach campaigns through health service activities (feeding centres, OPD, vaccination campaigns);
· it is important to monitor the extent and trends in the disease.

We list here the most important and most frequent deficiencies that occur in emergency situations. Most are concerned with a lack of vitamins, some with a lack of essential minerals. Full details on biochemical mechanisms and clinical pictures can be found in reference works.

1. Vitamin A deficiency:

Xerophthalmia and night blindness are the main identifiable symptoms of severe vitamin A deficiency; look for so - called <<Bitot - spots>> (dry patches on the conjunctive). Adequate supply of vitamin A is essential as recent studies have shown that subclinical vitamin A deficiency leads to increased risk of death.

2. Vitamin B1 (thiamine) deficiency:

Beri - beri is the full clinical picture of a deficiency of Vitamin B1. There are two different clinical pictures of beri - beri:

* <<dry>> beri - beri: bilateral peripheral polyneuritis, with evolution to flaccid paralysis.
* <<wet>> beri - beri: cardio - vascular syndrome with oedema and heart failure.

Early deficiency symptoms are less specific: fatigue, anorexia, abdominal discomfort.

3. Vitamin C (ascorbic acid) deficiency: Scurvy: typical signs are painful joints and swollen, bleeding gums and possible petechia or haemorrhages. A trial treatment with high doses of Vitamin C should rapidly alleviate the symptoms.

4. Vitamin B3/PP (Niacin) deficiency:

Pellagra is recognized by the "3 Ds": Dermatitis, Dementia, Diarrhoea. The typical skin lesions (dark and dry) are on sun - exposed parts (neck, face and arms).

5. Vitamin B2 (riboflavin) deficiency: The most characteristic finding is angular stomatitis. Other mucocutaneous symptoms may be accompanying symptoms.

In the table below an outline of the approximate needs and treatments are given (average values for adults; for children adaption is needed):

FIGURE

Annex 8: Food basket monitoring methodology

The objective of FBM is to regularly check food distributions in order to advocate better quantity and quality of rations if required and provide information regarding the quality of distribution activities. As the issue is highly sensitive, we must be sure of the validity of our information and be careful how we use it to promote the rights of the populations with whom we work.

The method we describe below aims to check if families have received what they are entitled to receive - this does not mean that they will consume all the food (they can sell part of it), or that the food will be fairly distributed among family members.

This method is only applicable if distribution is done to the head of the household at central distribution points, which is not always the case !

IN PRACTICE:

1. Choose a point at a <<strategic distance>> from the distribution point, where you post two monitors and one supervisor, with a 50 kgs and a 5 kgs balance. Have two monitors present at the distribution point itself, to select the families.

2. A random systematic sample of 30 families is drawn from all families receiving food at the distribution point. The selected family receives a ticket and is accompanied to the point where the ration will be weighed. (e.g. If 500 families have to attend today, you will measure the ration of every 500/30 = 16th family. It is always better to have 3 or 4 families more than the 30 requested.)

3. Get accurate information on the time elapsed since the last distribution.

4. Determine the number of people in the family.

5. Weigh all food items separately and note their weights on the survey form (see below).

6. Afterwards, calculate the energetic value and the protein content of the <<average>> ration. Use a list of nutritional values for different food commodities as in Annex 5.

7. Report the result as an average general food ration in Kcals/Person/day. Calculate the confidence interval.

C.I. = 1.96 x S/n^1/2

where S is the standard deviation of the sample and n is the number of families in the sample.

Incorporate this information with other food distribution information obtained from other sources in a << food basket monitoring report >> (results can be illustrated graphically).

8. Repeat FBM on a regular basis and plot the results on a graph to monitor trends in food distribution.

INTERPRETATION

- Food rations may not be equally distributed throughout the day. Commodities may run out, meaning some families get less towards the end of the day (this should be noted and reported).

- Different population groups may receive different levels of rations. Poorly serviced population segments must be identified and reported.

- The periodicity of distribution may be irregular, making it hard to calculate a daily ration. Different commodities may be distributed on different days. Regularity of distribution is as important as overall quantity, and irregularity is important to be reported.

- The most important bias to exclude is that by doing FBM, you influence the behavior of the distributors (i.e. because they know they are being <<controlled>>, they might give more to the families who will be checked). A way of avoiding this would be to give tickets to be measured to 150 families instead of 30, and at the measuring point you take only one in five families.

FIGURE

Annex 9: Analyzing nutritional survey data

FIGURE

FIGURE

Similar tables should be used to present analyses that show different rates of malnutrition by other important variables (i.e. ethnic groups, refugees compared to residents).

While interpretive analyses can help to define priority groups or areas for intervention one can also look further into the pattern of the descriptive analysis. One can look at the distribution of variables that should follow a normal pattern discrepancies can be used to indicate bias in selection procedures or abnormal circumstances.

The division and graphing of the sample measured into different age groups forms a so - called age - pyramid; usually these age groups are further divided by sex. A comparison of the age - pyramid of the sample and the expected age - pyramid may show differences. These differences can be due to bias in the selection procedure when choosing a sample, or they can be real, indicating excess mortality in certain vulnerable age - groups.

Often, information on age is not available; height/length can then be used as a proxy for age. Plotting the distribution of height by sex will give the same kind of information as an age pyramid, but its shape will be different because the growth speed decreases in older children. Furthermore, height distribution is more difficult to interpret as stunting effects the proportion of children in height classes as well as age.

To determine the degree of excess mortality, we must make a comparison of the distribution of age or height with the distribution of a reference population of children under five. The <<gaps>> in certain age or height classes indicate an under representation of certain corresponding age groups in the sample.

This may imply a bias in the survey procedure. If the survey methodology was strictly adhered to, this gives an indication of excess mortality in vulnerable age groups in the past. Excess mortality leads to an underestimation of the true malnutrition rate as determined by the survey results.

FIGURE

· There are expected to be more children in the younger classes as some children inevitably die over time - therefore we get a slight pyramid shape.

· The 54 - 60 month age group has far fewer members than the other age groups however the age group only represents a period of 6 months, whereas all the other groups are for 12 months.

· Doubling the number of children in the 54 60 month age group would provide roughly expected numbers.

· There is also a lower than expected number of children in the 18 - 29 month age group.

The survey was implemented well, and there is no reason why we would have selected fewer children in this age group, so we conclude that there has been some excess mortality in this age group. It is then necessary to try and investigate why this age group would have suffered greater mortality than other age groups and devise interventions to focus on the identified problems.

Annex 10: Drawing of a random number

A random number is a number chosen from a list of numbers in a way which gives the same chance to each number being selected.

To start with, the interval in which the number should fall is determined. For example, a random number is required to choose the first cluster in a range 0001 to 1342.

This means that a 4 digit number is always required, and must be less than 1342. Several draws may be necessary in order to get a random number to fall in the interval.

RANDOM NUMBER TABLE

A table as shown on the next page can be used.

1st step:	the direction for reading the table must be chosen first. A
	random number table can be read in any direction: from top to
	bottom, from bottom to top, from left to right or from right to
	left.
2nd step:	the required number of digits is determined according to the
	range of the required value. Hence in order to draw a random
	number falling into a 0001 - 1342 range, 4 digits are necessary.
3rd step:	a pen is randomly pointed anywhere on the table. The pen is
	then moved according to the reading direction chosen to read
	the first 4 digit number. If it falls within the set interval, this
	number is kept.
4th step:	if the number falls outside the interval, the first 3 steps are
	repeated until an eligible number is drawn.

BANK NOTE TECHNIQUE

If a random number table is not available, the serial number written on a bank note can be used.

1st step:	a direction for reading the number is chosen. From left to right
	or from right to left.
2nd step:	the number of digits requested is determined according to the
	range needed. For example to draw a number falling in the
	range 01 - 13 a 2 digit number is required.
3rd step:	the necessary number of digits is read on the bank note in the
	chosen direction. If this number falls outside the interval,
	another bank note should be used for a new draw.

FIGURE

Annex 11: Standardization of anthropometric measuring techniques

It is essential during the training of enumerators to test that they measure children in a standard and accurate way. The test can be used for assessing the quality of any measurements: weight, height as well as mid - upper arm circumference.

1. Definitions

Accuracy: ability to obtain a measurement which will duplicate as closely as possible the reference value.

Precision: ability to repeat a measurement on the same subject with a minimum variation.

These two abilities are complementary. An enumerator may be precise but not accurate: he finds a wrong value for the measure, but he <<precisely>> finds the same wrong value every time. In the same way, an enumerator may be accurate but not precise, meaning the mean measure on a number of measures is close to the reference measure, but wide variation between measures exists.

2. Principle

The standardization test consists of repeating a measure twice on 10 different children, with a time interval between measures on the same child. The amplitude of the variation between repeated measures is calculated to assess precision, and the mean measure is calculated to assess accuracy. Each enumerator is then given some sort of a score of competence in performing measures. Misunderstanding and measuring errors can then be corrected during the training process.

3. Practical organization of the test

The test is carried out during the training process. Ten children aged 6 to 59 months are gathered in a room where the test will be performed. For example, if the measure of height/length is assessed, each enumerator performs the measure and records it for each child on a form. A second series of measures is performed and the enumerators once again record their measures, but on a different form. The supervisor performs the measure as well in order to obtain the reference measures, assuming he is the most precise and accurate measurer available.

4. Analysis

For each enumerator and for the supervisor, the following steps are followed:

Step 1: results of the two measures for each child are entered in column a and b. In order to facilitate the calculations, the height and mid - upper arm circumference are entered in millimeters and the weight in 100 grams.

Step 2: column d is the difference between the two measures: d = a - b.

Step 3: in the column labelled d^2 the value of d is squared: d^2 = (a - b)^2.

Step 4: in the column labelled <<sign>>, the number of occurrence of the most frequent sign in column <<d>> is entered. For example 7 is entered if there are 7 + signs and 3 - signs.

Step 5: column <<s>> is the sum of column a + column b: s = a + b.

These first 5 steps are common to the supervisor and the enumerators. The following 4 steps are only carried out for the enumerators since the test is meant to compare measures of the enumerators to those of the supervisor.

FIGURE

Step 6: the column S of the supervisor is added to each of the enumerator's forms.

Step 7: the difference between the s of the enumerators and the S of the supervisor is entered in column D.

Step 8: this difference is squared and entered in the column labelled D^2. D^2 = (s - S)^2.

Step 9: the greatest number of identical signs (+ or - but the largest) is entered in the column labelled sign.

FIGURE

5. Interpretation

A summary form is established. In this form, the sum of the column d^2 and D^2 is calculated: sum(d^2) and sum(D^2).

sum(d^2) reflects the precision. It represents the sum of the squares of difference between 2 measures on the same child. The acceptable value for the sum(d^2) of an enumerator is equal to twice the value of the sum(d^2) of the supervisor. The sum(d^2) of the supervisor is not zero. One component of the lack of precision is related to the equipment used to perform the measures, and that is why the reference value is calculated from the <<performance>> of the supervisor.

sum(D^2) measures the accuracy. It is the sum of the squares of difference between the sum of the 2 measures on the same child between the supervisor and the enumerator. The acceptable value for the sum(D^2) is fixed at three times the sum(d^2) of the supervisor.

Analysis of the signs allows us to assess whether the lack of precision or accuracy is always in the same direction. For example, an enumerator overestimating the height of a child will have most of the signs for precision as positive (i.e. case of the enumerator No 5 in our example). Such a systematic error can be quantified. Its value is sum(/20) (2 times 10 measures = 20 measures), being 8.9 millimeters in our example.

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Annex 12: Data collection forms

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SURVEYOR MANUAL

An individual data form is filled in for each child surveyed. When a cluster has been completed, and before leaving the section, the supervisor and the enumerators fill in the cluster data form. At this stage it is still possible to correct any mistakes and check validity criteria. Any mistake should be corrected by going back to the child.

The cluster data form is attached to the surveyor manual, on which all questions to be asked are written in the local tongue. Such a manual can be designed for systematic sample surveys as well.

HOW TO FILL IN THE CLUSTER DATA FORM

A sheet mentioning all instructions is attached to the cluster data form. It is the reference for the enumerators when performing the measurements in the field.

· Cluster number / Allege / section

A list of all the clusters with their names and numbers is distributed. This cluster number is the one entered on the collecting form.

· Date of the survey

The date of the day when the data was collected is recorded.

· First birth date induded in the survey

This box is filled in on the day of the survey by the team supervisor. This date is the date of the day after the survey, but 5 years before. For a survey taking place on the 30/01/1991, the first birth date for inclusion in the survey is the 31/01/1986.

· Last birth date of inclusion in the survey

This date is the date of the survey minus 6 months. For example if the survey takes place on the 30/01/1991, the last birth date of inclusion in the survey will be the 30/07/1990.

· Birth date before which children are measured standing

This is the date of the survey minus two years. For a survey taking place on the 30/01/1991, the first birth date before which children should be measured standing would be the 30/01/1989.

Annex 13: W/H Reference tables

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Annex 14: Selection of food items for selective feeding programmes

There might be a need to purchase food items from own funds. If time allows it,
consult head quarters and ask for a quotation. If buying locally, be prepared to check on quality specifications.

1. Blended foods Check for:

- nutritional value (energy minimum 350 Kcal/100g; fat min. 20% of energy, protein around 15g per 100g, micronutrients)
- bacterial safety and hygiene;
- necessary cooking time (pre - cooked or not) and other utilization information;
- shelf - life/Expiry date;
- packaging and labelling.

The digestibility, taste, energy density and the shelf - life will depend on the heat treatment type that has been used; extrusion cooking is to be preferred over roasting.

Food items for feeding programmes have to fulfil certain specific criteria. One should not accept food donations indiscriminately. The use of poor quality or inappropriate food stuffs for the treatment of acutely malnourished children and/or adults can be dangerous.

Dependency on several donors might result in the supply/use of a variety of food items over time. This can be very confusing for the staff or mothers, who have to change recipes and to adapt to new diet. Try to classify these different items in similar categories. Take into account: energy density (Kcal/100g), fat and protein content, palatability and acceptability, digestibility.

2. Dried Milk: quality control

Check for:

a. Consistency: if the milk powder forms lumps, the humidity is too high and storage conditions must be checked. We can not be sure that the milk powder has not developed bacterial or fungal infection. The milk powder may no longer be safe and it may be necessary to discard it.

b. Colour: Dried milk is normally light yellow. If it is brownish, there has been a chemical reaction of the sugar and protein. The milk powder must be discarded, because the quality of the protein has been affected.

c. Smell: If the milk smells rancid, the milk must be discarded.

Dried Skimmed milk is preferred over full milk; the higher fat content of full milk makes it less digestible, can provoke diarrhoea, and its shelf - life is limited.

Dried Skim Milk should be fortified with vitamin A (5,000 to 10,000 IU/100g and, D3, 500 to 1,000 IU /100g). If it is not indicated on the bag, consider the milk powder not fortified. Furthermore, the vitamin A is broken down on storage: after 6 months, vitamin A content can be considered negligible. In these cases milk powder can only be used in combination with prophylactic vitamin A distributions.

Policy of the UNHCR related to the acceptance, distribution and use of milk products in feeding programmes iN refugees settings

1. UNHCR will accept, supply and distribute donations of milk products only if they can be used under strict control and in hygienic conditions, e.g. in a supervised environment for on - the - spot consumption.

2. UNHCR will accept, supply and distribute milk products only when received in a dry form. UNHCR will not accept liquid or semi - liquid products including evaporated or condensed milk.

3. UNHCR will accept, supply and distribute dried skim milk (DSM) only if it has been fortified with vitamin A.

4. UNHCR supports the principle that in general ration programmes protein sources such as pulses, meat or fish are preferred to dried skim milk. UNHCR notes that DSM pre - mixed centrally with cereal flour and sugar is useful for feeding young children especially if prepared with oil.

5. UNHCR will advocate the distribution of dried skimmed milk in a take - away form, only if it has been previously mixed with a suitable cereal flour, and only when culturally acceptable. The sole exception to this may be where milk forms an essential part of the traditional diet (e.g. nomadic population) and can be used safely.

6. UNHCR will support the policy of the World Health Organization concerning safe and appropriate infant and young child feeding, in particular by protecting, promoting and supporting breast - feeding and encouraging the timely and correct use of complementary foods in refugee settings.

7. UNHCR will discourage the distribution and use of breast - milk substitutes in refugee settings. When such substitutes are absolutely necessary, they will be provided together with clear instructions for safe mixing, and for feeding with a cup and a spoon.

8. UNHCR will take all possible steps to actively discourage the distribution and use of infant - feeding bottles and artificial teats in refugee settings.

9. UNHCR will advocate that when donations of DSM are supplied to refugee programmes, the specific donors will be approached for cash contributions to be specially earmarked for operational costs of projects to ensure the safe use of this commodity.

Paper prepared by UNHCR, 17/8/93: Programme coordination and Budget section, Food and Statistical Unit.

Annex 15: Oral rehydration for severely malnourished children

Normal ORS treatment, as recommended by the WHO, should be used for the treatment of dehydration in mildly and moderately malnourished children. Severely malnourished children suffer from an imbalance of electrolytes that makes the use of normal ORS dangerous for treating dehydrated children with severe malnutrition, except from when they suffer from cholera or severe diarrhoea when normal ORS should also be used.

In the treatment of dehydration for severely malnourished children, it is necessary to reduce the sodium content of the traditional ORS formula and increase the potassium content.

Special ORS sachets are currently available (from Nutriset) for the treatment of dehydration in severely malnourished children. These sachets have a re - adjusted formula. If the special ORS sachets are not available in the field it is necessary to dilute normal ORS to half strength and add 25g of sugar per litre and 2g of potassium (KCl) per litre.

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Unlike the use of normal ORS, we do not give a malnourished child a large initial dose of ORS to begin treatment, as this can overload the circulatory system. Thus, we give the required amount (5 - 15 ml/Kg/hour) slowly over the whole treatment period until signs of dehydration have disappeared.

Only treat dehydration intravenously in cases of severe shock and with great caution.

Annex 16a: Preparation of High Energy Milk

High energy milk is prepared in order to provide 100 Kcal/100 ml with 2.8g of protein/100 ml.

Average ration per child per day:1.8 litre of HEM.

1. Recipe based on DSM (Dried Skimmed Milk)

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The premix (milk powder, sugar and oil) should be prepared in advance. Always weigh the ingredients, do not use quantities measured by volume. The premix can be kept for about one week, provided that it is stored in a dry place.

The milk should be made up just before distribution. The water used should be boiled cold water. Once made up, the high energy milk should not be kept for more than 2 hours and should be protected from flies.

Annex 16b: Recipes for porridge for use in therapeutic and wet supplementary feeding programmes

The porridge can be prepared for children in Therapeutic feeding as well for children in wet Supplementary feeding centres.

Usually, a porridge will provide around 150 Kcal/100 ml and around 4g of protein/100 ml.

1. Recipe one: Maize flour + DSM based porridge

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PREPARATION:

Always prepare a sample and taste the porridge before distribution. The porridge should be semi - liquid.
Generally the preparation is:

Add 1 volume of premix to 2 - 3 volumes of water
Boil for 10 - 15 minutes
Cooked porridge should not be kept for more than 2 hours.

Annex 16c: Recipes for premix for dry ration supplementary feeding programmes

Each ration should provide at least 1000 Kcal per child per day and 30 - 45g of protein.

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The premix should be prepared before distribution. Always prepare a sample and taste the porridge before distribution. The porridge should be semi - liquid when prepared.

The premix can be kept at home for about one week, it is recommended to keep it covered and in a dry and clean place.

Preparation of dry rations at home:

- Add 1 volume of premix to 2 - 3 volumes of water.
- Boil for 10 - 15 minutes (more for receipes 3 and 4).

Cooked porridge should not be kept for more than 2 hours.

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Annex 17a:Example of a Therapeutic feeding centre

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Annex 17b: example of layouth of a <<wet>> supplementary feeding centre

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Annex 17c: Example of a DRY SFP

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Annex 18a: Example of an Attendance register (tfp or SFP)

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Annex 18b: Example of a Nutritional Status Monitoring (SFP)

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Annex 19a: TFP individual monitoring card

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Annex 19b: SFP individual monitoring card

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Annex 19c: Individual card for Supplementary feeding centre

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Annex 19d: Example of an individual card for dry blanket SFC

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Annex 20: Feeding programme indicator graphs

It is necessary to follow various indicators to allow an appreciation of how well the programme is functioning - Indicators can be graphed to help interpret trends and interpret different indicators together.

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It is very important to follow the percentages of discharge, defaulting and death. These three indicators can be graphed together to help interpret the three indicators together and see if the programme is improving or if extra effort is required.

Figure 20a shows an example from a TFP. At the start of the programme, there are very few recoveries as it takes some time to rehabilitate severely malnourished children. Consequently, the proportion of children defaulting and dying is high.

As the programme proceeds, the proportion of children recovering improves as more children are rehabilitated and as the management of the programme improves.

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This graph should be interpreted with an appreciation of the absolute numbers.

Figure 20b shows a graph with the total number of admissions and exits. It shows how, at the beginning, there is a high rate of admissions and low numbers of exits. Over the course of the programme, admissions decrease and the numbers exiting increase.

CHECK LIST FOR FEEDING CENTRES

CAMP: NAME OF THE SUPERVISOR.

I. STAFF

1) Clear job description for each member of the staff
2) Appropriate number of staff (*)
3) A training course has been organized for the staff
4) The planning of the training is respected

II. FEEDING CENTRE STRUCTURE

1) Sufficient space for the present children
2) The different phases of the centre are separated
3) Appropriate number of latrines (*)
4) Appropriate number of showers (*)

III. FUNCTIONING

· Admission (supervisor or assistant)

1) Explanations given to the mother at child's admission
2) The mother receives blankets, matting, a cup, a chamber pot, soap, etc..., for her installation
3) Criteria for admission respected
4) Medical checking on the day of the admission
5) Good transcription of medical checking on child's record
6) Measles vaccination checked and updated on the record
7) Adequate diet prescribed
8) Diet written down on child's record
9) Systematic treatments correctly prescribed and given

· Surveillance

1) Weight correctly checked
2) Weight regularly checked (*)
3) Weight graph correctly rayed out
4) Daily check-up of children in Phase I
5) Good medical reference system
6) ORS is available and given if necessary
7) Correct medication (hour, prescription respected)
8) Prescribed diets respect the protocol of dietetic care
9) Control by staff of good food intake
10) Duration of stay in Phase I is < 1 week
11) Follow-up of absent children (identification, report)
12) Problems are reported to supervisor (*)
13) Transmission book of staff daily updated

· Discharge

1) Discharge criteria respected
2) Measles immunization up - to - date
3) Transfer form correctly filled (*)

IV. DATA COLLECTION AND ANALYSIS

· Register book

1) Feeding Centre register book correctly filled

· Feeding Centre card

1) Feeding Centre cards correctly and fully filled

· Weekly statistics

1) Weekly summaries correctly filled
2) Graphs regularly done (semester, month)
3) Regular meetings with the Centre's staff
4) Active follow - up of defaulters

V. WATER - HYGIENE

1) Sufficient quantity of water/No of children (*)
2) Drinking water available (*)
3) Sufficient quantity of drinking water /each building
4) Feeding Centre's floor daily washed with chlorine
5) Latrines clean
6) Dustbin available

VI. KITCHEN

· Kitchen

1)The kitchen is big enough for the Centre's capacity
2) Adequate quantity of stoves / children admitted (*)
3) Absence of scraps on floor and shelves
4) Enough material (*)
5) Premix is stocked in a clean and dry place

· Dish washing area

1) Washing area is big enough
2) Washing is properly done (*)
3) The dishes are put away in a clean place

VII. STORAGE

1) Store is big enough
2) Store is in good condition and the aeration is good
3) The damaged goods are stocked apart
The goods stocking respects the following rules:
4) Store is clean
5) The rotation rules of the stocks are respected
6) In and out stock properly recorded
7) The expiration dates of the goods are controlled

VII. OTHER POINTS
1) Mothers participate in the Centre's running
2) Health meetings are organized in the Centre

Annex 22: MSF nutrition kits

The MSF Nutrition kit was designed to contain all the elements necessary to start a feeding programme quickly. Many of the materials should be available locally and so if there is time it is often preferable to chose your own materials.

The kit lists are also useful for helping decide what you need to run a nutrition programme.

The kits are arranged in modules for different components of a nutrition programme. The kit lists are being updated. Refer to the MSF kit guide for latest kit specifications. MODULE 1: Nutrition Surveys/Surveillance

MODULE 1 and 2: Screening and Registration to Nutrition Programmes

MODULE 3: Therapeutic Feeding Programmes for 100 Children

MODULE 4: Supplementary Feeding Programmes for 250 Children

All modules will contain the MSF nutrition guidelines - other nutrition books are available through headquarters.

MODULE 1 Nutrition surveys/Screening

1 Salter scales (25 kg) and hanging pants
50 MUAC armbands
4 Clipboards - folding double for protection of sheets
4 Exercise books (notebooks)
8 Pens
8 Pencils
4 Rubbers
4 Sharpeners
4 Rulers
4 Indelible marker pens (permanent markers)
4 Scissors
1 Calculator - solar
4 Plasticized W/H tables - in Z-Scores and % of the median
1 Height boards - MSF plastic or wooden pieces for field construction = to be reviewed.
2 Rolls of OXFAM sticky measuring tape
4 Nylon light weight backpacks
1 Set of instructions for training survey staff
1 Roll of strong nylon rope (15m)
1 MSF nutrition guidelines
1 Manual counter
1 Expatriate nutritionist
1 Standard 1 kg weights (to check scales)

* Extra salter scale and height board could be ordered separately.

MODULE 2 Registration (to be used in conjunction with Module 1 for screening and registering for nutrition programmes - 350 people)

400 I.D. Bracelets - clear + red popper
1000 I.D. bracelets - clear + green popper
4 Register books - hard back A4
400 MSF individual monitoring cards - TFP
1000 MSF individual monitoring cards - wet SFP
4 Card boxes - plastic (size for card A4)
2 Pocket calculator - solar
10 Indelible marker pens
10 Pens
10 Pencils
10 Rubbers
10 Pencil sharpeners
10 Rulers
4 Plasticized W/H tables - in Z-Scores and % of the median
1 Graph paper (packet)

MODULE 3 Therapeutic feeding kit (100 children)

1 100 litres cooking pot with lid
2 50L cooking pots with lids
2 Wooden paddles
120 Mastic cups - 400 ml
120 Plastic bowls
10 Metal teaspoons
500 Mastic teaspoons
4 Measuring jugs - 1 litre
4 Scoops marked for sugar, oil, cam, etc.
4 Ladles - 250 ml capacity
4 Whisks
2 Tin openers
1 Salter scale (25 Kg) and weighing pants
1 Salter scale (50 Kg)
4 Measuring spoons calibrated for measuring 2g and 10g of Potassium chloride
2 Alarm clocks + batteries
4 Scrubbing brushes - floor
4 Scrubbing brushes - pots/pans
4 Plastic water containers (20L)
12 Plastic buckets + lids (10L)
6 Torches + batteries
5 Indelible marker pens
25 Plastic potties
4 Large food mixing bowls/washing up bowls - wide rimmed
1 Adult bathroom scale

500 Water purifying tablets (chloramine)
10 Bars of soap
4 Clipboards
30 Candles + matches
30 Naso - gastric tubes (CH No. 8 Luer)
30 Naso - gastric tubes (CH No. 10 Luer)
60 Syringe (60ml Luer)
1 Pestle and mortar
200 Milk cards
1 MSP nutrition guidelines
5 Syringe of 20ml (Luer)
2 Water filter

MODULE 4 Supplementary feeding kit (250 children)*

1 Cooking pot - 100L
2 Cooking pot - 50L
3 Wooden Paddles
500 Plastic cups - 400 ml
500 Plastic bowls

500 Plastic teaspoons
10 Metal spoons
4 Scoops
4 Measuring jugs (5L)
1 Measuring jug (1L)
6 Ladles (250 ml)
3 Wisks
2 Tin openers
4 Scrubbing brushes - floor
4 Scrubbing brushes - pots/pans
10 Graduate plastic buckets + lids
8 Plastic water containers (201)
500 Water purifying tabs
2 Alarm clocks + batteries
1 Salter scale (50 kg)
1 Salter scale (25 Kg) and weighing pants
1 Measuring spoon calibrated for 2g and 10g of Potassium chloride
5 Indelible marker pens
4 Large food mixing bowls
20 Bars of soap
1 MSF nutrition guidelines

* This Module is designed for wet supplementary feeding - it can be used for dry supplementary feeding programmes as well but there will be a lot of wasted material. It is advised that dry supplementary feeding programme materials be purchased locally.

Instructions for the construction of a height measuring board

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The board should be made of strong, but light wood (1 - 2 cm thick). Wood should be polished to avoid splinters and pieces should be fixed together with screws rather than nails.

Measuring tape should be fixed down either side of the board to make reading the measurement easier when the child stands along the middle of the board.

The tape should be fixed in place by the supervisor of the survey and should be fixed along a ruled line to ensure it is straight and not at an angle. We preferably use OXFAM sticky measuring tape which is designed to minimize errors in reading the measurement. Do not stretch the tape when securing it to the board and make sure that the tape starts at zero at the bottom of the board, flush with the foot piece.

65 cm should be clearly marked children below this should not be measured (too young) unless their age is known.

85 cm should be clearly marked children below this should be measured lying down unless their age is known.

110 cm should be clearly marked children above this should not be measured (too old) unless their age is known.

The sliding head board should be made so that it slides easily up and down the board.

The head piece sides should overlap the height board so that they guide the headpiece up and down the board and minimize sideways movement but the fit should not be so tight that it is difficult to slide the head piece.