Welcome!Emergency nutrition continues to be an important focus of WV’s nutrition programming, particularly the implementation of Community-based Management of Acute Malnutrition (CMAM formally known as CTC) for children with severe acute malnutrition. As another year begins, we hope these Emergency Nutrition Updates (ENU) will help provide you with helpful and exciting information covering:

• tools, guidelines, and recommendations • latest research • upcoming events• staff updates • news from the field - an opportunity for you to share

challenges and successes faced in implementing emergency nutrition

ENUEMERGENCY NUTRITION UPDATE

ONE STEP AT A TIMEThe past 18 months has been a busy one in WV with both the establishment of the Global Health Centre (GHC) as well as the Nutrition Centre of Expertise (NCoE), which sits within the GHC. A key focus for the NCoE is emergency nutrition, particularly coordinating capacity building. Key capacity building achievements in the past 18 months has included:

1. Capacity built in CMAM• Capacity building and program implementation in Niger, Ethiopia,

Southern Sudan, Kenya, and • Somalia. • Increased capacity of 25 technical nutrition/health staff and 4

community mobilisation facilitators• Two Africa regional CMAM staff employed• WV CMAM Conference in Canada attended by 70, provided a

comprehensive overview of CMAM programming and identified steps for continued institutionalization of CMAM in the WV context

2. Policy guidance provided• WVI Milk policy reviewed and updated in view of recent

developments in infant feeding, particularly around HIV and breastfeeding.

3. External partnerships developed and strengthened• Near completion of the first phase of a CMAM Institutional

Capacity Building Agreement between WV and Valid International & development of a Phase 2, three year MOU with Valid International.

• Active participation in IASC Global Nutrition Cluster capacity development working group and nutrition in emergencies WG of the United Nations System Standing Committee on Nutrition (SCN)

In FY09 the GHC/NCoE’s key objectives will be; 1. Strengthen and expand CMAM capacity2. Build WV capacity for improved Infant and Young Child Feeding in

Emergencies 3. Provide technical guidance on latest developments in emergency

nutrition

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World Vision’s Milk Policy

DO YOU KNOW WV’S POSITION? WV strongly advocates for breastfeeding however there are exceptional circumstances where breast milk substitutes (BMS) may be needed. WV’s Milk Policy governs the procurement and use of milk products in WV field programs. To ensure you know what this important policy includes go to http://www.ennonline.net/pool/files/ife/wv-milk-policy-revised-july-25-final.pdf

NEW!!! EMERGENCY NUTRITION ONLINE NETWORKThe Emergency Nutrition Network with funds from USAID have recently established an online network forum for nutrition staff to interact and discuss key technical issues. For more information go to http://www.en-net.org.uk/

JANUARY– MARCH 2009 ISSUE 1

In 2006 WHO released new nutrition growth reference standards, replacing the 1979 NCHS/WHO standards.

Key advantage – new standards are able to identify children at higher risk of dying from SAM at an earlier stage, making them easier to treat at a lower individual cost.

Key challenge – the new cutoffs tend to identify approximately 4 times more children as severely malnourished meaning additional resources are neededThe Inter-Agency Standing Committee of Nutrition has recently released a factsheet to assist staff to transition from NCHS to new WHO standards. The below summarizes some of the key recommendations:

For estimating prevalence of acute malnutrition in surveys: • Survey reports should be reported using

both the NCHS reference and the WHO standards until the WHO standards have been fully adopted.

• Include MUAC measurement in surveys for estimating case load as MUAC is considered an independent criterion of admission to therapeutic feeding programme for infants and children over six months of age.

• Use a combination of children meeting the criteria of MUAC, weight-for-height and oedema for estimating the number of children that would require treatment.

For feeding programs:• Continue using the NCHS reference until

further guidance. Note: In countries/locations where agencies agree to use 2006 WHO criteria for program admission and discharge, WV should use what is agreed among agencies in order to promote consistency and smooth referral between programs. In such situations, NO’s should contact WVI Nutrition contacts before making commitment in order to ensure any training needs are met.

Note: Most statistical software can analyse data using both NCHS and the new WHO standard eg:

• ENA (Emergency Nutrition Assessment) software for SMART : http://www.nutrisurvey.de/ena/ena.html

• WHO Anthro: http://www.who.int/childgrowth/software/en

The full fact sheet ‘WHO Growth Standards in Emergencies’, including links to additional software can be found at: http://www.humanitarianreform.org/humanitarianreform/Default.aspx?tabid=157

Important Changes to Nutrition Growth Standards

........................................................TOOLS, GUIDELINES & RECOMMENDATIONS

NEWS FROM THE FIELD

Key Background:• Nutritional impacts of the high cost of food

caused by the recent global food crisis is significant for the most vulnerable (children, pregnant and lactating women)

• Nutritional assessment conducted by WV national offices in 2008 indicated increased prevalence of acute malnutrition in many ADPs.

• In some ADPs prevalence of acute malnutrition were above 15% (the cut off point for classifying a situation critical).

• Severe acute malnutrition is a medical emergency and the risk of mortality is high for children suffering from severe acute malnutrition unless treatment is provided early.

CMAM Prioritized:• As a result of this, the global and Africa

health and nutrition teams prioritized a number of National Offices and ADPs in

Africa for emergency nutrition intervention using the Community-based Management of Acute Malnutrition (CMAM) programming model.

• CMAM programming is the main tangible activity that shows WV’s responsiveness to the food crisis

• CMAM model was chosen to reach the maximum number of children with acute malnutrition and ensure access and coverage by providing treatment at many decentralized sites.

CMAM funding status:• 8 national offices in Africa, and 1

(WV Haiti) in LACRO are currently implementing CMAM

• In addition, 4 national offices in Africa plan to start CMAM in FY09

• In total, the FY09 total budget for CMAM program stands at $18.1 million

• $12.9 Million is being invested on CMAM programs in FY09

• Of this 71% of the needs are already funded and most projects are up and running

• 29% of the funding needs still remain unmet• The gap in funding will have significant

impacts in the survival of children

Note about CMAM funding and additional activities:• CMAM encompasses more than just the

cash contributions from WV • WV works with UNICEF and WFP

in country to provide the RUTF and supplementary food. The costs can actually be much higher than what is being asked; the above funding status reflects a bare minimum and it could be double this amount if we did not have these engagements.

• Engagement with FPMG and HEA to seek out funding opportunities with WFP for supplementary feeding component of CMAM

• Engagements with UNICEF supply chain division in Copenhagen and their regional office for Eastern and Southern Africa to develop a potential partnership for RUTF supply.

o NB: UNICEF prefers that partnership arrangement for RUTF supply be made at country level between WV and UNICEF country offices. To this end, WV National Offices have been advised to engage with UNICEF country offices on this issue. So far, WV South Sudan, DRC, Kenya have formalized agreement with UNICEF at country level

• Plans underway to buy buffer stock (25% of a project’s RUTF needs) through the global supply management team

• The food crisis M&E coordination (under the leadership of Jamo Huddle) is also looking at improving the collection and analysis of data on nutrition and food security indicators

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Global Food Crisis Response: CMAM UpdateSubmitted by Mesfin Teklu (WV GHC Emergency Health Technical Director)

Malnutrition in South Sudan remains rampant and continues to kill children unnecessarily. While Ready to Use Therapeutic Foods (RUTF) such as Plumpynut have been found to be very effective in treating severe acute malnutrition, the majority of RUTF is imported from overseas and thus only limited programs are able to afford and provide.

Local production of RUTF has been trialed in a number of countries through franchise arrangements but ultimately these need some NGOs etc buying the product for final free distribution to the beneficiaries.

Given the challenges of cost and sustainability, there is a need to explore opportunities for utilization of local and in some cases naturally occurring uncultivated foods that are familiar to the affected communities. The use of these easily available resources has the potential to stimulate indigenous knowledge and practices and help empower communities to address acute malnutrition. One idea is the use of peanuts and oil from the Lulu tree (very common in lakes state and parts of Warrap state) to contribute to the production of RUTF. Indigenous knowledge of the tree already exists and with initial resources for training the community on food hygiene, preparation, storage, quality control and administration amongst other things there is real opportunity for local development.

Some key challenges to consider would be ensuring the amount of ingredients which would need to come out of the production area as well as enabling access to these products for those who are most affected.

It’s hoped that such a venture targeting households could contribute health benefits and returns to households through the treatment of their malnourished children and consequently raise the potential for increased production. This in the long term goes

along way to increasing the human productivity in south Sudan through reduced child mortality and morbidity.

Note: The above article is a contribution from a WV South Sudan staff member and does not necessarily constitute the views of the WV Nutrition CoE. It is important to note that local production requires careful planning and consideration, as not all local products are appropriate for treatment of acute malnutrition.

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A CMAM Snapshot - South SudanSubmitted by Cyprian Ouma (WV Africa CMAM Regional Advisor)

WV Rwanda’s Collaboration in Food Security and Nutrition SurveySubmitted by Olufemi Owoeye (WVR National Health Co-ordinator)

WV Rwanda’s Collaboration in Food Security and Nutrition SurveySubmitted by Olufemi Owoeye (WVR National Health Co-ordinator) WVR is happy to announce that the Rwanda Comprehensive Food Security & Vulnerability Assessment and Nutrition Survey (2009 CFSVA & Nutrition Survey) is currently being undertaken and results of the survey will be out by the end of March 2009. UNICEF, WFP, WVR and the National Institute of Statistics are jointly conducting the survey with WVR contributing $25,000 in funds (provided by WV Canada) to the surveys total budget of $495,000, as well as personnel. It is hoped this survey will help determine the status of acute malnutrition in the country, determine whether CMAM programming is needed and if so, advocate for support.

NEWS FROM THE FIELD

WFP and World Vision have recently developed a new field level agreement (FLA) for the supply of supplementary

food for CMAM, with food now delivered and pre-positioned in the Satellite stores for distribution. The month of February

had a recovery rate of 92.8 %( 153) and 4.6% (7) defaulted. In the same month, 223 children were admitted in the OTP.

This high recovery was attributed to the constant supply of Plumpynut and

follow-ups of children in the program by the CHW and Nutrition assistants. Many children were reported during the weekly follow-ups to be suffering from diarrhoea. Health education has been intensified by the CHWs. A nutrition survey is planned

for May 2009.

(STOMS) Sustainable Treatment of Malnutrition in Sudan Submitted by Cyprian Ouma (WV Africa CMAM Regional Advisor)

Where in the WV world is CMAM?

Countries currently programming CMAM

Ethiopia, Kenya, Niger, Somalia, North Sudan,

South Sudan, Zimbabwe, DRC

Countries planning to commence CMAM in FY09Angola, Zambia, Mauritania

and Burundi

STAFF MEMBER POSITION LEVEL

Sarah CarrNCoE Emergency NutritionistIncl Global Co-ordination of CMAM including Valid

Global

Kaitrin BothNCoE Emergency NutritionistIncl CMAM Communications and Operational Research

Global

Mesfin TekluGHC, Emergency Health Technical DirectorIncl coordination of HEA and Global Health Team on emergency nutrition

Global

Claire BeckGRRT – Health & Nutrition SpecialistIncl available for deployment

Global

Anne-Marie Connor French-speaking Community Mobilization Advisor based at WVC – Incl available for deployment Global

Mariana Stephens FPMG Nutrition Specialist Global

Sisay SinamoAfrica Regional Nutrition AdvisorIncl coordination of Africa Regional CMAM Project

Regional

Cyprian OumaAfrica CMAM Regional Advisor Incl available for deployment

Regional

Brenda AkwaniAfrica CMAM Regional AdvisorIncl available for deployment Regional

Esther Indiani Asia Sub-regional MCH & Nutrition Specialist Regional

Naureen M Butt MEER Regional Nutrition Coordinator Regional

For questions or contributions to the WV ENU, please contact the WV Nutrition Centre of Expertise nutrition_coe@wvi.org NCOE is hosted by WVCanada.

Global Health & Nutrition

Nutrition Centre of Expertise

Key Emergency Nutrition Contacts at Global and Regional Level

........................................................STAFF UPDATES

In April 2008, WV participated in the International Workshop on the Integration of CMAM in Washington, DC. The acceptance of WV Niger’s abstract allowed both San San Dimanche, WV National Nutrition & Health Coordinator and the Niger Ministry of Health’s Nutritionist to present on their experiences related to MOH integration, scaling up and their respective analysis of promising practices.

To see the presentations and learn more about what others are doing in this important area go to http://www.fantaproject.org/publications/ENN_CMAM08.shtml

Recent Research Cost Effectiveness of CMAM in ZambiaWhile children under 5 years of age with SAM have high mortality rates in Asia and Africa, and primary care based treatment of SAM has shown good outcomes, the cost-effectiveness of this approach has been largely unknown. A recent study aimed to determine cost-effectiveness by estimating the cost-effectiveness of CMAM for children with SAM in government primary health care centres in Lusaka Zambia compared to no treatment. The study found that CMAM was at least 80% likely to be cost-effective if society was willing to pay at least $88 per DALY gained. This was deemed possible in Zambia where the gross national income per person per year is $1,000 (2006). The study concluded that CMAM is relatively cost effective compared to other priority health care interventions in developing countries such as immunization, micornutritient supplementation and treatment of pneumonia and diarrhea. To read more go tohttp://www.resource-allocation.com/content/7/1/2

Could This Be You?

........................................................RESEARCH & GLOBAL PARTICIPATION