National Guideline

For
Emergency Nutrition Intervention

Ethiopian Public Health Institute

May 2022, Addis Ababa, Ethiopia
Acknowledgements
This national guideline for emergency nutrition intervention has been prepared with the active
participation of nutrition experts from several organisations, regions, institutions, and agencies in the
country.

The Ethiopian Public Health Institute greatly appreciates Mr Biruk Tadesse (Senior Nutrition Expert) for
leading and coordinating the entire process of this guideline development and finalisation.

The development of this guidelines was carried out under the auspices of the Ethiopian Public Health
Institute. In this regard, the support extended by Mr Mesfin Wossen (Director of Diseases and Health Events
Surveillance and Response Directorate) is gratefully acknowledged.

Special appreciation and thanks go to the following individuals, who have provided significant support and
contributions relevant to the development of this document:

1. Biruk Tadesse (EPHI) 11. Miraf Tesfaye (MOH)

2. Dessalegn Geleta (EPHI) 12. Cecile Basquine (UNICEF)
3. Mekonnen Balcha (EDRMC) 13. Muzemil Muktar (WFP)
4. Dr Betty Lanyero (WHO) 14. Hanna Mekonnen (EPHI)
5. Emana Alemu (EPHI) 15. Dr Ayana Yeneabat (BRE-OPM)
6. Yoseph Teklu (UNICEF) 16. Ann Bush (OPM)
7. Rashid Abdulai (UNICEF) 17. Mark Essex (BRE-OPM)
8. Habtamu Ayigegn (EPHI) 18. Prof Tefera Belachew (BRE- OPM)
9. Yibeyin Mulualem (EPHI) 19. Bella Roman (BRE-OPM)
10. Shiberu Kelbesa (MOH) 20. Dr Abraham Alano (BRE-OPM)

Finally, we would like to extend our deepest appreciation to the Building Resilience in Ethiopia (BRE)
programme for the technical and logistics contributions. BRE-TA is jointly implemented by the Federal
Ministry of Health (MoH); the Ethiopian Public Health Institute (EPHI) and Oxford Policy Management
(OPM) with funding from the Foreign; Commonwealth & Development Office (FCDO) of the United
Kingdom and United States Agency for International Development (USAID). We look forward to BRE-
TA and other partners continued collaboration in the implementation of the guidelines.

I
Foreword
The Ethiopian Public Health Institute (EPHI) is working as a technical arm of the Ministry of Health to
deliver comprehensive health emergency management in the country. This guideline is primarily intended
for stakeholders involved in emergency nutrition intervention at the woreda, zonal, regional, and federal
levels. It also provides health workers, nutritionists, and humanitarian actors with the enhanced skills and
knowledge needed to address the specific challenges encountered during emergency nutrition response.

Addressing malnutrition requires complementary multisectoral strategies and approaches that respond both
to long-term development challenges and to immediate needs, linked to the survival and wellbeing of
families and communities. Natural and man-made disasters can destroy lives and livelihoods and wipe out
years of development gains in a matter of hours or even seconds. When the resilience of families degrades
in emergency situations, so does their nutritional status.

It is our profound hope that the guidance and operational recommendations provided here can contribute to
a decisive shift from reactive emergency response to proactive anticipative risk reduction and management,
resulting in better health and nutrition outcomes for the population.

While EPHI acknowledges that technical knowledge and expertise continue to evolve in the area of
emergency nutrition interventions through time, the effective use of this guideline will mark an important
milestone. In this regard, EPHI calls upon all stakeholders to work together for the purpose of further
improvements on emergency nutrition interventions.

Aschalew Abayneh
Deputy Director General
Ethiopian Public Health Institute

II
Table of contents

Acknowledgements ........................................................................................................................................ I
Foreword ....................................................................................................................................................... II
Table of contents .......................................................................................................................................... III
List of tables and figures ............................................................................................................................... V
List of abbreviations .................................................................................................................................... VI
Definitions of terms .................................................................................................................................... VII
1. INTRODUCTION ................................................................................................................................ 1
1.1 Overview of nutrition in emergencies ................................................................................................. 1
1.2 Rationale ............................................................................................................................................. 4
1.3 Purpose and scope of the guidelines ................................................................................................... 4
1.4 Users of the guidelines ........................................................................................................................ 4
2. NUTRITIONAL PREPAREDNESS .................................................................................................... 6
2.1 Planning for identified risks and hazards ............................................................................................ 8
2.2 Coordination and collaboration........................................................................................................... 9
2.3 Capacity development ....................................................................................................................... 11
2.4 Surge capacity ................................................................................................................................... 11
2.5 Resource mobilisation ....................................................................................................................... 12
2.6 Logistics management ...................................................................................................................... 12
3. NUTRITIONAL ASSESSMENT AND SURVEILLANCE .............................................................. 13
3.1 Nutrition surveillance........................................................................................................................ 13
3.2 Nutrition assessments in an emergency ............................................................................................ 14
3.3 Early warning .................................................................................................................................... 16
4. EMERGENCY FOOD AID AND NUTRITION RESPONSES ........................................................ 20
4.1 General Food Ration ......................................................................................................................... 20
4.2 Prevention and treatment of MAM ................................................................................................... 22
4.3 Prevention and treatment of SAM .................................................................................................... 26
4.4 Infant and Young Child Feeding in Emergencies ............................................................................. 28
4.5 Prevention and control of micronutrient deficiencies during an emergency..................................... 31
4.6 Disease-related undernutrition .......................................................................................................... 33
4.7 Food safety during emergencies ....................................................................................................... 34

III
 4.8 Psychosocial considerations during emergency nutrition response .................................................. 36
5. SUPPLY MANAGEMENT IN EMERGENCIES .............................................................................. 38
6. MONITORING AND EVALUATION .............................................................................................. 42
6.1. Monitoring GFD .............................................................................................................................. 42
6.2. Monitoring interventions for the treatment of MAM ....................................................................... 43
6.3. Monitoring interventions for the treatment of SAM ........................................................................ 44
6.4 Monitoring IYCF-E interventions..................................................................................................... 44
6.5 Monitoring micronutrient interventions ............................................................................................ 45
6.6. Monitoring performance indicators ................................................................................................. 46
REFERENCES ........................................................................................................................................... 49
8. ANNEXES .............................................................................................................................................. 51
Annex 1. Emergency treatment of SAM ................................................................................................. 51
Annex 2. Monthly nutritional screening reporting form for children aged 6–59 months old ................. 54
Annex 3. Monthly nutritional screening reporting form for PLW .......................................................... 55
Annex 4. Vitamin A supplementation and deworming reporting form for children aged 6–59 months 56
Annex 5. Essential commodities for the management of SAM and MAM ............................................ 57
Annex 6. The UNICEF conceptual framework for undernutrition ......................................................... 60
Annex 7. The IPC reference table ........................................................................................................... 61
Annex 8. Standards for population nutritional requirements – for planning purposes in the initial stages
of an emergency ...................................................................................................................................... 63
Annex 9. Bin Card .................................................................................................................................. 64

IV
List of tables and figures

Table 1. Nutrition surveillance benchmarks ............................................................................................... 18

Table 2. Summary of nutrition assessment tools during an emergency ...................................................... 16
Table 3. Emergency nutrition surveillance data inventory ......................................................................... 13
Table 4. Classification of situation severity based on the IPC classification .............................................. 19
Table 5. General Food Rations (grams) ...................................................................................................... 22
Table 6. When to open and close an SFP.................................................................................................... 25
Table 7. Supplementation to prevent vitamin A deficiency ........................................................................ 33
Table 8. Performance outcome indicators................................................................................................... 47
Table 9. Exit categories for therapeutic and supplementary feeding .......................................................... 47
Table 10. Summaries of indicators used for therapeutic feeding ................................................................ 48

Figure 1. Risk analysis and monitoring graph .............................................................................................. 8

Figure 2.The roles of different sector ministries under the coordination of DRMC ................................... 10
Figure 3. Programme recommendation for the prevention of acute malnutrition and treatment ................ 24

V
List of abbreviations
CMAM Community-based Management of Acute Malnutrition

EPHI Ethiopian Public Health Institute

GAM Global Acute Malnutrition

GFD General Food Distribution

IASC Inter-Agency Standing Committee

IDP Internally Displaced People

IYCF Infant and Young Child Feeding

KAP Knowledge Attitude and Practices

MAM Moderate Acute Malnutrition

MANTF Multi-Agency Nutrition Task Force

MDD Micronutrient Deficiency Disease

MND Micronutrient Deficiency

MoH Ministry of Health

MUAC Mid-Upper Arm Circumference

NGT Nasogastric Tube

OTP Outpatient Therapeutic Programme

PLW Pregnant and Lactating Women

RUTF Ready-to-Use Therapeutic Food

SAM Severe Acute Malnutrition

SBC Social and Behaviour Change

SFP Supplementary Feeding Programme

TFP Therapeutic Feeding Programme

UNICEF United Nations International Children’s Emergency Fund

WFP World Food Programme

WHO World Health Organization

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Definitions of terms

Term Definition

Acute Acute Malnutrition is a form of undernutrition. It is caused by a decrease in food consumption

Malnutrition and/or illness, resulting in bilateral pitting oedema or sudden weight loss. It is defined by the
presence of bilateral pitting oedema or wasting – a low Mid-Upper Arm Circumference or a
low Weight-For-Height.

Anthropometry Anthropometry is the study and technique of human body measurement. It is used to measure
and monitor the nutritional status of an individual or population group.

Blanket A Blanket Supplementary Feeding Programme is an intervention that aims to prevent Acute
Supplementary Malnutrition among a vulnerable group. A supplementary ration is provided for everyone in
Feeding an identified vulnerable group for a defined period. This might be all children aged 6–24
Programme months or aged 6–59 months, and/or all pregnant and lactating women, regardless of their
nutritional status.

Bilateral Bilateral pitting oedema, also known as kwashiorkor or oedematous malnutrition, is a sign of
pitting oedema Severe Acute Malnutrition. It is defined by bilateral pitting oedema of the feet and is verified
when thumb pressure applied to the top of both feet for three seconds leaves a pit (an
indentation) in the foot after the thumb is lifted. It is an abnormal infiltration and excess
accumulation of serous fluid in connective tissue or in a serous cavity.

Community- Community-Based Management of Acute Malnutrition refers to the management of Acute

Based Malnutrition through: i) inpatient care for 6–59-month-old Severe Acute Malnutrition children
Management of with medical complications and Severe Acute Malnutrition infants under 6 months
Acute with/without medical complications; ii) an outpatient therapeutic programme for 6–59-month-
Malnutrition old Severe Acute Malnutrition children without medical complications; iii) community
outreach; and iv) services or programmes for children aged 6–59 months of age and Pregnant
and Lactating Women with Moderate Acute Malnutrition.

Emergency or An emergency or humanitarian crisis is an event which critically threatens the health, safety,
humanitarian security, or wellbeing of a large group of people. A crisis is triggered by a hazard that may be
crisis natural or manmade, with rapid or slow onset, and of short or protracted duration.

Formula 75 Formula 75 (75 kcal/100 ml) is a therapeutic milk recommended by the World Health
Organization for the stabilisation phase of children with Severe Acute Malnutrition and
medical complications.

Formula 100 Formula 100 (100 kcal/100 ml) is a therapeutic milk recommended by the World Health
Organization for the nutrition rehabilitation of children with Severe Acute Malnutrition after
stabilisation in a Stabilisation Centre. Formula 100 has a similar nutrient composition to
Ready-to-Use Therapeutic Food.

Formula 100 Formula 100 diluted (100 kcal/130 ml) is a therapeutic milk recommended by the World
diluted Health Organization for the stabilisation and rehabilitation of infants 0–6 months of age with
Severe Acute Malnutrition and without bilateral pitting oedema in a Stabilisation Centre.

Food security Food security occurs when people, at all times, have physical and economic access to
sufficient, safe, and nutritious food that meets their dietary needs and food preferences for an
active and healthy life. A family (or country) may be food secure, yet include individuals who

VII
Term Definition
are nutritionally insecure. Food security is therefore a necessary but not sufficient condition
for nutrition security. Hunger is an outcome of food insecurity, where dietary intake, at
population level, falls below minimum requirements (typically averaged as 2,100 kcal per
person per day).

Fortified A Fortified Blended Food is a mixture of cereals and other ingredients, such as soya beans or
Blended Food pulses that have been milled, blended, pre-cooked by extrusion or roasting, and fortified with
a premix of a sufficient amount and range of vitamins and minerals. Super Cereal Plus is an
example of a Fortified Blended Food.

Global Acute Global Acute Malnutrition is a population-level indicator referring to overall Acute
Malnutrition Malnutrition defined by the presence of bilateral pitting oedema or wasting defined by a
Weight-for-Height < -2 z-score (World Health Organization standards). Global Acute
Malnutrition is the sum of Severe and Moderate Acute Malnutrition (Global Acute
Malnutrition = Severe Acute Malnutrition + Moderate Acute Malnutrition).

Mid-Upper A Low Mid-Upper Arm Circumference Indicator is an indicator of wasting, used for a child
Arm that is 6–59 months of age. A Mid-Upper Arm Circumference < 11.5 cm indicates severe
Circumference wasting, or Severe Acute Malnutrition. A Mid-Upper Arm Circumference ≥ 11.5 cm and <
Indicator 12.5 cm indicates moderate wasting, or Moderate Acute Malnutrition.

Moderate Moderate Acute Malnutrition, or moderate wasting, is defined by a Mid-Upper Arm

Acute Circumference Indicator ≥ 11.5 cm and < 12.5 cm or a Weight-for-Height ≥ -3 z-score and < -
Malnutrition 2 z-score (World Health Organization standards) in children aged 6–59 months. Moderate
Acute Malnutrition can also be used as a population-level indicator defined by Weight-for-
Height ≥ -3 z-score and < -2 z-score (World Health Organization standards).

Micronutrient Micronutrient deficiencies are a form of undernutrition that is related to vitamins and
deficiencies minerals. Deficiencies of iron, iodine, vitamin A, and zinc are among the top 10 leading
causes of death through disease in developing countries. Other deficiencies which are more
specific to emergencies include those of thiamine (B1), riboflavin (B2), niacin (B3), and
vitamin C.

Outpatient An Outpatient Therapeutic Programme is a service treating patients with Severe Acute
Therapeutic Malnutrition without medical complications through the provision of routine medical
Programme treatment and nutrition rehabilitation with Ready-to-Use Therapeutic Food. Patients attend
outpatient care at regular intervals (usually once a week) until the discharge criteria are
reached.

Public Health Public Health Emergency Management is a process of anticipating, preventing, preparing for,
Emergency detecting, responding to, controlling, and recovering from the consequences of public health
Management threats in order that health and economic impacts are minimised.

Ready-to-Use Ready-to-Use Supplementary Food is an energy-dense, mineral- and vitamin-enriched food

Supplementary specifically designed to treat Moderate Acute Malnutrition. Ready-to-Use Supplementary
Food Food has a similar nutrient composition to Ready-to-Use Therapeutic Food, but has a different
source of protein and a vitamin and mineral premix. Ready-to-Use Supplementary Food is
soft and can be consumed easily by children from the age of six months without adding water.
Like Ready-to-Use Therapeutic Food, Ready-to-Use Supplementary Food is not water-based,
meaning that bacteria cannot grow in it and that it can be used safely at home without
refrigeration and in areas where hygiene conditions are not optimal. Unlike fortified blended

VIII
Term Definition
food, it does not require preparation before consumption. Plumpy’sup® is an example of a
lipid-based Ready-to-Use Supplementary Food.

Ready-to-Use Ready-to-Use Therapeutic Food is an energy-dense, mineral- and vitamin-enriched food

Therapeutic specifically designed to treat Severe Acute Malnutrition. Ready-to-Use Therapeutic Food has
Food a similar nutrient composition to Formula 100. Ready-to-Use Therapeutic Food is soft and can
be consumed easily by children from the age of six months without adding water. Unlike
Formula 100, Ready-to-Use Therapeutic Food is not water-based, meaning that bacteria
cannot grow in it and that it can be used safely at home without refrigeration and in areas
where hygiene conditions are not optimal. It does not require preparation before consumption.
Plumpy’nut® is an example of a lipid-based Ready-to-Use Therapeutic Food.

Severe Acute Severe Acute Malnutrition is defined by the presence of bilateral pitting oedema or severe
Malnutrition wasting (Mid-Upper Arm Circumference Indicator < 11.5 cm or a Weight-for-Height < -3 z-
score [World Health Organization standards]) in children aged 6–59 months. A child with
Severe Acute Malnutrition is highly vulnerable and has a high mortality risk.

Severe wasting Severe wasting is a sign of Severe Acute Malnutrition. It is defined by a Mid-Upper Arm
Circumference Indicator < 11.5 cm or a Weight-for-Height < -3 z-score [World Health
Organization standards]) in children aged 6–59 months. Severe wasting is also called non-
oedematous malnutrition. The child with severe wasting has lost fat and muscle, and appears
very thin (e.g. signs of ‘old man face’ or ‘baggy pants’, i.e. folds of skin over the buttocks).

Severe wasting Severe wasting with bilateral pitting oedema is the simultaneous condition of severe wasting
with bilateral (Mid-Upper Arm Circumference Indicator < 11.5 cm or Weight-for-Height/Weight-for-
pitting oedema Length <-3 z-score) and bilateral pitting oedema of any grade (+, ++, or +++).

Sphere Project The Sphere Project Humanitarian Charter and Minimum Standards in Disaster Response is a
Humanitarian voluntary effort to improve the quality of assistance provided to people affected by disaster
Charter and and to enhance the accountability of the humanitarian agencies in disaster response. Sphere
Minimum has established Minimum Standards in Disaster Response (often referred to as Sphere
Standards in Standards) and indicators to describe the level of disaster assistance needed. Visit
Disaster www.sphereproject.org for more information.
Response

Stabilisation A Stabilisation Centre is a service to treat children with Severe Acute Malnutrition with
Centre medical complications until their medical condition is stabilised and the complications are
resolved (usually four to seven days). Treatment then continues in an Outpatient Therapeutic
Programme until the discharge criteria are reached. Inpatient care for Severe Acute
Malnutrition with medical complications is provided in a hospital or health facility with 24-
hour-care capacity.

Super Cereal Super Cereal Plus is a blend of cereals and legumes (mostly
Plus
corn/wheat/rice and soy), pre-cooked, available in dry form, and fortified with vitamins and
minerals. Its formulation was designed to target pregnant and lactating women and
malnourished individuals on Anti-Retroviral Therapy. The nutritional profile consists of 752–
939 kcal, 31–38 g protein (16%), and 16–20 g fat (19%); it meets the Reference Nutrient
Intake and Protein Digestibility Corrected Amino Acid Score. Shelf life is up to 12
months. The packages come in 25 kg (net) bags.

Targeted Targeted Supplementary Feeding Programme is an intervention that aims to treat patients with
Supplementary Moderate Acute Malnutrition, and prevents deterioration of the condition to Severe Acute

IX
Term Definition
Feeding Malnutrition. The supplementary food ration is targeted at individuals with Moderate Acute
Programme Malnutrition in specific vulnerable groups, such as children aged 6–59 months and
malnourished pregnant and lactating women with infants under six months.

Undernutrition Undernutrition is a consequence of a deficiency in nutrient intake and/or absorption in the

body. The different forms of undernutrition that can appear in isolation or in combination are
acute malnutrition (bilateral pitting oedema and/or wasting), stunting, underweight (a
combined form of wasting and stunting), and micronutrient deficiencies.

Underweight Underweight is a composite form of undernutrition, including elements of stunting and

wasting, and is defined by a Weight-for-Age z-score below two standard deviations of the
median (World Health Organization standards). This indicator is used in growth monitoring
and promotion and child health and nutrition programmes aimed at the prevention and
treatment of undernutrition.

Wasting Wasting is a form of acute malnutrition. It is defined by a Mid-Upper Arm Circumference

Indicator < 12.5 cm or a Weight-for-Height < -2 z-score [World Health Organization
standards]) in children aged 6–59 months.

Weight-for-Age The Weight-for-Age Index is used to assess underweight. It shows how a child’s weight
Index compares to the weight of a child of the same age and sex in the World Health Organization
standards. The index reflects a child’s combined current and past nutritional status.

Weight-for- The Weight-for-Height/Weight-for-Length Index is used to assess wasting. It shows how a

Height/Weight- child’s weight compares to the weight of a child of the same length/height and sex in the
for-Length World Health Organization standards. The index reflects a child’s current nutritional status.
Index

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 1. INTRODUCTION

1.1 Overview of nutrition in emergencies

Humanitarian crises exacerbate nutritional risks and often lead to an increase in acute malnutrition.
Emergencies include both manmade (conflict) and natural disasters (floods, drought, cyclones, typhoons,
earthquakes, volcanic eruptions, etc.). Complex emergencies are combinations of both manmade and
natural disasters, often of a protracted nature. Millions of people are affected by humanitarian crises every
year. The increasing frequency and scale of emergencies requires nutrition to be addressed in all phases of
a response.1

Crisis situations, whether acute or protracted, impact on a range of factors that can increase the risk of
undernutrition, morbidity, and mortality. They may involve: the large-scale destruction of property and
infrastructure; the erosion of livelihood strategies and purchasing power; a breakdown of and reduced
access to essential services, including health services, water supply, and sanitation; and the displacement
of large numbers of people. Emergencies can also disrupt social systems and the quality of care/feeding
practices. Household access to food may be negatively affected and people may find themselves in
overcrowded settlements with their families divided. As a result, at the individual level, there is often an
increased risk of deteriorating health and nutritional status, resulting in a greater likelihood of death.

Who is most vulnerable to undernutrition in emergencies?

Some population groups are more nutritionally vulnerable than others in emergencies, based on
physiological, geographical, social, economic, and refugee status, as described below.

Physiological vulnerability
Individuals can be physiologically vulnerable for two reasons. First, nutrient requirements increase at
certain ages. Infants and young children who are growing and developing quickly are particularly
vulnerable, as are PLW, who require more nutrients for intra-uterine growth and to breastfeed their infants.

Second, reduced appetite and ability to eat can also create vulnerability. Young children are also exposed
to a higher risk (compared to other population groups) of contracting infections, which can further increase
nutrient requirements, impede nutrient use, and reduce appetite.2 Older people, the disabled, and people
living with chronic illness, such as HIV and AIDS, may all suffer from a reduction in appetite, difficulties
in chewing, and difficulties in accessing food, all of which makes them vulnerable to undernutrition.3

Geographic vulnerability
In some emergencies, populations who live in certain geographical areas are at nutritional risk. For example,
those living in drought- or flooding-prone areas are likely to be less food and nutritionally secure. Certain
livelihood groups are vulnerable when natural resources become scarce, and populations who reside in areas
prone to conflict or in densely populated urban areas (slums) are also nutritionally vulnerable.

1
USAID, Multi-sectoral nutrition strategy 2014–2025, Technical Guidance Brief on Nutrition in Emergency.
2
Addressing Undernutrition in Emergencies; European Commission; Brussels, 12.3.2013 SWD (2013) 72 final.
3
Older men and women are those aged over 60 years, according to the UN, but a definition of ‘older’ can vary in different contexts.

1
Social vulnerability
The poorest households are often some of the most vulnerable to emergencies as they often struggle the
most to cope with shocks. The impact of the food, fuel, and economic crisis in 2008, and again in 2011, is
a good example of this. With fewer resources, poor people resort to eating less frequently, and consume a
less diverse and nutrient-deficient diet.

There is evidence that vulnerable households (and their most nutrition-vulnerable members, the focus of
this document) are likely to not have access to and/or cannot afford a nutritious diet (Fill the Nutrient Gap
2020). Most of the relief food security interventions are designed to provide rations that aim to fulfil
kilocalories only (not other macro- and micronutrients). This is so because nutritious diets can be up to five
to eight times more expensive than kilocalorie-based diets. However, the Ethiopian Public Health Institute
(EPHI) has developed mechanisms to prioritise the resources, when these are limited (Terms of Reference
(ToR) of the National Technical Working Group for the Cost / Non-Affordability of Healthy Diets 2020).

Gender also plays a role in a person’s social vulnerability. Women/girls and men/boys face different risks
in relation to the deterioration of their nutritional status in emergency contexts. These different
vulnerabilities are related both to their differing physiological nutritional requirements and to socio-cultural
factors related to gender. For example, in some emergency situations where food is in short supply,
women/girls may be more likely to reduce their food intake as a coping strategy in favour of other household
members. This can contribute to acute malnutrition among women and girls. Furthermore, because of social
traditions, men/boys may be favoured and fed better than women and girls in some societies, although a
recent systematic review shows wasting is more common in boys than girls in many contexts with possible
biological and social causes4.

Political vulnerability
Communities or individuals exposed to violence or marginalisation may be vulnerable. Emergency
situations can lead to population migration and displacement. Refugees and internally displaced people
(IDPs) who flee with little or no resources are at greater risk of being food insecure as they may be
completely cut off from their normal food sources, social structures, and coping mechanisms. Their
situation also depends on the size of the refugee and IDP population, whether they are living in large,
overcrowded camps, in small groups, or with host families, whether they have access to land and income-
earning opportunities, and on the food security of the host country and population. Populations hosting
refugees and IDPs are also often increasingly vulnerable to nutrition crises.

Specific vulnerabilities within Ethiopia

In Ethiopia, pastoralists, primarily found in four regions – Afar, Oromia, Somali, and the Southern
Nations, Nationalities, and People's Region (SNNPR) – are a particularly vulnerable group. As an
economic and social system, pastoralism operates effectively in low and highly variable rainfall
conditions. However, with an increasing population, climate change, and increased barriers to
international markets, pastoralist livelihoods systems are becoming increasingly vulnerable. Traditional
livestock practices have deteriorated and there has been significant degradation of some wet season
grazing areas. Additionally, grazing land has been taken away from pastoralists for other purposes, such

4Thurstans S, Opondo C, Seal A, et al. Boys are more likely to be undernourished than girls: a systematic review
and meta-analysis of sex differences in undernutrition. BMJ Global Health 2020;5: e004030.

2
as farming and settlement along pastoralist migratory routes. The pressures on pastoralists and their
livelihoods, particularly in times of drought, make them highly vulnerable to acute and chronic food
insecurity and malnutrition.

Seasonal vulnerability is also cause for concern in Ethiopia, given the dependence of agriculturalists on
rain. Like pastoralists, in times of drought their available food and monetary resources decrease
dramatically, often resulting in spikes in undernutrition. Recent study in rural Ethiopia have shown that in
some situations child height growth velocity follows a seasonal pattern and that seasonal undulations in
food security manifest as energy stress among women, men, and children5.

What types of malnutrition occur during emergencies?

Of concern in emergencies is the increased risk of moderate and Severe Acute Malnutrition (SAM)
because acute malnutrition is strongly associated with death. A child with SAM is around 12 times more
likely to die than a non-wasted child, while a child with MAM has a three to four times greater risk of
mortality. On average, household members with Moderate Acute Malnutrition (MAM) are five to eight
times more numerous than those with signs of SAM.

In many long-term emergencies, however, the prevalence of acute malnutrition may be relatively low,
while rates of other forms of malnutrition, such as stunting, are high. Stunting inhibits a child from
reaching his/her full physical and mental potential. It also carries a higher risk of mortality (up to 5 times)
than non-stunted children. It can have a major impact on work output and national economic
development. Furthermore, small mothers have small babies, who are more likely to be sick and die.
There is also increasing recognition of the negative impacts of concurrent wasting and stunting in
individual children. Stunting, therefore, is becoming an increasingly important measure of nutritional
wellbeing in chronic emergencies.

Causes of acute malnutrition

The United Nations International Children’s Emergency Fund (UNICEF) conceptual framework, found
in Annex 6, is a useful tool to help understand the many factors that can impact on nutrition status. It
identifies three levels of causality: immediate; underlying; and basic. All three can be disrupted during
emergencies.

The immediate causes of acute malnutrition are a lack of dietary intake, and/or disease. This can be a
result of consuming too few nutrients or an infection, which can increase nutritional requirements and
prevent the body from absorbing the nutrients consumed. Whether or not an individual gets enough food
(both staple and nutrient-dense) to eat or whether s/he is at risk of infection is mainly the result of factors
operating at the household and community level, including:

• Inadequate household food and nutrition security;

• Inadequate care; and
• Inadequate services and an unhealthy environment.

5Fantahun, et al. (2018). Seasonality and determinants of child growth velocity and growth deficit in rural
southwest Ethiopia. BMC; 18:20. DOI.10.1186/ s/2887-018-0986-1

3
In practice, there is significant overlap in these three groups of underlying causes.

All three clusters of underlying causes of undernutrition are subject to seasonal variation. For example,
access to food typically reduces prior to the harvest when the workload is also high (for agricultural
producers), or prior to the rains when the workload finding water and pasture is high (for pastoralists).

The third level of factors contributing to undernutrition operates at the basic level. This refers to the
resources available (human, structural, financial) and how they are used (the political, legal, and cultural
factors). Adverse political, legal, and cultural factors may defeat the best efforts of households to attain
good nutrition.

1.2 Rationale

Ethiopia faces recurrent natural hazards and manmade humanitarian crisis and the associated high burden
of nutritional emergencies. Due to this, field practitioners are often caught in day-to-day emergency
response and may fall short of developing and maintaining comprehensive and effective emergency
nutrition preparedness and response guidance, tools, and resources to help them ease the process.

In response, EPHI, the Ministry of Health (MoH), and the Ethiopia Disaster and Risk Management
Commission have developed this interim guidance to help country-level nutrition clusters, nutrition
sector coordination, and nutrition working groups strengthen collective emergency nutrition preparedness,
surveillance, and response towards effective protection of the nutritional status of populations.

1.3 Purpose and scope of the guidelines

The purpose of these guidelines is to provide harmonised practical direction to service providers,
policymakers, programmers, and stakeholders on the current standards and recommendations on
emergency nutrition interventions.

The guidelines also aim to:

• guide nutritionists and humanitarian workers in their analysis of the situation and in putting
contextual factors other than the nutritional situation into perspective in order to fully understand
the response environment.
• guide nutritionists and health workers in drawing up a strategy for nutritional health intervention
that best meets the needs of a particular emergency.
• coordinate decision making regarding nutritional health intervention in emergency situations; and
• strengthen the coordination of the emergency response among stakeholders.

1.4 Users of the guidelines

A variety of nutrition programmers, health service providers, and institutions working on nutrition can
benefit from these guidelines. They are designed for use by:
1. Emergency Nutrition Programme managers and Public Health Emergency (PHEM) officers at
national, regional, zonal, sub-city, and woreda levels.

4
2. Health service providers at community and health facility level (health extension workers, health
workers in Outpatient Therapeutic Programmes (OTP) and at Stabilisation Centres, and
surveillance officers);
3. Teaching institutions that train health professionals.
4. Nutrition experts and humanitarian workers.
5. Government officials within the relevant ministries.
6. Donors and United Nations agencies (UNICEF, World Food Programme (WFP), and World
Health Organization (WHO)); and
7. Non-governmental organisations (NGOs).

5
2. NUTRITIONAL PREPAREDNESS
Preparedness is usually associated with measures taken in advance or in anticipation of an emergency. It
can also be seen as an early action and capacity development tool which aims to mitigate negative
impacts, by improving the overall effectiveness, efficiency, timeliness of response, and recovery.

Preparedness is part of risk-informed programming (which also includes disaster risk reduction, climate
change adaptation, peace building, and social protection). In most emergencies, external support can take
days, in some cases weeks, to arrive. Therefore, it is vital that there is a plan in place, based on the
available in-country capacity, to deal with the initial phase of an emergency.

Some of the key preparedness actions are listed below.

Coordination

• A mechanism for the emergency coordination of nutrition is established.

• ToR for nutrition cluster staff is available.
• ToR for the nutrition cluster is agreed upon.
• Technical working group and strategic advisory group are created and ToR available.
• A contact list of nutrition sector partners is available and updated.
• The nutrition cluster participates and contributes to inter-sector coordination.
• Cluster members are familiar with humanitarian principles, the cluster approach, and
accountability to affected populations.

Information management

• Role and responsibilities for information management are agreed upon with government and
cluster members.
• A platform for storing and sharing documents is operational.
• Data collection tools are harmonised and available to all members.

Needs assessment, analysis, and monitoring

• The rationale and methods for needs assessment and analysis are understood by partners.
• Historical nutrition data have been retrieved and analysed.
• Nutrition is included in a joint/common rapid assessment.
• Rapid and standard nutrition assessments have been agreed upon by all partners.
• Nutrition screenings and surveillance systems have been set up.

Resources

• Donor relations have been established.

• Cluster members are familiar with the Central Emergency Response Fund (CERF) and common
appeals mechanisms.
• Cluster members have built preparedness for supplies management.

6
Implementation and monitoring

• Capacity mapping is performed and regularly updated.

• Preparedness measures for specific nutrition interventions have been taken.
• A Gap Analysis is performed and regularly updated.
• Rapid response mechanism implementation is discussed.
• A capacity building strategy/plan has been designed.
• Monitoring and evaluation of preparedness is performed.

Communication and advocacy

• A communication and advocacy strategy have been agreed with members and implementers.
• Mechanism for accountability to affected population is established including with participation of
members from the community

Risk analysis and monitoring

The Inter-Agency Standing Committee (IASC) defines risk analysis and monitoring as the first pillar of
emergency preparedness planning. A clear and common understanding of the risks which may trigger a
crisis significant enough to require a coordinated response is fundamental to the entire preparedness
process. The risk analysis informs the planning, while monitoring ensures that the process is responsive to
emerging risks.

Emergency response plan methods for risk analysis and monitoring actions

1. Identify the hazards by answering the following questions: What phenomenon, activity, or
conditions may affect the nutrition status of the population (natural disasters, armed conflicts, epidemics,
financial crisis, etc.)? If more than one is identified, how do they interact? How are they likely to develop
over time? What are the causal pathways?

2. Rank the risks: All hazards should be ranked by the perceived impact (on a scale of 1–5) and
likelihood of happening (on a scale of 1–5). Risk = Impact x Likelihood. Risks should then be ranked
from low to high.

3. Define thresholds: Thresholds for the risk values, as calculated above, should then be set by the
Humanitarian Country Team or National Coordination Centre and the actions needed when exceeded are
defined (e.g. when risk > 10, initiate contingency planning).

4. Monitor the risk: A mechanism should be established to track the hazards, and in particular those with
a high-risk value.

Figure 1 shows graphically how the above actions can be plotted and monitored ….

7
IMPACT

Critical 5

Severe 4

Moderate 3

Minor 2

Negligible 1

1 2 3 4 5
Likelihood
Very unlikely Unlikely Moderately likely Likely Very likely
Seriousness = Impact x Likelihood

Figure 1. Risk analysis and monitoring graph

2.1 Planning for identified risks and hazards

Emergency nutrition planning should primarily depend on the strategic national/regional PHEM plan, the
Emergency Preparedness and Response Plan, bi-annual rapid seasonal need assessment, woreda hotspot
classification, nutritional surveys, and other nutritional findings.

The different steps involved in the development of an emergency nutrition preparedness plan are:
• Mapping of stakeholders.

8
 • Identifying and establishing preparedness planning team from different stakeholders.
• Identifying the vulnerable areas and groups within the population (physiological, geographical,
and political vulnerability);
• Assessing and estimating the number of expected malnutrition cases, including micronutrient
deficiencies, to anticipate the risks of possible large caseloads of malnourished children.
• Defining the ‘thresholds’ for the emergency response (the health system can no longer manage
the cases without the support of external bodies);
• Monitoring the prevalence and number of cases of acute malnutrition.
• Developing plans to prevent, protect against, respond to, and recover from natural and manmade
disasters.
• Ensuring the integration of emergency nutrition preparedness plan with stakeholders; and
• Preparing monitoring mechanisms and tools to ensure that the preparedness plan is
operationalised.

2.2 Coordination and collaboration

W

At federal level: The Ethiopia Disaster Risk Management Commission and/or the equivalent bodies at
subnational and local levels are responsible for coordinating preparedness and responses to emergencies,
including those caused by natural and manmade hazards (see Figure 2). During emergency nutrition
interventions, the coordination of numerous sectors, partners, and UN agencies is very important. It is
essential to increase cooperation and collaboration between health and other sectors (e.g. agriculture,
water, energy, law enforcement, transport, migration, foreign affairs, and trade) before, during, and after
all types of emergencies.

The Multi-Agency Nutrition Task Force (MANTF), which is the technical taskforce at federal level,
oversees and ensures the proper technical operation of preparedness and response activities. Health and
nutrition operational activities are planned and monitored through the PHEM Operation Centres. These,
with their respective centres at regional level, alongside the Strategic Emergency Coordination Centre, are
responsible for mobilising and prioritising resources. The information about the emergency is centrally
gathered and communicated through these channels.

At regional/zonal level: A Multi-sectoral emergency nutrition coordination forum comprising all

concerned sectors, UN agencies, and NGOs coordinates the emergency technical activities at regional
level. The regional Disaster Risk Management -Technical Working Group Coordination and Emergency
Operation Centres will be activated based on the pre-set criteria, if necessary. The regions are therefore
preparing Emergency Preparedness and Response Plans, and to carry out search and rescue operations
and coordinate joint impact assessment and humanitarian responses for affected and displaced peoples.

At woreda/community level: Local governmental structures with representatives of at-risk communities

closely coordinate awareness creation and messaging of the threats, and take appropriate emergency
response measures, including relocating at-risk populations. Activities include the dissemination of alert
messages and continuous monitoring updates, and the coordination of emergency response at times of
emergency. Incident command posts should be established depending on the severity of the disaster.

9
 Multisectoral Coordination
Public Health Institute / Ministry of Women Ministry of Water,
Ministry of Agriculture Ministry of Education
Ministry of Health Social Affairs Irrigation and Energy

Roles and • General food rationing that meets nutrient • ECD kits • MUAC screening of under-fives and PLW • Protection • Besides nutrition, key
responsibilit requirements (adequate food basket are made conducted as part of integrated vaccination campaign risks messages on hygiene
ies composition, including the use of fortified available at or any other health campaign assessments practices are delivered as
vegetable oil) mother and • Formation of peer groups (mother-to-mother support and gender part of the nutrition
• Enhancement of livelihoods, food, and baby- groups) promoting adequate IYCF practices as well analyses are services
nutrition security in selected communities friendly as attendance at antenatal care and postnatal care undertaken
through improved diversification of food spaces clinics by nutrition • In some communities, a
sources • Maternal nutrition and health promotion activities target partners and group of resourceful
• Links b/n national social safety nets or cash • Integrated pregnant women by providing counselling and the results individuals is created to
transfer programmes and nutrition SBC education on maternal nutrition and IYCF, the inform the promote preventative
interventions, e.g., women and mothers strategies promotion of healthy/safe antenatal/postnatal practices, design of practices, including those
engaged in an IYCF focused SBC programme with a and referral to medical antenatal care services/delivery the nutrition identified as indirect
are eligible for cash transfer programmes; or focus on assistance response causes of malnutrition
households engaged in promotion of adequate promoting • Integrated health and nutrition interventions for IDPs related to water, sanitation
complementary feeding activities are eligible adequate and affected communities (CMAM, micronutrients, • Gender- and hygiene (WASH)
for cash transfer programmes childcare immunisation, treatment of diarrhoea, pneumonia, based
• Multi-sectoral Knowledge Attitude and and feeding prevention of malaria) violence • Integrated SBC strategies
Practices (KAP) surveys include nutrition, practices • Supporting health facilities to provide MNCH and prevention with a focus on promoting
food security and livelihood indicators among nutrition services through outreach activities is integrated IYCF practices, hygiene
others. (antenatal care, postnatal care, new-born care, IYCF into the practices, the use of safe
• Linkages b/n general food distribution (GFD) counselling, growth monitoring, micronutrient nutrition drinking water, and the
and nutrition services: Mid-Upper Arm distribution (vitamin A) and deworming tablets, response use of improved sanitation
Circumference (MUAC) screening, referral to management of childhood illness etc.) facilities
Community-based Management of Acute • Linkages between Blanket Supplementary Feeding
Malnutrition (CMAM) programmes, provision Programmes (SFPs) and nutrition services (MUAC • SMART and KAP surveys
of micronutrient supplements, promotion, and screening, referral to CMAM programmes, provision include WASH indicators
referral to antenatal care of micronutrient supplements, promotion and referral
• Nutrition SMART and KAP surveys include to antenatal care)
assessment of General Food Ration coverage • Nutrition SMART and KAP surveys include health
indicators

Figure 2.The roles of different sector ministries under the coordination of DRMC

10
Steps to establish strong Emergency Nutrition Coordination and Collaboration:

1) Map all governmental and NGOs working on nutrition and identify areas of intervention.
2) Establish emergency nutrition working group. If there is existing similar committee/working group
or team, it is better to use the existing group.
3) Establish a communication platform.
4) Develop ToR and agree on these.
5) Institute regular meeting and discussion.
6) Implement activities based on the agreed ToR.
7) Monitor and evaluate the implementation of preparedness activities.
8) Put in place training on critical topics relevant for the members of the coordination and fill
knowledge gaps (e.g. coverage surveying mechanisms).6

2.3 Capacity development

Before implementing capacity buildings activities, it is better to define, identify, and plan needs in terms
of what you want to provide. In PHEM management, the capacity development activities are classified
into two:
• System capacity building:
✓ developing and strengthening nutrition and PHEM programmes, partnership,
multispectral relationship, reporting system
• Human capacity building:
✓ developing and strengthening comprehensive short- and long-term capacity building
training for health and nutrition professionals
✓ strengthening the capacity of women, women’s organisation, and women’s development
arms

2.4 Surge capacity

Surge capacity is the ability of an organisation to rapidly and effectively increase its available resources in
a specific geographic location in order to meet increased demand to stabilise or alleviate suffering in any
given population. It used when there are unforeseen emergencies to mobilise staff from different
regions/zones/woredas within a short period of time.

Effective surge capacity requires access to resources: human, financial, and material. People and money
are undisputedly the core elements, while the availability of human resources for swift deployment is the
anchor of any response.
A surge capacity mechanism includes not only the different standing capacities, i.e. people, money, and
materials, but also the tools, policies, procedures, and resource configurations that an agency/organisation
adopts when mobilising that capacity.

6 Source: Global Nutrition Cluster Handbook, UNICEF 2013.

11
2.5 Resource mobilization

Emergency nutrition response needs huge resources to respond to emergency effectively and productively
and to get the intended result. Mobilising resources is the key activity in emergency nutrition response for
the utilisation of resources in a rapid manner to implement the predetermined goals.

Resource mobilisation refers to not only to funds but also to human resources, goods, and services.

o Financial resources: government budget and local resources.

o Human resources: permanent staff of government, seconded staff, NGO staff, volunteers, interns;
and
o Goods and services: vehicles, printing facilities, training, advice services, communication
equipment, etc.

2.6 Logistics management

The logistics management of acute malnutrition should be handled jointly with the government and UN
agencies, including EPHI, EPSA, UNICEF, MoH, and WFP. The emergency supply chain management
will be done based on the emergency supply chain playbook.

Annexes 4 and 5 provides a list the essential nutrition commodities and supplies needed for the
management of SAM and MAM.

12
3. NUTRITIONAL ASSESSMENT AND SURVEILLANCE

3.1 Nutrition surveillance

This is the process of gathering, analysing, interpreting, and disseminating nutrition information. The
purpose of nutrition surveillance is to detect changes in the nutrition status of the population over a
period. Nutrition surveillance information will guide the planning, implementation, and evaluation of
health and nutrition services/interventions. It is also defined as ‘Information for Action’.7

Surveillance data includes:

- Data from the periodic nutrition surveys;

- Results from the periodic nutrition screening;
- Reports from the supplementary and therapeutic feeding centres and health clinics;
- Health surveillance data; and
- Morbidity and mortality data.
Table 1 presents the types of malnutrition and some epidemic prone diseases surveillance data, source,
collection period and geographic area or level of administration

Table 1. Malnutrition and some epidemic prone diseases surveillance data inventory

Geographic
Data collection
Data Data source area/level of
periods
administration

National/Regional/Zonal /Woreda Weekly/Monthly Woreda/Regional

Health

Malaria EPHI/Region/Zone/Woreda Weekly Facility/Woreda

Measles EPHI/Region/Zone/Woreda Weekly Facility/Woreda

Cholera EPHI/Region/Zone/Woreda Weekly Facility/Woreda

Diarrheal diseases EPHI/Region/Zone/Woreda Weekly Facility/Woreda

SAM admission inpatient MoH/EPHI/Region/Zone/Woreda Weekly/Monthly Facility/Woreda

SAM admission outpatient MoH/EPHI/Region/Zone/Woreda Weekly/Monthly Facility/Woreda

SAM death MoH/EPHI/Region/Zone/Woreda Weekly/Monthly Woreda

MoH/ EPHI/Regional Health Bureau

MAM admission (RHB) /Zonal Health Department (ZHD)/ Weekly/Monthly Facility/Woreda
Woreda Health Office (WoHO)

Nutritional screening MoH and EPHI/RHB/ZHD/WoHO Monthly Woreda

13
 coverage

Prevalence of Global
Acute Malnutrition MoH and EPHI/RHB/ZHD/WoHO Survey Woreda
(GAM) (% GAM)

Proxy GAM and proxy

MoH and EPHI/RHB/ZHD/WoHO Screening Woreda
SAM

Vitamin A coverage;
prevalence of EPHI/Ethiopian Demographic Health
Survey Woreda
micronutrient deficiency Survey
(MND) (Vit. A, B, C, D)

KAP on IYCF-E MOH/EPHI/partners Survey Woreda

WASH MoWIE/MOH/EPHI/partners Monthly Woreda

Education and child

MoE/MoWYC Monthly Woreda
protection

Cost and non-affordability

analysis based on food
Region, tailored zone
market monitoring and MoA Monthly
as per need
household expenditure
surveys

Indicators of malnutrition during an emergency

Nutrition assessment, surveillance and different surveys collect data to track indicators on the acute
malnutrition and micronutrient status of children and PLW, IYCF practices, and the anthropometric status
of children aged 0–59 months and PLW

• Indicators of acute malnutrition during emergencies

o weight-for-height;
o mid-upper arm circumference; and
o bilateral pitting edema.

3.2 Nutrition assessments in an emergency

An understanding of the context of the emergency nutrition situation is necessary to develop an

appropriate response. The analysis of data on the affected population and area increases the understanding
of the extent and possible causes of malnutrition. A thorough assessment that includes a good
understanding of the community, its context, and its concerns should guide all emergency response
planning. Information should be collected on community structures (both formal and informal), key
stakeholders (traditional authorities, traditional and modern health practitioners, civil society, etc.),
literacy levels, who is responsible for children, who makes key decision on household resource allocation,
attitudes to health and malnutrition, and health-seeking behaviour.

14
3.2.1. Rapid nutrition assessments

Rapid nutrition assessments can be undertaken as part of initial assessments to obtain an overview of the
nutritional situation, and determine the areas and population groups affected by an emergency. The
information collected during rapid assessment provides data on gender disparities in nutritional status in a
population, when results are disaggregated by sex, age groups (0–6 months, 6–24 months, and 24–59
months), and PLW.

Rapid nutrition assessments are frequently multi-agency (involving several agencies) and multi-sectoral
(involving several technical sectors) in order to ensure a broad analysis of risks, needs, and priorities, and
to make recommendations to ensure that all the health and nutrition needs of an emergency-affected
population are met.8

It is also reasonable to recommend and implement nutrition interventions temporarily based on the rapid
nutrition assessment results. However, the assessment should not be taken as a substitute for the standard
nutrition assessment. Once an appropriate intervention has been identified, a standard emergency nutrition
assessment should be conducted simultaneously with implementation.9

3.2.2. Repeated surveys

Repeated surveys refer to statistically representative population-based surveys carried out at regular
intervals. This category covers national surveys regularly undertaken in stable situations, such as the
Ethiopian Demographic Health Surveys, the UNICEF-supported Multiple Indicator Cluster Surveys,
SMART survey, partner emergency nutrition surveys, and the World Bank-supported Living Standards
Measurement Surveys.

It also includes small-scale surveys that are carried out to guide specific nutrition-related programmes.
Repeated small-scale surveys are used in planning, monitoring, and evaluating development projects, and
are also commonly used during emergencies:10 these are mainly based on MUAC measurements and
contribute to defining specific situations.

3.2.3. Community-based sentinel site surveillance

Sentinel site surveillance refers to the monitoring of purposively selected communities or service delivery
sites. Data are collected on all potential respondents (children 0–59 months of age and PLW) who visit
sentinel sites and health clinics. Table 2. below summarize the different nutrition assessment tools that
can be used during an emergency

8 Cluster G.N. A Toolkit for Addressing Nutrition in Emergency Situations. 2008 (June): 1–87. Available from:
papers2://publication/uuid/A41A3FB2-C81D-42B9-AB2D-FDDA52DD4DD2
9 ENCU/DPPA. Guiding Principles for Rapid Nutrition Assessments. 2006 (March): 1–16. Available from:

https://www.nutritioncluster.net/sites/nutritioncluster.com/files/2020-01/Tool_-_Rapid_Nutrition_Assessment-_final_version.pdf
10 Jeremy Shoham, Fiona Watson. The use of nutritional indicators in surveillance systems. Tech Support Facil to FAO’s

FIVIMS Manag by Nutr Work 2001: 1–49.

15
Table 2. Summary of nutrition assessment tools during an emergency

Methodology Appropriate for

SMART (‘Full SMART’) survey • usually recommended for an area wider than woreda, such as adjacent
woredas (zones) with relatively homogenous population
• where there is no recent nutrition data and access to the survey areas is
relatively good

Rapid SMART survey • where a full SMART survey is not feasible

• in contexts where access to survey area is limited
• small geographic area in delimited zone (e.g. group of villages,
IDP/refugee camps or settlements, urban slums, neighbourhoods, and
sometimes woredas) in a population that shares similar characteristics
(equally affected by crisis, having equal access to services, similar
cultural practices, same livelihood zone, etc.)

Rapid nutrition assessment • where conducting population surveys is not possible

• in a very small area such as an IDP settlements and the worst affected
areas (to determine the worst-case scenario)
• used to determine the need for more thorough assessment using
SMART survey methodology

MUAC screening using Centers for • where conducting population surveys is not possible
Disease Control (CDC) tools • concurrently with active case finding for the treatment of acute
malnutrition
• can be done in small and wider geographic areas, such as through
MUAC screening campaigns or routine services delivery
• monitoring trends in proportion of acute malnutrition in a defined
geographic area

3.3 Early warning

Early warning is the complex process aimed at reducing the impact of the hazard by providing timely and
relevant information by monitoring identified indicators.11 Data collected through nutrition surveillance
systems is used for early warning of a deteriorating nutrition situation to enable mitigating actions to be
taken. An early warning system produces an alert. This alert is specific to an area or a livelihood zone,
and provides advance notice. As a result of the warning, there is time to make substantial adjustments,
according to the context. The early warning system includes three components: a process to monitor
indicators; a contextualised analysis of their values and trends; and the means to communicate these
findings.

Early warning information is generated using real-time, weekly, and monthly reports, and comparison of
these with the baseline can help lead to early action/early response. The early action has two dimensions:

11 UNDP. Five approaches to build functional early warning system, 2018.

16
the disaster risk reduction activities (which are linked with development); and the early response (saving
livelihoods, based on the contingency plan).12

3.4.1. Early warning indicators

Early warning indicators can be categorised based on degree to which they warn about impending
disaster: early indicators; stress indicators; and late indicators. As the term suggests, early indicators give
sufficient lead time to take measures that minimise the negative impact of the anticipated shock. Stress
indicators are people’s own perceptions of the current food and nutrition security situation and their
responses to it. Late indicators, also known as outcome indicators, are used to assess the physical and
behavioural consequences of a disaster (which has already happened) on the affected population.

Two important points to make about indicators. First, it is important to recognise that an early indicator in
one agro-ecology or livelihood zone may be a stress or late indicator in another one, and vice versa. For
example, the death of livestock may be considered an early indicator in a crop-dependent area but it is a
late indicator in pastoral areas, where livelihoods heavily depend on livestock. Likewise, a late indicator
for one sector may be an early indicator of another sector. Crop damage by pest infestation is late
indicator for crop sector but may serve as an early indicator for health and nutrition. Second, a single
indicator is unlikely to provide a realistic assessment of the situation or the imminence of a disaster. It is
often a combination of indicators that result in shocks such as food shortages (of both staple and nutrient-
dense items).

3.4.1. Nutrition early warning threshold

In Ethiopia, the standard framework for assessing the severity of a situation is multi-agency seasonal
(Meher and Belg) needs assessments, Household Economy Analysis baselines, regular food and nutrition
security monitoring and early warning, verification assessments, and disaster area assessments. This
framework identifies the proportion of households with a food/energy gap or livelihood change strategies
that can endanger lives or livelihoods.

Analysing, interpreting, and reporting nutrition data in an emergency

Data collection is the key aspect of the early warning and surveillance in Ethiopia. The system collects
and analyses early warning data and publishes early warning bulletins for dissemination. The process
involves the collection of large amounts of data for its regular monitoring and baseline database. There
are different types of data that are collected by the early warning system. Both quantitative and qualitative
data are collected regularly on a weekly and monthly basis using well-structured forms or questionnaires

Regular monitoring is a continuous activity, one which focuses on tracking potential risks for nutrition
conditions at the earliest time possible so that appropriate measures can be taken to reduce disaster risks –
before risks turn into disasters. The major interests of the nutrition sector are the determinants of factors
of malnutrition, such as production (crop, livestock, and other related variables), people’s access to food
(market supply and price, asset and other sources of household income), and communities’ consumption

12Ababa, A. National Disaster Risk Management Commission of Ethiopia Guideline for Multi-hazard, Multi-sectoral and Area-
specific Early Warning and Early Response in Ethiopia Early Warning and Emergency Response Directorate. 2017 (April).

17
(food consumption, nutrition, water, and health). Other threats/shocks, such as drought, flooding, El Nino,
and price volatility, are regularly monitored.

Once data have been analysed, the survey results should be put in context to explain the findings and
make recommendations for interventions. In order to respond to these challenges, the following questions
need to be answered:

• How critical is the level of malnutrition and mortality for the population in the current season and
within the context of the area?

• How can the nutrition and mortality levels be explained?

The interpretation of the results is probably the most difficult part of a nutrition survey because there is no
standard method for interpreting nutrition data, and there are many different factors to consider at the
same time. However, proper interpretation of the results is crucial in order to design the right intervention.
Table 3 below describes the nutrition situation benchmarks and recommended actions

Table 3. Nutrition situation benchmarks and recommended actions

Nutrition situation Recommended actions

Global Acute malnutrition rate >15% OR Emergency food aid: General Food Ration; blanket supplementary
10–14% with aggravating factors* feeding
Therapeutic feeding of severely malnourished individuals

Global Acute malnutrition rate 10–14% OR No general rations

5–9% with aggravating factors*
Targeted supplementary feeding
Therapeutic feeding of severely malnourished

Global Acute malnutrition rate < 10% with No emergency food and nutrition intervention
no aggravating factors

*Aggravating factors include the following:

• Household food insecurity;

• High prevalence of HIV/AIDS;
• Crude mortality rate greater than 1/10,000 per day;
• Under-five crude mortality rate greater than 2/10,000 per day;
• Epidemic of measles or whooping cough (pertussis);
• High prevalence of respiratory or diarrhoeal diseases; and
• High prevalence of pre-existing malnutrition, e.g. underweight and/or stunting.

18
The nutrition assessment report should provide an accurate account of the nutrition situation in a given
area for intervention planning, decision making, and advocacy. The report should be presented in the
standard format, which has been developed and should be used by all agencies undertaking nutrition
surveys in Ethiopia. Table 4 below describes the classification of situation severity based on IPC
classification

Table 4. Classification of situation severity based on the IPC classification

Phase 5
Phase 1 Phase 2 Phase 3 Crisis Phase 4 Catastrophe/ Famine
None/Minimal Stressed Emergency

Food consumption
First-level outcome

(focus on energy Minimally Moderately Extremely

Adequate Very inadequate
intake) adequate inadequate inadequate

Livelihood
change Near collapse
Accelerated Extreme
(assets and Sustainable Stressed of strategies
depletion depletion
strategies) and assets
Second-level outcome

Nutritional status
Minimal Alert Serious Critical Extreme critical

CDR: 1–1.99/
Mortality CDR: <0.5 / CDR: <0.5 / CDR: 0.5–0.99/ CDR: >2/
10,000 / day or
10,000 / day 10,000 / day 10,000/day 10,000/day
>2 x reference

Food availability,
access utilisation,
Borderline Extremely
Contributing factors

and stability Adequate Inadequate Very inadequate

adequate inadequate

Stressed Results in
Results inlarge
Hazards and None or minimal livelihoods Results in assets near complete
vulnerability food assets and
effects and food and food losses collapse of
food losses
consumption livelihood assets

19
4. EMERGENCY FOOD AID AND NUTRITION RESPONSES
This chapter describes the range of food and nutrition interventions that are commonly employed in
emergencies. There is no fixed blueprint for which interventions to employ in nutrition emergencies;
however, it is useful to consider the following:

• The severity of the situation (including the mortality, the food security situation, trends in
undernutrition and the likely determinants of undernutrition, and whether the situation is likely to
get better or worse) – this dictates the urgency of the response;
• The sub-groups of the population that are at greatest nutritional risk;
• Whether the community understands the situation and their levels of capacity; and
• The cost and feasibility of possible responses.

In an emergency setting, emergency food aid and nutrition interventions are programmes set up to
➢ General food distribution to all affected community with the full basket commodities
➢ Integrate management of acute malnutrition (SAM and MAM) as per the MoH protocol;

➢ Provide other critical nutrition services (i.e. growth monitoring, micronutrient

supplementation, and protection of IYCF practices); and

➢ Provide food to a population that does not have access to food (both staple and nutrient-
dense), while filling the nutrient gap (not only kilocalories).

In essence, the emergency nutrition intervention works to reduce high rates of acute malnutrition of large,
vulnerable populations. There are three types of emergency nutritional interventions: general dietary
programmes, supplementary, and therapeutic feeding programmes (TFPs). The SFPs are an ideal nutrition
intervention for the management of MAM patients, whereas the TFPs are ideal for management of SAM
patients. Emergency nutrition interventions require substantial resources to set up and monitor NGOs
often to support EPHI with implementation. The intervention should identify a vulnerable population,
distribute food, and offer basic medical treatment, micronutrient supplementation, and if possible,
nutrition education.

4.1 General Food Ration

General Food Ration distributions should be introduced only when absolutely necessary, targeted to those
most in need, and discontinued as soon as possible. The aim of the emergency food aid response is to
deliver rapidly an adequate quantity and quality of food to the affected population to reduce the risk of
acute malnutrition and mortality so that communities, households, and individuals can survive and
recover from the emergency situation.

A General Food Ration is provided to households highly affected by food insecurity. Organisation and
coordination are the key to success of a food distribution operation. If the population is entirely dependent
on General Food Rations as a source of food, then the rations must provide at least 2100 kcal per person
per day; in most cases, because of limited resources, they do not provide the minimum dietary
requirements of micronutrients (vitamin and minerals). This is a challenge, and requires prioritising
resources for households with children and PLW in view of the first 1,000 days of life approach.

20
General Food Rations are usually provided as dry rations for people to cook in their homes. The local
community’s food habits, tastes, and preferences must be taken into consideration when distributing
General Food Rations.

The General Food Ration bridges the gap between the population’s requirements and their own food
resources from market trading, wage labour, garden plots, community sharing, food stocks, small
livestock, etc. The same ration is given to every member of the household regardless of age or individual
need.

The food basket for the General Food Ration consists of food commodities in sufficient quantities to meet
a family’s basic nutritional requirements and to provide a buffer against shortages or spoilage. Adequate
fuel, cooking utensils, mills and other grinding facilities must also be available to assisted households and
communities. Some bartering and trading of food aid and the sale of small livestock to the local
population to buy other foods should be expected to a certain degree and should not be discouraged;
refugees typically set up marketplaces in camps. Bartering and trading generally improves dietary
diversity and quality and provides income to buy essential non-food items, such as clothes or soap.
Trading foods does not mean that beneficiaries do not need all the rations. More expensive foods that give
higher returns are more likely to be traded, while cheaper foods are more likely to be consumed by
beneficiaries.

The basic food basket (General Food Ration) includes the following:

• Culturally acceptable staple food, such as maize, wheat, rice, millet, sorghum, or oats;
• A pulse or legume, which is a source of complementary protein, such as lentils, beans, peas, or
peanuts (groundnuts);
• Red palm oil (a natural rich source of vitamin A), vitamin A-fortified vegetable oil, such as
groundnut, soya, sunflower, or rapeseed oil;
• A fortified blended food – the main one distributed by the EFP is corn-soy blend; and
• Iodised salt.

Sugar and locally available meat or fish can also be part of the food basket. Where possible, the food
basket should also include locally available and culturally acceptable foods, such as fruits, vegetables,
condiments/spices, tea, and coffee, in order to add nutrients, taste, and variety to basic foods, to increase
the palatability, familiarity, and acceptability of prepared foods and for the preparation of
cultural/traditional foods and dishes. Populations generally will not consume a monotonous diet of three
commodities (e.g. wheat, beans, and oil) for months at a time (see Table 5 below).

Dried skim milk should not be part of the food basket and should not be distributed to the population
because of the high risk of contamination when prepared with unclean water or under unsanitary
conditions, and because of the danger dried skim milk poses for young children in particular. The only
safe use of dried skim milk is for therapeutic feeding under strict supervision. Breast milk substitutes
should be used only in very exceptional circumstances and when provided as generic, non-brand formula.
The International Code of Marketing of Breast milk Substitutes states:

21
• No donations of breast-milk substitutes, bottles or teats should be given to any part of the health care
system and donations made to institutions outside the health care system to infants who have to be fed
on breast-milk substitutes should be continued as long as the infants concerned need them.

Table 5 presents five examples of General Food Rations that meet minimum energy, protein, fat, and
micronutrient requirements, and that provide about 2,100 kcal, which is the established international
average minimum energy requirement.

Table 1. General Food Rations (grams)

Food item 1 2 3 4 5
Cereal 400 450 350 400 400
Pulses 60 60 100 60 50
Vitamin A-fortified oil 25 25 25 30 30
Fortified blended foods 50 40 50 40 45
Iodised salt 5 5 5 5 5
Sugar 15 20 25
Fish/meat 10 30

4.2 Prevention and treatment of MAM

Acute malnutrition, or ‘wasting,’ is a condition that generally results from weight loss due to illness
and/or reduced food intake. The degree of acute malnutrition of children and PLW is classified as either
moderate or severe based on anthropometric and clinical measures. Children and PLW with MAM have a
greater risk of dying because of their increased vulnerability to infection, as well as the risk of developing
SAM, which is more immediately life threatening.
At present, the most common interventions for the management (prevention and treatment) of MAM in
emergencies are SFPs. During emergency situations, SFPs should be a short-term measure and not a
means for compensating for inadequate household food security or general rations.13 This is possible if
the same household can get access to social protection programmes (e.g. PSNP), with a clear nutrition-
sensitive focus. A significant and continued reduction in the prevalence of MAM is likely only if an SFP
is implemented alongside adequate General Food Rations, access to health service, WASH, appropriate
IYCF practices and social behavioural change and communication.
SFPs
The goal of SFPs is to rehabilitate individuals affected by MAM or at risk of becoming malnourished by
providing a supplementary food ration which is highly nutritious.

SFP: There are two ways to distribute food commodities during emergencies: on-site feeding (or wet
ration) and take-home (or dry ration). The ideal dry ration supplementary food provides 1000 to 1200
kcal; 35 g to 45 g of protein; and fat supplies 30% of the required energy. On-site feeding
supplementary food provides 500 to 700 kcal per beneficiary per day; includes 15 g to 25 g of
protein; and fat supplies 30% of the required energy.

13 IASC 2008 A Toolkit for Addressing Nutrition in Emergency Situations.

22
When to establish an SFP

The decision about whether to implement SFPs should take into consideration:

1. Malnutrition rates: current and previous prevalence of GAM and SAM in children aged 6–59
months, reported in z-scores.
2. Contextual factors: including the causes of malnutrition, the socio-economic situation, the food
security situation, general ration quantity and coverage, and the presence of other humanitarian
interventions.
3. Public health priorities: whether other priority needs are already being met (shelter, water
healthcare, etc.).
4. Available human, material, and financial resources and the objectives of the project.
A decision-making framework relating malnutrition rates and SFPs adapted from WHO by the
Government of Ethiopia’s Disaster Risk Management and Food Security Sector (DRMFSS) is
outlined in Table 8.
Principles of SFPs
• SFPs aim to prevent and rehabilitate acute malnutrition.
• A take-home specialised nutritious food is provided to the patient (children under five and PLW),
with follow-up visits conducted at a nearby health facility every two weeks.
• For SFPs to achieve the intended outcomes, it is critical that effective and appropriate links are
made with food security interventions to avoid the risk of sharing the specialised nutritious food
with other members of the household.
There are two types of SFP: blanket and targeted.

Blanket SFPs
The main aim of a blanket SFP is to prevent widespread acute malnutrition and to reduce excess mortality
among those at risk by providing a food/micronutrient supplement for all members of the vulnerable
group (e.g. children under five, people with HIV and AIDS, the elderly, and the chronically ill).

Blanket SFPs may be set up under one or a combination of the following circumstances:
• At the onset of an emergency when general food distribution systems are not adequately in place;
• When there are problems in delivering/distributing the general food ration;
• When large numbers of mild and moderately acute malnourished individuals are likely to become
severe due to aggravating factors;
• When there is an anticipated increase in the rates of acute malnutrition due to seasonally induced
epidemics; and
• In the event of MND outbreaks, to provide micronutrient-rich food to the target population.

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Targeted SFPs

This programme is set up and targeted to specific groups within an affected population, when:

❖ There are large numbers of mild and moderately acute malnourished individuals;
❖ A large number of children are likely to become mildly or moderately acute malnourished due to
aggravating factors, such as serious food insecurity or high levels of disease;
❖ There are children discharged from an existing TFPs;
❖ There is a high prevalence of people with HIV and AIDS;
❖ There is a high prevalence of micronutrient deficiencies; and
❖ There is short-term hunger among pre-schoolers.

Figure 3. Programme recommendation for the prevention of acute malnutrition and treatment

Duration and closure of SFPs

Closing down nutritional interventions is a complex process involving an overall assessment of health,
nutrition, food security, etc. Phase-out criteria must not be seen as a set of strict rules but should be
viewed within the context of the situation. The closure of an SFP should be designed in a phased
approach in consultation with local authorities. Table 5 below outlines criteria for opening and closing an
SFP.

Depending on the magnitude of the emergency situation, SFPs can be phased out in a progressive manner,
for example:

⇒ a blanket SFP accompanied by a TFP (with/without GFD), followed by

⇒ a targeted SFP accompanied by a TFP (with GFD), followed by
⇒ return to only GFD and routine PHC activities for management of SAM

24
The duration of a blanket SFP depends on the scale and severity of the emergency, as well as the
effectiveness of the initial response.14 The situation should be assessed at regular intervals and the
programme re-oriented as needed, depending on whether the situation has improved (e.g. adequate
general rations established, epidemics are under control, and safe and sufficient water is present). The
nutritional status of the population should be assessed (for example, through an anthropometric survey)
before the decision to close a blanket SFP is taken. At the end of this period, if the situation is still poor,
either blanket feeding could be continued, or targeted feeding could replace the programme to ensure that
the most vulnerable are treated.

When feasible and appropriate, a gradual process of handover and integration into local primary health
services and community health programmes, such as safe motherhood, HIV/AIDS, immunisation, and the
integrated management of childhood illnesses, should be undertaken.

For both blanket and targeted SFPs, partners should assess the situation three months before the
end of the programme and ensure proposals to continue are sent to donors in a rapid manner to
avoid breaks in supplies or the unintended closure of SFPs. Table 6 below summarises the open and
phased closure criteria.

Table 2. When to open and close an SFP

Blanket SFP Targeted SFPs

When to open

• At the onset of an emergency if a reliable pipeline • There are large numbers of malnourished
for an adequate GFD is not fully in place. individuals OR a prevalence of >15% GAM 15
(or 10–14% with aggravating factors) among
• The prevalence of GAM is ≥ 20% or 15–19% children aged 6–59 months.
among children aged 6–59 months, plus
aggravating factors.
• An increase in prevalence of acute malnutrition is • There is an increase in acute malnutrition
anticipated due to seasonal deterioration in the compared to previous nutritional trends.
underlying causes of undernutrition, e.g. during a
lean season in a highly food insecure or difficult-
to-reach population. • There are large numbers of children who are
at risk of becoming malnourished due to
• To prevent malnutrition in the most vulnerable
factors such as poor food security and high
part of the population, e.g. aged 6–23 months.
rates of disease, i.e. a prevalence of 5–9%
• To prevent malnutrition in new-borns through the acute malnutrition in the presence of
nutritional support of PLW. aggravating factors.
• The population is difficult to reach due to
logistical and/or security problems when more
frequent and targeted SFP is not possible due to
time, access, and implementing partner capacity
limitations.

14Initial planning timeframes generally anticipate a duration of three months for a blanket SFP.
15Prevalence of acute malnutrition reflects the proportion of the child population (aged 6–59 months) whose weight-for-height is
below -2 z-scores, and/or have bilateral oedema (swelling).

25
 Blanket SFP Targeted SFPs
• In the event of MND outbreaks, to support overall
response, through the provision of micronutrient-
rich food, fortified commodities, or micronutrient
supplementation to the target population.

When to close

• When the prevalence of GAM among children • When there is reliable and adequate food
under 5 is < 15% with no aggravating factors accessibility and availability meeting
OR when the prevalence of GAM among minimum nutritional requirements. Food
children under 5 is < 10% in the presence of security may be ensured through general food
aggravating factors. distribution or local production (GFD should
• When there is reliable and adequate food continue for a minimum of 4–6 months after
accessibility and availability meeting SFP closure).
minimum nutritional requirements. Food
• When the prevalence of GAM is <10%
security may be ensured through general food
without aggravating factors.
distribution or local production (GFD should
include specific fortified food for children and • When control measures for infectious diseases
vulnerable individuals, and continue for a are effective.
minimum of 4–6 months after SFP closure).
• When no seasonal deterioration of nutritional • When no seasonal deterioration in nutritional
status is expected. situation is expected.
• When mortality among children under 5 years • When there are fewer than 30 children
is < 2.3/10,000/day AND the crude mortality remaining in the programme.
rate is < 1.14/10,000/day.
• When no major population influx is expected.
• When there has been a consistent decrease in
SFP admissions for two consecutive months.
• When disease control measures are effective.

4.3 Prevention and treatment of SAM

Objectives and overview of a TFP

TFPs aim to rehabilitate individuals with SAM. SAM is characterised by severe wasting and/or bilateral
pitting oedema. The management of SAM includes a package of activities to decrease mortality and
morbidity related to acute malnutrition and potentially contributing to a reduction in its prevalence.

Until recently, individuals with SAM were treated exclusively as in-patients in hospitals, health centres
and health posts. Developments in ready-to-use therapeutic foods (RUTF) over the past years, however,
along with evidence of impact and a new classification of acute malnutrition have resulted in an improved
approach to treatment. In this, depending on the severity of SAM, individuals can be effectively treated
on an outpatient basis or through a combination of inpatient and outpatient services. See Annex 7 for
details on the new classification of acute malnutrition; this includes criteria for defining SAM with and
without complications.

26
Components of a TFP

Outpatient care

Patients with appetite and no medical complication or those who have completely recovered from any
medical complications can be treated at home on an outpatient basis. The OTP is run from a health centre
or health post. In the OTP, the patient visits the health facility every week or every two weeks. During the
routine visits, the health worker assesses progress, monitors weight gain, and checks for associated
medical complications that may require referral to inpatient care. The patient receives routine medication
as necessary and RUTF supplies for the next week (or two weeks in areas where visits are every two
weeks). Individual counselling and health and nutrition education in groups is also provided during these
visits.

Inpatient care

Complicated cases need medicalised attention in the first phase of recovery. Treatment for inpatient care
in Ethiopia is provided through Therapeutic Feeding Units in hospitals or health centres and follows
WHO guidance.16,17 Children aged 6–59 months admitted into inpatient therapeutic care for the
stabilisation of their condition will be referred to outpatient care as soon as their medical complications
are resolving, their appetite has returned, and any oedema has reduced.

Children suffering from SAM have delayed mental and behavioural development. To address this,
sensory stimulation should be provided to the children throughout the period they are in inpatient care.

Community mobilisation

The quality of engagement with communities is a vital determinant of the success of the OTP.
Community mobilisation – a range of activities that help implementers understand the affected
communities, build relationships with them, and foster their participation in programme activities – is
crucial for effective early case finding. Early case finding and the quality of service provision are the two
most important determinants of case fatality rates, programme coverage, and impact. Sensitisation
messages should provide essential information about the programme’s aims and methods. If sufficient
initial efforts are put into sensitisation, self-referrals from the community will occur. However, to
maximise coverage, it is important to supplement self-referral with continual active case finding.

For additional information on the steps and procedures for treating severely malnourished children a
Therapeutic Feeding Unit, hospital or in the community, see:

 FMOH (2019), Guidelines for the Management of Acute Malnutrition

16 WHO (1999) Management of severe malnutrition: a manual for physicians and other senior health workers, Geneva, WHO.
17 WHO (2003) Guidelines for the inpatient treatment of severely malnourished children, Geneva, WHO.

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4.4 Infant and Young Child Feeding in Emergencies

In the context of humanitarian assistance for nutrition, Infant and Young Child Feeding in Emergencies
(IYCF-E) refers to a range of nutrition and care interventions that improve child survival and growth.
These include appropriate and evidence-based support for (exclusive) breastfeeding and counselling,
formula or emergency feeding interventions, when necessary, nutrient-dense complementary feeding
interventions for children > six months, and support for improved care practices, child development, and
child protection. Special attention should be paid to address any cultural practices surrounding
breastfeeding and feeding that may discriminate against girls.18

In a humanitarian crisis, other less recognised influences on IYCF practices must be addressed, including
security, privacy, and shelter for mothers. The psychosocial components of nutrition (including the
psychological, emotional and social dimensions of a child and mother’s health and wellbeing) are of
crucial importance, as they can have a considerable impact on nutritional status. Nutrition has extremely
close links with care practices and a child’s nutritional status is often determined as much by feeding
practices, home environment, and the attention received from the primary caregiver as by the food
consumed. Evidence also indicates that inclusion of psychosocial stimulation for mothers and children in
programmes for the treatment of undernutrition can improve the long-term health and development of
children.19

While the focus is on reinforcing good IYCF practices that are also advocated in non-emergency
situations, there is a greater sense of urgency in emergencies as the consequences of poor IYCF practices
are heightened. Population displacement, overcrowding, food insecurity, poor water and sanitation, the
decreased availability of caregivers, and an overburdened healthcare system all negatively impact on a
mother’s capacity to feed and care for her young infants and children and may overwhelm the capacity of
the family to provide adequate support.

Infants who are not breastfed are especially at risk: recent research reveals that breastfeeding has the
potential to reduce mortality in children under five years old by 12%20 to 20%,21 which is more than any
other preventative measure.22 Rapid and appropriate complementary feeding also features in the top three
interventions for preventing deaths in children under five, with the potential to prevent a further 6% of
deaths.23

The Mini-Ethiopian Demographic Health Survey in 2019 found that 59% of children under six months
are exclusively breastfed and 71% of infants six to nine months are given complementary foods. A strong
intervention in an emergency can be a catalyst for improvement in IYCF practices over the longer term.

18 Addressing Undernutrition in Emergencies; European Commission; Brussels, 12 March 2013, SWD (2013), 72 final.
19 Nahar, B. et al. (2008) Effects of psychosocial stimulation on growth and development of severely malnourished children in a
nutrition unit in Bangladesh, European Journal of Clinical Nutrition (September 20080.
20 R Black et al. (2008) Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet,

371: 243–60.
21 Save the Children UK (2009) Hungry for Change.
22 Black, R.E., et al. (2003) Where and why are 10 million children dying every year? The Lancet 361.
23 Jones G. et al. (2003) How many child deaths can we prevent this year? (Child Survival II) The Lancet: 65–71.

28
A rapid, appropriate response on IYCF-E relies on policy development and implementation, coordination,
strong communication and advocacy, assessment and monitoring, technical capacity and resources. The
prevailing IYCF practices of an emergency-affected population should inform the IYCF-E response.

Multi-sectoral collaboration, coordination, and preparedness at all levels is needed to meet the broad
nutritional and care needs,24 and integrate IYFC-E support into services that target mothers, infants,
and young children implementing basic measures (such as providing shelter, security, access to
adequate household food and water, non-food items). Frontline assistance to mothers and caregivers
with young children is also required in the early response and may include IYCF interventions, such
as breastfeeding counselling and support, artificial feeding, and complementary feeding
interventions.

When are IYCF-E interventions implemented during an emergency?

In every emergency context, a minimum or basic level of IYCF intervention is indicated, even in areas
where economic, nutrition, and health indicators are relatively good pre-crisis. Initial rapid assessments
should always include key information on IYCF and be supported by informed observation and
discussion.

Early assessment should establish pre-crisis feeding practices based on standard indicators: the exclusive
breastfeeding rate in 0–<6 months; the proportion of infants currently not breastfed; the conspicuous
availability of breast milk substitutes, milk products, or bottles; and any reported issues by the population
(mothers/caregivers) and health professionals regarding IYCF.

Artificial feeding in emergencies

Any support of artificial feeding in an emergency should be based on a needs assessment by skilled
technical staff, including a risk analysis on whether it is acceptable, feasible, affordable, sustainable, and
safe. This applies both in the context of HIV, where replacement feeding may have been established pre-
crisis, or in any population where infants may be artificially fed. Infants and young children supported in
these programmes must be monitored closely and acceptable, feasible, affordable, sustainable, and safe
criteria reassessed periodically.

Acceptable, feasible, affordable, sustainable, and safe criteria

Acceptable: The mother perceives no problem in replacement feeding. Potential problems may be
cultural or social, or due to the fear of stigma and discrimination.
Feasible: The mother (or family) has adequate time, knowledge, skills, resources, and support to correctly
mix the formula or milk and feed the infant up to 12 times in 24 hours.
Affordable: The mother and family, with community or health system support, if necessary, can pay the
cost of replacement feeding without harming the health or nutrition status of the family.
Sustainable: There is availability of a continuous supply of all ingredients needed for safe replacement
feeding for children up to one year of age (or older).
Safe: Replacement foods are correctly and hygienically prepared and stored, and fed preferably by cup.

24Source: The Sphere Project (2011). Sphere Handbook, ‘Chapter 3: Minimum Standards in Food Security and Nutrition’. The
Sphere Project, Geneva.

29
IYCF-E core interventions

1. Establishment of supportive spaces (IYCF corner and/or mother and baby area)
2. Basic frontline feeding support
3. Group education and information sharing
4. Nutrition care and counselling for PLWs
5. Support for early initiation of exclusive breastfeeding
6. Skilled IYCF counselling (one-on-one)
7. Further IYCF support for particularly vulnerable children, e.g. orphans, LBW, acutely
malnourished
8. Access to safe, adequate, and appropriate complementary foods
9. Support safe and adequate feeding for non-breastfed infants less than 6
months old, while minimizing the risks of artificial
feeding

IYCF-E indicators:

➢ Early initiation rate of breastfeeding in new born infants: this is a key benchmark of the
effectiveness of an emergency response.
➢ The proportion of infants under six months that are exclusively breastfed compared to pre-crisis
rate; this should not go down.
➢ Non-breastfed infants have access to an adequate amount of an appropriate breast milk substitute,
and are provided with the supportive conditions and access to the healthcare needed to reduce the
risks from artificial feeding.
➢ Incidence of watery diarrhoea in infants 0–6 months, 6–12 months, and 12–24 months.
➢ Proportion of children aged 6–24 months with access to nutritious, energy-dense, complementary
foods.
Basic multi-sectoral actions

a) Priority access for PLWs to essential services

b) Prevention of separation of children from their caregivers
c) Registration of households with PLW, children 0–23 m, and higher risk groups
d) Private and safe spaces to breastfeed
e) Standardised, clear, and accurate messages on IYCF-E

Messages to support effective breastfeeding

• Your breast milk is providing essential food and is protecting your baby against illness.
• When feeding, hold the baby close and keep the baby’s head, neck, and body in a straight line.
• Breastfeed frequently, day and night (at least eight times a day if the baby is less than six months
old).
• Hold the baby close to your breast against your skin, even when not feeding.
• Using a baby sling/wrap can help keep your baby close and will help the baby feel secure (local
context dependent – assess whether this is practised in the area or not).

30
 • Feed your baby whenever s/he shows you they want to drink, including at night.
• If baby is less than six months, they need only breast milk and nothing else. Do not give water, tea,
other milk or any other food to the baby before six months of age.
• If baby is more than six months, continue to provide breast milk as the main source of fluid
• Let the baby finish one breast; then offer the other breast.
• Avoid giving baby feeding bottles or pacifiers.

4.5 Prevention and control of micronutrient deficiencies during an emergency

Micronutrient deficiencies can easily develop during an emergency or be made worse if they are already
present. This happens because livelihoods and food crops are lost; food supplies are interrupted; diarrhoeal
diseases break out, resulting in malabsorption and nutrient losses; and infectious diseases suppress the
appetite whilst increasing the need for micronutrients to help fight illness. For these reasons it is essential
to ensure that the micronutrient needs of people affected by a disaster are adequately met. For this to happen
it is critical that general food-aid rations are adequate and well balanced to meet nutrient needs, and that
they are distributed regularly and in sufficient quantities.

It is important to understand the health and nutritional context that the affected individuals came from
before the emergency. If MND are endemic in the pre-emergency context, it is fair to assume that they
will be exacerbated during the emergency and that a micronutrient response will be necessary.

Combating MND is difficult because there are often no visible signs or symptoms until the deficiency is
severe. Biochemical tests can be conducted to measure the levels of specific micronutrients in the body,
but these surveys are costly, often not feasible during an emergency situation, and are therefore not
recommended. Clinical case definition can also be problematic and in emergencies can often only be
determined through an individual response to supplementation.

The diagnosis of some MND types is possible through simple clinical examination (such as iron
deficiency anaemia and vitamin A). Deficiencies of micronutrients such as vitamin C (scurvy), niacin
(pellagra), thiamine (beriberi) and riboflavin (ariboflavinosis) are the most commonly observed in food
aid-dependent populations.25

Over 10% of deaths among children under five years of age are attributed to deficiencies in vitamin A,
zinc, iron, and iodine.26

A low diversity diet without micronutrient-fortified foods is a strong predictor of MDDs. Appropriate
ration planning and the monitoring of food assistance programmes can greatly reduce the risk of
micronutrient malnutrition; ensuring that MDDs are monitored as part of the health information system is
important for effective surveillance.

25 Micronutrient Initiative Toolkit, Micronutrient Initiative, Ontario, Canada 2005

26 See Table 6 in: Black, R.E. et al., Maternal and Child Undernutrition Study Group. Lancet 2008; 371: 243.

31
When micronutrient deficiencies are not only due to infections, the dietary component has to be carefully
observed, and the ration composition (micronutrients) provided in the relief interventions has to be
checked.

On the basis of assessed needs, the following nutrition strategies to both treat and prevent MND during
emergencies is recommended. The combination of response options adopted depends on the level and
severity of the problem:

• The provision of fresh food items that are complementary to a General Food Ration (e.g. through
fresh food vouchers);
• The provision of fortified food aid commodities,27 such as fortified cereal, CSB+/++ (corn soya
blend), lipid-based nutrient supplement and iodised salt, and/or powders or sprinkles for home
fortification in the general ration;
• Special attention to the quality of complementary feeding for children under two years of age;
• The distribution of micronutrient supplements,28 either as single micronutrient (e.g. Vitamin A for
children, iron/folic acid for pregnant women) or population-level supplementation29 in the case of
widespread deficiencies of specific micronutrients, such as scurvy (vitamin C deficiency), pellagra
(niacin deficiency), and beriberi (vitamin B and thiamine deficiencies);
• The integration of micronutrients in the prevention and treatment of certain diseases; zinc has been
shown to be effective in the management of diarrhoeal diseases (the prevention of future episodes as
well as reduction in the duration of current episodes), which in turn can have serious nutritional
consequences; and
• The provision of vitamin A alongside, for example, measles vaccinations, can help to protect children
against infection; the EDRMC therefore supports interventions aimed at incorporating zinc and
vitamin A into delivery of healthcare services, e.g. through the provision of zinc with low-osmolality
oral rehydration salts.

The distribution of micronutrient supplements is a critical approach in combating micronutrient

malnutrition. Vitamin A capsules for children, and iron and folic acid tablets for pregnant women are well
established components of preventative public health programmes.

Vitamin A supplementation

Xerophthalmia (clinical signs of deficiency) is often reported during nutritional emergencies.

Supplementation reduces mortality among children aged 6–59 months by roughly 23% in populations
with clinical signs of Vitamin A Deficiency.

A standard prophylactic supplementation regimen in emergencies is recommended in the early-stage

emergency response. The recommended doses for preventative use are given in Table 7. Due to the toxic
effect of excess doses, those known to have received a routine high-dose vitamin A supplement within the
30 days previous to a supplementation intervention should not receive an additional dose. It is important

27 See WHO/FAO 2006: http://www.who.int/nutrition/publications/micronutrients/9241594012/en/ and WHO 2009:

http://www.who.int/nutrition/publications/micronutrients/wheat_maize_fortification/en/
28 See WHO (2006): http://www.who.int/making_pregnancy_safer/publications/Standards1.8N.pdf
29 See WHO/WFP/UNICEF 2007: http://www.who.int/nutrition/publications/micronutrients/WHO_WFP_UNICEFstatement.pdf

32
to monitor the supplementation of vitamin A in children discharged from TFPs, in children re-admitted to
SFPs, and in children who have recently participated in mass measles vaccination campaigns where
vitamin A was distributed. Vitamin A supplementation should be recorded on the child growth card or
other health-related cards.

Table 3. Supplementation to prevent vitamin A deficiency30

Frequency of dose
Population group Oral dose

Infants 0–6 months 50,000 IU Once

Infants 6–12 months 100,000 IU Every 4–6 months
Children > 1 year 200,000 IU Every 4–6 months*
Pregnant and other women aged
Not more than 10,000 IU Daily
15–49
Once during the first 8 weeks
Breastfeeding women 200,000 IU
after delivery**
*Adequate protection can also be achieved with smaller, more frequent doses, e.g. 10,000 IU weekly or 50,000 IU
monthly.
**If the mother is not breastfeeding, the supplement should be given within six weeks of delivery to prevent any risk
of teratogenicity (malformation of the baby) in a subsequent pregnancy.

4.6 Disease-related undernutrition

There are strong linkages between health and nutrition status, and consequently programming in the two
sectors should be well-coordinated. A number of priority health interventions will significantly impact the
nutritional status of the population, while many nutrition interventions are conducted through the
healthcare system.

In emergencies, with displaced, overcrowded populations and often a breakdown in health services,
infectious diseases become more prevalent and risks of epidemics are elevated. The most important
interventions to prevent epidemics are:

1. Improving sanitary conditions through ensuring clean and adequate water supplies, personal and
food hygiene, and sanitation;
2. Avoiding overcrowding;
3. Providing vector control (such as mosquito nets and residual spraying); and
4. Providing essential health services to treat new cases of disease and vaccinating against measles
and meningitis.
The major causes of excess morbidity and mortality in emergencies are acute respiratory infections,
diarrhoeal diseases, malaria (where prevalent), measles, and undernutrition.

Other communicable diseases, such as meningococcal meningitis and typhoid, may cause large-scale
epidemics, while tuberculosis may result in high levels of morbidity and mortality among emergency-
affected populations, especially in long-term emergencies, where living conditions are poor. Poor
reproductive health, trauma/injury, mental health, and psychosocial issues contribute to excess morbidity

30 Source: World Health Organization (2000) The Management of Nutrition in Major Emergencies, WHO, Geneva.

33
and mortality, while gender-based violence and its consequences, including HIV, are also a major
concern.

Prompt diagnosis and appropriate treatment of communicable diseases (according to protocols and
guidelines) are essential to reduce and prevent excess mortality in emergencies.

 See EPHI/PHEM (2011) Guidelines on Public Health Emergency Management

Common diseases related to undernutrition

Undernutrition can be caused and aggravated by diseases; therefore, supporting free access to healthcare
and promoting a healthy environment is an essential component of the prevention and treatment of acute
undernutrition The synergistic relationship between undernutrition, micronutrient deficiencies, and
various infectious and parasitic diseases is well known (including diarrhoeal diseases, HIV/AIDS,
tuberculosis, intestinal helminthic infection, respiratory infections, malaria and measles).

Undernutrition and micronutrient deficiencies facilitate infection, and some infections may result, directly
or indirectly, in the development of undernutrition and micronutrient deficiencies. However, in the current
programmatic structure of nutritional programmes, the importance of underlying diseases is often
unaddressed.

Considering the specific needs of children below five years of age and their mothers as well as pregnant
women; the following interventions are needed:

• Deworming as part of integrated child health programmes;

• Prevention and early treatment of diarrhoeal diseases;31
• Prevention and early treatment of measles and malaria.32

Acute lower respiratory tract infections are a major cause of morbidity and mortality in emergencies. It is
estimated that 25–30% of deaths in children under five years old are due to acute lower respiratory tract
infections, and 90% of these deaths are due to pneumonia.33

Risk factors for pneumonia include low birth weight, undernutrition, vitamin A deficiency, poor
breastfeeding practices, poor ventilation in shelters (smoke from indoor fires for cooking or heat), chilling
in infants, and overcrowding.

4.7 Food safety during emergencies

In the emergency context, displaced or devastated communities are often dependent on the provision of
food aid to meet their basic nutritional requirements. When food aid is provided, issues around food
handling, preparation, and storage are highlighted because the normal food systems, including cooking

31 See Joint WHO/UNICEF Statement (2004): http://whqlibdoc.who.int/hq/2004/WHO_FCH_CAH_04.7.pdf

32 See Conclusions and recommendations of the WHO Consultation on prevention and control of iron deficiency in infants and
young children in malaria-endemic areas (2006, currently under revision).
http://www.who.int/nutrition/publications/micronutrients/FNBvol28N4supdec07.pdf
33 World Health Organization, Ed. Connolly, M.A. (2005) Communicable disease control in emergencies: A field manual,

Geneva, WHO.

34
facilities and access to fuel and water, are often disrupted, and yet food must continue to be prepared and
eaten. In an emergency, food-borne illnesses are common due to inadequate hygiene and poor
infrastructure. The link between food safety and malnutrition is very clear, with poor food handling
leading to diarrhoea and other gastro-intestinal complaints, which in turn can set up the viscous cycle of
infection and malnutrition.

The ease of preparation of food aid commodities is especially important during the early stages of an
emergency. People are often weak and malnourished due to the emergency situation and need rapid
access to appropriate food that is easy to prepare and consume despite the possible lack of fuel and
cooking facilities.

Food handling, preparation, and storage

Food handling, preparation, and storage cover how food aid is packaged, delivered, prepared, and stored.
Standards that detail the quality of food commodities and a system of quality control for all commodities
must be implemented to ensure that food distributed to beneficiaries is of good quality; is safe for human
consumption; and meets the required nutritional specifications (WFP, 2005). It is very important to follow
one of the protection principles of Sphere Standards34 – to enhance the safety, dignity, and rights of
people, and avoid exposing them to harm.

Sphere standard and key indicators

• Food commodities conform to national (recipient country) and other internationally accepted
standards.
• All imported packaged food has a minimum six-month shelf life on arrival in the country and is
distributed before the expiry date, or well within the ‘best before’ period.
• There are no verifiable complaints about the quality of food distributed.
• Food packaging is sturdy, convenient for handling, storage and distribution, and not a hazard for
the environment.
• Food packages are labelled in an appropriate language with, for packaged foods, the date of
production, the ‘best before’ date, and details of the nutrient content.
• Storage conditions are adequate and appropriate, stores are properly managed, and routine checks
on food quality are carried out in all locations.
• There are no adverse health effects resulting from inappropriate food handling or preparation at
any distribution site.
• The recipients of food aid are informed about and understand the importance of food hygiene.
• There are no complaints concerning difficulties in storing, preparing, cooking, or consuming the
food distributed.
• Every household has access to appropriate cooking utensils, fuel, and hygiene materials.
• Individuals who cannot prepare food or cannot feed themselves have access to a carer who
prepares appropriate food promptly and administers feeding where necessary.

34 The Sphere Project (2018) Humanitarian Charter and Minimum Standards in Humanitarian Response

35
 • Where food is distributed in cooked form, staff have received training in safe storage, handling of
commodities, and the preparation of food, and understand the potential health hazards caused by
improper practices.

4.8 Psychosocial considerations during emergency nutrition response

Psychosocial support: This refers to actions that address both the psychological and social needs of
individuals, families, and communities. Psychosocial support is essential for maintaining good physical
and mental health, and provides an important coping mechanism for people during difficult times.

Mental health and psychosocial problems in emergencies are highly interconnected. The problems may be
predominantly social or psychological in nature.

Significant problems of a predominantly social nature include:

➢ Pre-existing (pre-emergency) social problems (e.g. extreme poverty; belonging to a group that is
discriminated against or marginalised; political oppression; women, children);
➢ Emergency-induced social problems (e.g. family separation; disruption of social networks;
destruction of community structures, resources and trust; increased gender-based violence); and
➢ Humanitarian aid-induced social problems (e.g. undermining of community structures or
traditional support mechanisms) during food and non-food item distribution.

Similarly, problems of a predominantly psychological nature include:

➢ Pre-existing problems (e.g. severe mental disorder; alcohol abuse);

➢ Emergency-induced problems (e.g. grief, non-pathological distress, depression and anxiety
disorders, including post-traumatic stress disorder); and
➢ Humanitarian aid-related problems (e.g. anxiety due to a lack of information about food
distribution).

Thus, mental health and psychosocial problems in emergencies encompass far more than the experience
of post-traumatic stress disorder.

What are the psychosocial components of nutrition?

Nutrition has extremely close links with care practices and a child’s nutritional status is often determined
as much by feeding practices, the home environment, and the attention received from the primary
caregiver as by the food s/he eats.

Why are psychosocial issues key in emergencies?

In emergency situations, the social, physical, and psychological damage produces changes in behaviour
and emotion, impacting on feeding practices.

The poor nutritional, mental, or physical health of caregivers in an emergency context may render them
unable to provide psychosocial stimulation to their children and may affect their own and their children’s
feeding practices. Similarly, the capacities to care for children or any other vulnerable groups within the
population might be overwhelmed, increasing the risk of malnutrition, and potentially limiting the

36
efficiency of nutrition treatment. As a result, emergencies can provoke and aggravate cases of chronic or
acute malnutrition and micronutrient deficiencies through the impact they have on psychosocial
wellbeing.

When should psychosocial issues be addressed?

Psychosocial issues should be addressed in all emergency programmes wherever possible and during and
even post emergencies since psychological time is not directly correlated with chronological time: people
may still be affected years after the end of the war by a specific and traumatic event.

How are psychosocial issues addressed during emergency nutrition interventions?

Strengthening the traditional care system in the community, even in emergency settings, can be ideal in
terms of cultural appropriateness, empowerment, and sustainability. Solutions within the families can
often provide the best opportunities to support care practices and survival.

Within emergency nutrition programmes, different activities to support the psychosocial aspects of
nutrition may be put in place. These can include:

➢ Stimulating the children and helping the families to favour the child’s development, including the
psychological and emotional aspects of this;
➢ Supporting play sessions for mother and child, and ensuring that a play area with toys is available
to parents and staff to interact with malnourished children;
➢ Offering social and psychological support to the families or caregivers;
➢ Ensuring that PLW with malnutrition are screened for mental disorders and linked to Mental
Health and Psychosocial Support service (Psychological First Aid, counselling, psychotropic
medication, etc.);
➢ Providing staff training in psychosocial issues to improve their knowledge, understanding, and
attitude towards patients and their families;
➢ Offering breastfeeding corners for pregnant and breastfeeding women to provide mothers with a
space to share experiences, and to receive advice and reinforce self-esteem;
➢ Collaborating and networking with local services and/or specialised organisations to assist and
support especially vulnerable groups (PLW, girls, those with disabilities, etc.); and
➢ Facilitating discussions between the families and the staff when a severely malnourished child
has to be treated in an inpatient facility to clarify who will take care of the rest of the family and
the household in the absence of the mother (this emphasises the need for processes that support
mothers and family structures).

Even if some activities target the caregiver and/or the child specifically, it is essential to work closely
with the whole family.

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 5. SUPPLY MANAGEMENT IN EMERGENCIES
Emergencies, such as conflict situations or flooding, can happen suddenly and cause large casualties and
significant damage to society. In general, a disaster can be defined as ‘a shocking event that seriously
disrupts the functioning of a community or society, by causing human, material, economic or
environmental damage’.35 When a large-scale disaster happens, immediate emergency responses are
needed in order to save lives and relieve and control the damage. Emergency logistics represents ‘the
support function that ensures the rapid delivery of emergency resources and rescue services into the
affected locations so as to assist in rescue activities to aiding people in their survival during and after a
disaster’.36

Large-scale emergency nutrition response will require mobilisation of metric tonnes of bulk supplies,
such as RUTF, RUSF, F75, F100, treatment kits, and other essential medicines. The delivery is time-
sensitive to avert excess mortality. This section guides with steps to be taken to ensure that logistic and
supply mobilisation is rapid and streamlined as much as possible, while maintaining national standards.
There is no fixed blueprint but it is useful to consider the following essential steps during planning and
response:

1. Needs assessment;
2. Resource mapping and mobilisation;
3. Procurement;
4. Prepositioning, warehouse, and storage;
5. Distribution; and
6. Transport.

1. Needs assessment

Needs assessments in nutrition emergencies involve systematically gathering and analysing information
relating to the needs, conditions, and capacities of an affected population – diverse women, men, girls,
and boys of all ages, including those with specific needs – in order to determine gaps between a current
situation and minimum national standards. It must be conducted rapidly with the active involvement of
the persons affected and the national stakeholders and partners (UN, NGOs, and civil society). This will
help to define the type of emergencies, e.g. conflict or climate related (drought, flooding, desert locust
infestation, etc.) Population displacements, disease outbreaks, and their impact on the community will
need to be mitigated with the required interventions.

• Carry out a rapid nutrition assessment on the scope and scale of emergency, the geographical
areas, and the number of affected people.
• Determine needs and formulate response requirements in close coordination with all relevant
stakeholders.

35 Galindo, G., and Batta, R. 2013 Review of recent developments in OR/MS research in disaster operations management.
European Journal of Operational Research Volume 230, Issue 2, 16 October 2013, Pages 201-211
36 Danish Refugee Council (2008) Programme Handbook, Emergency Logistics and Transport Management, Danish Refugee

Council, Copenhagen, Denmark, Chapter 8i, pp. 1–9.

38
 • Assess and determine the existing capacities at different administrative levels (kebele, woreda,
zonal, regional, federal).
• Assess the available supplies, warehouses, vehicles, means of transport, and contractors.
• Determine additional needs based on gaps identified.
• Determine existing transport infrastructure: road, air, donkey/camel.
• Differentiate appropriate entry points: sea, air, and land.

2. Resource mapping and mobilisation

Resource mobilisation involves fund raising for the humanitarian response against humanitarian response
plans. Ensuring an effective emergency response and positive nutrition outcomes for crisis-affected
populations requires substantial funding. Successful resource mobilisation will thus rely on an
understanding of the humanitarian financing landscape in Ethiopia during the time of crisis, together with
the resources available to the government, and the transparent mapping of other actors, their priorities,
and their resources commitment. The government’s commitment to protecting lives of the citizens will
facilitate the accelerated mobilisation of logistics and resources through the following steps.

o Develop response plan, led by the government showing all needs, funding, human resource,
logistics, supplies, and quantities.
o Identify available resources and gaps, and explore on who will contribute what.
o Conduct stakeholder analysis to identify actors among government partners (UN, INGOs,
etc.) and other actors, including the private sector.
o Assign key tasks linked to the response plan based on the stakeholder analysis.
o Establish coordination forum for regular updates (daily, weekly, biweekly, as needed).

3. Forecasting and procurement

The qualities of successful humanitarian response include the ability to rapidly identify needs and engage
in fundraising, forecasting, procuring, transporting, distributing, and delivering products and services to
people in need. The procurement of products (e.g. medicines, food, or non-food-items) and services (e.g.
transport, warehousing, and data collection and analysis) is a critical activity for emergency nutrition
response. A huge proportion of humanitarian response budgets go on procurement; thus, strict ethical
guidelines must be followed while striving to simplify procurement process to ensure accountability and
integrity of supplies, and to protect against the misuse of national guidelines. The following benchmarks
are to be observed:

• Establish rapid procurement processes appropriate to the emergency situation to ensure the
country has the resources needed to meet identified needs.
o Establish a list, specification, and quantity of the items required for the emergency
response.
o Maintain pre-qualified suppliers of standard essential items for emergency response
locally/internationally. Assess their delivery capacity/time for appropriate follow-up
action.
o Place emergency procurement and notify the government authorities organising the
emergency response .

39
 o Ensure that the lead government authority coordinates with regulatory bodies (customs
agencies and the Ethiopian Food and Drug Authority) to expedite the process.

4. Prepositioning, warehouse, and storage

As a preparedness measure, the Government of Ethiopian and emergency nutrition response actors must
pre-position emergency supplies at the national, regional, zonal, and woreda levels in preparation for
humanitarian responses. The goal is to ensure that supplies and logistics are closer to the affected areas
for rapid response.

o In the response plan, ensure that different items needed, and in the right quantities, and in the
geographic area where they are needed, are clearly mapped and that a delivery plan is in place.
o Ensure that a minimum stock to cover three months is maintained at all times.
o Map existing warehouse capacity, including EPSA hubs, RHB stores, Woreda health office,
health facilities, partners, and selected temporary storage sites.
o Make arrangement for warehousing and storage to protect supplies and ensure accountability
through an organised system, until they can be delivered to their ultimate recipients.
o Ensure standard documentation using standard recording and reporting formats.
o Coordinate with the security authority for safeguarding and protecting supplies.
o Ensure coordinated transport and delivery to maximise efficiency.
o Update regularly on prepositioning provided at various levels and red flags on depleting stocks
for urgent replenishment.

5. Distribution

The ultimate objective of the process in the logistics management process is to ensure that the supplies get
into the hands of the intended recipients when and where they need it. This is end-user delivery, and all
bottlenecks must be consciously removed to achieve this objective. For emergency nutrition response the
following steps will be followed:

• Clearly establish channels of distribution, including health system, MHNTs, and local
administration.
• Link distribution channels to key actors based on established cluster database maintained by the
nutrition cluster.
• Establish new partnerships where gaps are identified (i.e. where there is a lack of key actors).
• Link key actors with prepositioning sites.
• Deliver the response to the people affected by a disaster (or to partners entrusted with the
distribution of relief supplies) according to the plan, through well-organised distribution systems
that ensure accountability to prevent misuse or wastage.
• Use standard recording, reporting, and requesting formats and procedures to ensure stock
monitoring.

40
6. Transport

o Put in place transport arrangements to ensure supplies reach the places where they are needed.
o Develop a transport strategy that takes into account the need for different types of transport to
deliver supplies from one place to another.
o Define your transport requirements for personnel and supplies.
o Consider all transport modes and always establish alternative options.
o Identify what supplies or people need to be moved and to where.
o Identify feasible, available transport options, requirements, and route and schedule planning.
o Arrange contracts with transport providers.
o Ensure insurance terms are included.
o Ensure all appropriate transport documents are in place.
o Ensure appropriate controls are in place at the sending and receiving stages.
o Consider and develop a strategy for back transport of equipment and material after the emergency
is over.

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6. MONITORING AND EVALUATION
Monitoring and evaluation (M&E) activities form an integral part of all nutrition interventions to improve
quality and accountability, and provide opportunities for learning.

Monitoring is the periodic oversight of the implementation of an activity to establish the extent to
which input deliveries, work schedules, other required actions, and targeted outputs are proceeding
according to plan, so that rapid action can be taken to correct deficiencies detected.
Evaluation is a process to determine, as systematically and objectively as possible, the relevance,
effectiveness, efficiency, and impact of activities in the light of specified objectives.

There are guidelines for M&E for nutrition and nutrition-related interventions in emergencies. These are
detailed in the intervention guidelines highlighted within each section of these guidelines. The Sphere
Project provides the most widely accepted indicators for food security and nutrition interventions in
humanitarian emergencies.

 See the Sphere Project (2018) Humanitarian Charter and Minimum Standards in
Humanitarian Response, Chapter 3: Food Security and Nutrition.

6.1. Monitoring GFD

A good monitoring system should determine:

• Appropriate targeting: whether the decision to target food within a certain geographical area is
appropriate.

• Verify if the most vulnerable received the food aid: whether the groups in greatest need were
identified in the assessment and received the food aid.

• Realistic objectives: whether the objectives of the GFD were achievable and realistic.

• Effects: whether (and to what extent) the adverse effects of food assistance were avoided and whether
asset depletion of households was halted.

➢ Pipeline management (how much food is needed, how much is available, and the timing of the
arrival of food supplies);
➢ Food management (storage, warehousing, logistics, transport, etc.);
➢ Number and identification of beneficiaries (numbers of people in need, registration, ration
criteria, exit and entry criteria); and
➢ Management of food distribution (frequency, location).

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Box 1: Sphere Standards and key indicators relevant to GFD

Food Security, Food Transfers Standard 1: General nutrition requirements

Ensure that the nutritional needs of the disaster-affected population, including those most at risk, are
met.
Key indicators
• There is adequate access to a range of foods, including a staple, pulses (or animal products)
and fat sources that together meet nutritional requirements.
• There is adequate access to iodised salt for the majority (>90%) of households.
• There is adequate access to additional sources of niacin (e.g. pulses, nuts, dried fish, etc.) if the
staple is maize or sorghum.
• There is adequate access to adequate sources of riboflavin where people are dependent on a
very limited diet.
• There are no cases of scurvy, pellagra, beriberi, or riboflavin deficiency.
• The prevalence of vitamin A deficiency, iron deficiency anaemia. and iodine deficiency
disorders are not of public health significance.

See DRMFSS (2011) National Guidelines on Targeting Relief Food Assistance

6.2. Monitoring interventions for the treatment of MAM

The monitoring of MAM interventions can be divided into individual case monitoring, programme
performance monitoring, and community assessments. The supply system (management and transport of
equipment, materials, drugs, and therapeutic foods) will also require monitoring and reporting.

Box 2: Sphere key indicators for MAM

These indicators are primarily applicable to the 6–59-month age group, although other age groups
may be part of the programme.

• More than 90% of the target population is within a one day’s return walk (including time for
treatment) of the programme site for dry ration supplementary feeding programmes, and no
more than one hour’s walk for on-site supplementary feeding programmes.
• Coverage is >50% in rural areas, >70% in urban areas, and >90% in a camp situation.
• The proportion of discharges from targeted supplementary feeding programmes who have died
is <3%, recovered is >75%, and defaulted is <15%.

Refer to Guidelines for the management of moderate acute malnutrition 2011 for available tools.

43
6.3. Monitoring interventions for the treatment of SAM

Monitoring enables health workers, supervisors, and managers to ensure that appropriate treatment is
given to individuals and that the services provided are effective. The box below summarises the Sphere
key indicators against which interventions for the management of SAM should be monitored and
evaluated.
Box 3: Sphere key indicators for interventions for the management of SAM
These indicators are primarily applicable to the 6–59-month age group, although others may
be part of the programme.

• More than 90% of the target population is within a one day’s return walk (including time for
treatment) of the programme site.
• Coverage is >50% in rural areas, >70% in urban areas, and >90% in camp situations.
• The proportion of discharges from therapeutic care who have died is <10%, recovered is
>75%, and defaulted is <15%.

Routine data are collected for monthly reporting on:

• The number of new admissions;
• The number of discharges by category: cured, died, defaulted, non-recovered; and
• The number of children in treatment (beneficiaries registered).

In Ethiopia, the TFP Performance Monitoring Score Card is used by the Federal Ministry of Health and
partners for monitoring the OTP during site visits. This comprehensive monitoring tool collects
information on both process and performance indicators, as well as recording stock requirements and
relevant issues affecting programme performance. It also provides a framework for mentoring health
extension workers during the monitoring visit.

See MOH (2019) Guidelines for the Management of Severe Acute Malnutrition

6.4 Monitoring IYCF-E interventions

The relevant Sphere minimum standards and key indicators against which interventions should be
monitored are found in the box below.

Box 5: Sphere minimum standards and key indicators for IYCF interventions in
emergencies

Infant and young child feeding standard 1: Policy guidance and coordination
Safe and appropriate infant and young child feeding for the population is protected through the implementation of
key policy guidance and strong coordination.
Key indicators:

44
 • A national and/or agency policy is in place that addresses IYCF and reflects the Operational Guidance on
Infant and Young Child Feeding in Emergencies.
• A lead coordinating body on IYCF is designated in every emergency.
• A body to deal with any donations of breast milk substitutes, milk products, bottles, and teats is
designated.
• Code violations are monitored and reported.
Infant and young child feeding standard 2: Basic and skilled support
Mothers and caregivers of infants and young children have access to timely and appropriate feeding support that
minimises risks and optimises nutrition, health and survival outcomes.
Key indicators:
• Measurement of standard WHO indicators for early initiation of breastfeeding, exclusive breastfeeding
rate in children <6 months, and continued breastfeeding rate at one and two years.
• Caregivers have access to timely, appropriate, nutritionally adequate. and safe complementary foods for
children 6–<24 months.
• Breastfeeding mothers have access to skilled breastfeeding support.
• There is access to Code-compliant supplies of appropriate breast milk substitutes and associated support
for infants who require artificial feeding.

 Refer to the Operational guidance on infant and young child feeding in emergencies, developed
by the inter-agency Infant Feeding in Emergencies Core Group.

6.5 Monitoring micronutrient interventions

Box 4: Sphere indicators for M&E of micronutrient interventions in emergencies

• Cases of micronutrient deficiencies are treated according to current best clinical practice.
• Micronutrient interventions accompany public health interventions to reduce common diseases associated
with emergencies such as measles (vitamin A) and diarrhoea (zinc).

As for other nutrition interventions, M&E of micronutrient interventions and their impact is important to
identify:
• Whether the intervention is functioning adequately;
• Whether the intervention is available, affordable, and acceptable to the target population;
• To what extent the intervention is being used by the population, i.e. coverage; and
• The impact of the intervention on the micronutrient status of target population.

Guidance for monitoring interventions relating to vitamin A, iodine, and iron, as well as the identification
of the public health significance of deficiencies can be found in:
See FMOH (2004) National guidelines for control and prevention of micronutrient deficiencies.

45
6.6. Monitoring performance indicators

The performance of SAM and MAM services can be analysed from the weekly and monthly reports and
outcomes compared to international Sphere Standards.

• Indicators

The outcomes are calculated as a proportion of SAM or MAM programme discharges over the period
(usually monthly, quarterly, or annually). The following outcomes are monitored.

1. Cure rate: Proportion discharged from SAM or MAM treatment having reached the cure
discharge criteria.
𝑇𝑜𝑡𝑎𝑙 𝑑𝑖𝑠ℎ𝑎𝑟𝑔𝑒𝑑 𝑐𝑢𝑟𝑒𝑑
𝐶𝑢𝑟𝑒 𝑟𝑎𝑡𝑒 (%) = × 100
𝐶𝑢𝑟𝑒𝑑 + 𝐷𝑖𝑒𝑑 + 𝐷𝑒𝑓𝑎𝑢𝑙𝑡𝑒𝑑 + 𝑁𝑜𝑛 𝑟𝑒𝑠𝑝𝑜𝑛𝑑𝑒𝑟𝑠

2. Default rate: Proportion discharged having defaulted.

𝑇𝑜𝑡𝑎𝑙 𝑑𝑖𝑠ℎ𝑎𝑟𝑔𝑒𝑑 𝑑𝑒𝑓𝑎𝑢𝑙𝑡𝑒𝑟𝑠
𝐷𝑒𝑓𝑎𝑢𝑙𝑡 𝑟𝑎𝑡𝑒 (%) = × 100
𝐶𝑢𝑟𝑒𝑑 + 𝐷𝑖𝑒𝑑 + 𝐷𝑒𝑓𝑎𝑢𝑙𝑡𝑒𝑑 + 𝑁𝑜𝑛 𝑟𝑒𝑠𝑝𝑜𝑛𝑑𝑒𝑟𝑠

3. Deaths: Proportion discharged having died while registered for SAM or MAM treatment.
𝑇𝑜𝑡𝑎𝑙 𝑑𝑖𝑠ℎ𝑎𝑟𝑔𝑒𝑑 𝑑𝑖𝑒𝑑
𝐷𝑒𝑎𝑡ℎ 𝑟𝑎𝑡𝑒 (%) = × 100
𝐶𝑢𝑟𝑒𝑑 + 𝐷𝑖𝑒𝑑 + 𝐷𝑒𝑓𝑎𝑢𝑙𝑡𝑒𝑑 + 𝑁𝑜𝑛 𝑟𝑒𝑠𝑝𝑜𝑛𝑑𝑒𝑟𝑠

4. Non-cured: Proportion discharged having not achieved the cure discharge criteria.
𝑇𝑜𝑡𝑎𝑙 𝑑𝑖𝑠ℎ𝑎𝑟𝑔𝑒𝑑 𝑛𝑜𝑛 𝑟𝑒𝑠𝑝𝑜𝑛𝑑𝑒𝑟𝑠
𝑁𝑜𝑛 𝑟𝑒𝑠𝑝𝑜𝑛𝑑𝑒𝑟 𝑟𝑎𝑡𝑒 (%) = × 100
𝐶𝑢𝑟𝑒𝑑 + 𝐷𝑖𝑒𝑑 + 𝐷𝑒𝑓𝑎𝑢𝑙𝑡𝑒𝑑 + 𝑁𝑜𝑛 𝑟𝑒𝑠𝑝𝑜𝑛𝑑𝑒𝑟𝑠

• Other service indicators

Average length of stay: The period in number of days that a patient spends in treatment from admission
to discharge. Length of stay is calculated only for child patients cured. It should be calculated separately
for patients with wasting and bilateral pitting oedema since these will have different lengths of stay.

𝑆𝑢𝑚 𝐿𝑒𝑛𝑔𝑡ℎ 𝑜𝑓 𝑆𝑡𝑎𝑦

𝐴𝑣𝑒𝑟𝑎𝑔𝑒 𝐿𝑒𝑛𝑔𝑡ℎ 𝑜𝑓 𝑆𝑡𝑎𝑦 =
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐𝑎𝑟𝑑𝑠 𝑜𝑟 𝑐𝑎𝑠𝑒𝑠 𝑖𝑛 𝑡ℎ𝑒 𝑠𝑎𝑚𝑝𝑙𝑒

Average Weight Gain: The rate of weight gain per kilogram of body weight per day. Average Weight
Gain is calculated only for patients who have been cured and discharged.

𝑊𝑒𝑖𝑔ℎ𝑡 𝐺𝑎𝑖𝑛
𝐷𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒 𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑔𝑟𝑎𝑚𝑠 − 𝑚𝑖𝑛𝑚𝑢𝑚 𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑔𝑟𝑎𝑚𝑠
=
𝑀𝑖𝑛𝑖𝑚𝑢𝑚 𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑘𝑔 × 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑎𝑦𝑠 𝑏𝑒𝑡𝑤𝑒𝑒𝑛 𝑚𝑖𝑛𝑖𝑚𝑢𝑚 𝑤𝑒𝑖𝑔ℎ𝑡 𝑎𝑛𝑑 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒 𝑑𝑎𝑦

𝑆𝑢𝑚 𝑜𝑓 𝑤𝑒𝑖𝑔ℎ𝑡 𝑔𝑎𝑖𝑛𝑠 (𝑖𝑛 𝑔𝑟𝑎𝑚𝑠 𝑝𝑒𝑟 𝑘𝑔 𝑏𝑜𝑑𝑦𝑤𝑒𝑖𝑔ℎ𝑡 𝑝𝑒𝑟 𝑑𝑎𝑦)

𝐴𝑣𝑒𝑟𝑎𝑔𝑒 𝑊𝑒𝑖𝑔ℎ𝑡 𝐺𝑎𝑖𝑛 =
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐𝑎𝑟𝑑𝑠 𝑜𝑟 𝑐𝑎𝑠𝑒𝑠 𝑖𝑛 𝑡ℎ𝑒 𝑠𝑎𝑚𝑝𝑙𝑒

46
 • Outcome indicators

Table 8 below provides the international reference standards for MAM and SAM outcome indicators.

Table 4. Performance outcome indicators

Indicator Management of SAM Management of MAM

Cured > 75% > 75%
Defaulted < 15% < 15%
Died < 10% < 3%
Non-responder Not stated Not stated
Length of stay 60 days
Average Weight Gain *>5 g/kg/day Not applicable
Coverage: urban > 70% > 70%
Coverage: rural > 50 % > 50 %

M&E indicators

In addition to benchmark indicators for assessing efficiency and effectiveness of SFP and TFP listed in the
preceding sections, below are examples of currently used indicators in refugee and non-refugee situations.19

Table 5. Exit categories for therapeutic and supplementary feeding

INPATIENT CARE OUTPATIENT CARE SUPPLEMENTARY FEEDING

for the Management of SAM for the Management of SAM for the Management of MAM
with Medical Complications without Medical Complications

EXIT CATEGORY: CURED

Child 6–59 months meets Child 6–59 months meets Child 6–59 months meets
outpatient care discharge discharge criteria discharge criteria
criteria
Infant < 6 months meets
inpatient care discharge
criteria

EXIT CATEGORY: DIED

Child dies while in inpatient Child dies while in outpatient Child/PLW dies while in
care care supplementary feeding

EXIT CATEGORY: DEFAULTED

Child is absent for two Child is absent for three Child/PLW is absent for three
consecutive days consecutive visits consecutive visits

47
 EXIT CATEGORY: NON-RECOVERED

Child does not reach Child does not reach discharge Child/PLW does not reach
discharge criteria after 4 criteria after 4 months in discharge criteria after 4 months
months in treatment (medical treatment (medical in treatment (medical
investigation previously done) investigation previously done) investigation previously done)

Indicators for inpatient TFP

Table 6. Summaries of indicators used for therapeutic feeding

Indicators for TFPs for children aged 6–59 months

Indicator Description Formula Units Standard

Mean length Average length Sum no. days of admission Inpatient care till
of stay stays for of recovered children 6–59 full recovery 1
recovered months/ No 6–59 months month
children exists due to recovery
Inpatient and
outpatient care
combined < 2
months

Average Average no. Sum [(weight on exit (g) g/kg/day Inpatient care till
weight grams that minus minimum weight full recovery
gain recovered (g))/(weight on admission
>= 8g/kg/day
children gained (kg)) x duration of treatment
per kg per day (days)] / No recovered Inpatient and
since admission children outpatient care
into TFP combined
>=4g/kg/day

Recovery Proportion of No. of 6–59 months % > 75%

rate under-five exits recovered/total no. of under-
from TFP due five exits (recovered, died,
to recovery defaulted)
x 100

Death rate Proportion of No under-five deaths/total % < 10%

under-five exits no. of under-five exists
from TFP due (recovered, died, defaulted)
to death x 100

Default rate Proportion of No of under-five % < 15%

under-five exits defaulters/total no. of under-
from TFP due five exits (recovered, died,
to default defaulted) x 100

48
REFERENCES
1. Global Nutrition Report (2018) www.globalnutritionreport.org.
2. Ethiopia (2017) ‘Humanitarian Response Situation Report No. 16’ (November 2017).
3. Global report on food crises (2019) www.fsincop.net @FSIN_News.
4. Ethiopian Demographic Health Survey Report 2016.
5. UNICEF Ethiopia (2016) ‘Country briefing note on nutrition’, www.unicef.org/ethiopia.
6. Kasolo F., Roungou J.B., Perry H. (eds.) (2010) Technical guidelines for integrated disease
surveillance and response in the African region, 2nd edn., Brazzaville, Republic of Congo,
Atlanta, Georgia, USA.
7. Guidelines for selective feeding: the management of malnutrition in emergencies (2011).
8. EHaNRI, Centre PHEM (2012) ‘Public health emergency management guidelines for Ethiopia’,
Federal ministry of health of Ethiopia.
9. World Food Programme (2007) ‘Consolidated Framework of WFP Policies – An Updated
Version’, Rome, World Food Programme, 2007.
www.wfp.org/sites/default/files/wfp137486~2.pdf
10. World Food Programme (2005) ‘Definition of Emergencies’, Rome, World Food Programme,
http://docustore.wfp.org/stellent/groups/public/documents/eb/wfp043676.pdf
11. OCHA (1999) OCHA Orientation Handbook on Complex Emergencies,
http://www.reliefweb.int/ library/documents/ocha__orientation__handbook_on__.htm
12. IASC (2008) ‘Transitioning to the WHO Growth Standards: Implications for Emergency
Nutrition Programmes’, IASC Nutrition Cluster Informal Consultation Meeting Report. Geneva.
www.humanitarianreform.org/humanitarianreform/Portals/1/cluster%20approach%20page/cluster
s%20pages/Nutrition/WHO%20growth%20standards%20meeting%20report%20FINAL.pdf
13. WHO (1999) Management of Severe Malnutrition: a Manual for Physicians and Other Senior
Health Workers, Geneva, World Health Organization.
http://whqlibdoc.who.int/hq/1999/a57361.pdf
14. Collins S., Duffield A., and Myatt M. (2000) ‘Adults: Assessment of Nutritional Status in
Emergency-Affected Populations’, Geneva, the United Nations System Standing Committee on
Nutrition, 2000. www.unscn.org/layout/modules/resources/files/AdultsSup.pdf
15. WFP (2000) Food and Nutrition Handbook, Rome, World Food Programme.
http://foodquality.wfp.org/FoodNutritionalQuality/WFPNutritionPolicy/tabid/362/Default.aspx?P
ageContentID=537
16. IASC/Global Nutrition Cluster/Nutrition Works (2008) ‘Harmonized Training Materials
Package’, IASC Global Nutrition Cluster, UNICEF, New York.
http://oneresponse.info/GLOBALCLUSTERS/NUTRITION/Pages/Harmonized%20Training%20
Package.aspx

49
17. UNHCR (2010) Health Information System (HIS) – Standards and Indicators Guide (Revised
January 2010), Geneva, High Commissioner for Refugees. http://www.unhcr.org/protect/
PROTECTION/4614ab8e2.pdf
18. Ethiopian Mini Demographic and Health Survey Report 2019.
19. Operational Guidance on Infant and Young Child Feeding in Emergencies (2017) Version 3.0.
IFE Core Group.
20. By a registered medical practitioner under the Bangladesh Medical and Dental Council Act, 2010
(Act No. 61 of 2010)
21. Section 5.2.8 Operational Guidance on IFE (full reference above).
22. Section 5.2.8 Operational Guidance IFE.
23. WHO (2004) ‘Guiding Principles for feeding infants and young children during emergencies’,
WHO Geneva.
24. WHO, UNICEF, ‘Micronutrient Forum, Vitamin A supplements, a guide to their use in the
treatment and prevention of vitamin A deficiency’, 3rd edition, Geneva.
25. The Rehydration Project (1996–2007) Diarrhoea.org website, Rehydration Project.

50
8. ANNEXES
Annex 1. Emergency treatment of SAM
CONDITION IMMEDIATE ACTION

Dehydration If a patient with SAM and acute diarrhoea or severe vomiting has any signs of
dehydration (e.g. sunken eyes with recent onset of diarrhoea), and is not lethargic or
unconscious:
DO NOT GIVE IV FLUID; rehydrate orally as follows:
• Give 50 ml 10% glucose or sugar water (infants 25 ml) orally or by nasogastric tube
(NGT).
• Give ReSoMal 5 ml/kg every 30 minutes for 2 hours orally (if child is too ill, give
ReSoMal by NGT).
• Monitor pulse and respiration rates every 30 minutes during rehydration.
• Then, give ReSoMal 5–10 ml/kg every 2 hours in alternate hours with F-75 10 ml/kg
every two hours for up to 10 hours.
STOP if patient displays signs of hydration: clinically well and an alert, normal eye, tears,
moist tongue, and drinks normally.
STOP if patient shows signs of over-hydration (which may lead to congestive heart
failure): fast breathing, increase in both respiratory rate (≥5 breaths/min) AND pulse rate
(≥25 beats/min).

Shock If the patient has signs of shock (cold hands with slow capillary refill (longer than three
seconds) and/or weak or fast pulse) and is lethargic or unconscious:
• Give oxygen, 1–2 litres/minute.
• Keep the patient warm.
• Give sterile 10% glucose 5 ml/kg IV.
• Give IV fluid at 15 ml/kg for 1 hour, using one of the following solutions (in order of
preference):
o Ringer’s lactate with 5% dextrose*
* Add sterile potassium chloride (20 mmol/L).
(Or if above not available, use 0.45% saline with 5% glucose*)
DO NOT GIVE AS A BOLUS
• Monitor pulse and respiration rates every 10 minutes.
• Give antibiotics.
STOP IV if the child shows signs of over-hydration (may lead to congestive heart failure):
fast breathing, increase in both respiratory rate (≥ 5 breaths/min) AND in pulse rate (≥ 25
beats/min). Other signs of heart failure are: distension of the jugular veins, enlarged liver,
eyelid oedema, gallop rhythm, fine crackling in the lungs.

If there are signs of improvement after giving IV fluid for an hour, continue to give IV
fluid 15 ml/kg for a second hour.

51
 If there are NO signs of improvement after the first hour of IV fluid, assume patient has
septic shock. In this case:
• Give maintenance fluids 4 ml/kg/hour while waiting for blood.
• Order 10 ml/kg fresh whole blood and when blood is available, stop oral intake and IV
fluids.
• Give Furosemide 1 ml/kg IV at the start of the transfusion.
• Transfuse whole fresh blood 10 ml/kg slowly over three hours. If there are signs of heart
failure, give 7 ml/kg packed cells instead of whole blood.

If the patient with SAM has signs of shock, but is not lethargic or unconscious:
• Keep the patient warm.
• Give 10% glucose 5 ml/kg or 50 ml 10% glucose or sugar water (infants 25 ml) orally or
by NGT.
• Give antibiotics.
• Proceed immediately to full assessment and treatment; initiate oral or nasogastric feeding
with F-75.

Hypoglycaemia If the patient with SAM has hypoglycaemia (blood glucose < 3 mmol/L or < 54 mg/dl):
• Give sterile 10% glucose 5 ml/kg IV, then 50 ml 10% glucose or sugar water (infants 25
ml) by NGT, or what is first available.
• Keep the patient warm.
• Give antibiotics.
• Start feeding with F-75.

Hypothermia If the patient with SAM has signs of hypothermia (< 35°C axillary temperature):
• Warm the patient.
• Give sterile 10% glucose 5 ml/kg IV or 50 ml 10% glucose or sugar water (infants 25
ml) by NGT.
• Give antibiotics.
• Start feeding with F-75.

Severe If the patient with SAM has signs of severe pneumonia (central cyanosis, severe
pneumonia respiratory distress, inability to drink or retain fluids (i.e. vomiting up everything),
convulsions, low chest wall in-drawing, stridor (in a calm child), or fast breathing):
• Give oxygen, 1–2 litres/minute.
• Keep the child warm.
• Give antibiotics.
• Initiate cautious feeding by NGT.

Convulsions If the patient with SAM has signs of convulsions:

• Give Diazepam or Paraldehyde rectally.

52
 • Turn the unconscious child onto his/her side to reduce the risk of aspiration and stabilise
the body position.
• Give sterile 10% glucose 5 ml/kg by IV.

Severe anaemia If the patient with SAM has very severe anaemia (Hb < 4 g/dl or < 6 g/dl with respiratory
distress), a blood transfusion is required:
• Give whole fresh blood 10 ml/kg body weight slowly over three hours. If there are signs
of anaemic heart failure, give 7 ml/kg packed cells over three hours rather than whole
blood.
• Stop all oral intake and IV fluids during the transfusion.
• Give Furosemide 1 ml/kg IV at the start of the transfusion.

Congestive heart If the patient with SAM develops signs of fluid overload or heart failure during
failure rehydration (the first sign is fast breathing; other danger signs are increases in respiratory
rate (≥ 5 breaths/min) and in pulse rate (≥25 beats/min), distension of the jugular veins, an
enlarged liver, eyelid oedema, gallop rhythm, and fine crackling in the lungs):
• Stop all food intake and IV fluids. Do not give any fluids until the heart failure has
improved.
• Give Furosemide 1 mg/kg IV. Monitor the patient closely when giving furosemide and
reassess the child frequently until symptoms improve.
Give Digoxin 15 μg/kg IV only if the diagnosis of heart failure is unmistakable (elevated
jugular venous pressure).

Signs of If the patient with SAM has dry conjunctiva or cornea, corneal clouding or ulceration,
Blindness Bitot’s spots, or keratomalacia:
• Give vitamin A immediately (< 6 months 50,000 IU, 6–12 months 100,000 IU, > 12
months 200,000 IU) and repeat on Day 2 and Day 14.
• For corneal ulceration, instil 1 drop of Atropine (1%) into the affected eyes for pain and
to prevent the lens from pushing out.
• Administer Chloramphenicol eye drops every three hours or apply Tetracycline eye
ointment every four hours and bandage the child’s eyes when he/she is stable.
NOTE: Children with vitamin A deficiency are likely to be photophobic and will keep their
eyes closed. It is important to examine the eyes very gently to prevent corneal rupture.

53
 Annex 2. Monthly nutritional screening reporting form for children aged 6–59 months old
Implementatio Screening # 6–59 mo # 6–59 mo % 6–59
Year Month # 6–59 mo # 6–59 mo Total # of
n modality Total target pop with MUAC mo
Region Zone Woreda (Gregorian (Gregorian MUAC MUAC 6–59 mo
(HEP, CHD, population (6–59 mo) bilateral 11.5– screening
) ) <11.5cm >=12.5cm screened
EOS) 13.94% oedema 12.5cm coverage

54
Annex 3. Monthly nutritional screening reporting form for PLW
Screening #PLW % PLW
Implementation Total # % PLW
Year Month Total target pop with with
Region Zone Woreda modality (HEP, PLW screening
(Gregorian) (Gregorian) population PLW MUAC MUAC
CHD, EOS) screened coverage
(3.9%) <23cm <23cm

55
 Annex 4. Vitamin A supplementation and deworming reporting form for children aged 6–59 months
Vit A Target
Target # 6–11 # 12–59 Total # 6– # of
supplemen population for
Year Month population months months 59 months children Deworming
Total tation deworming
Region Zone Woreda (Gregorian (Gregorian for VAS (6– suppleme supplemen supplemen dewormed coverage
population coverage (24–59
) ) 59 months) nted with ted with ted with (24–59 (%)
(6–59 months)
13.94% Vit A Vit A Vit A months)
months) 10.43%

56
Annex 5. Essential commodities for the management of SAM and MAM
Essential commodities for the management of inpatients
Item or product Unit Quantity
Adhesive plaster Packet
Paediatric cannula Packet
Feeding syringe (60ml) Packet
Syringe with needle (5ml) Packet
NG tube-6 Packet
NG tube-8 Packet
NG tube-12 Packet
Thermometer Piece
Mebendazole or Albendazole Tablet
Amoxicillin Tablet
Ampicillin IV Vial
Water for injection (5ml) Vial
Gentamicin IV Vial
Paracetamol Bottle
Ceftriaxone IV Vial
Glucose Solution IV Packet
ReSoMal Packet
F-75 Tin
F-100 Tin
RUTF Packet
Inpatient Care Multi-Chart Piece
Referral Slip Piece
Monthly Statistics Report for Acute Malnutrition Piece
Registration Book for SAM Piece
Vitamin A Tablet
Weighing Scale Piece
MUAC Tapes Piece
Length/Height Board Piece
WFH/WFL Reference Tables Piece
Quick Reference Guide Piece
Guidelines for the Management of Acute Malnutrition Piece
IEC Materials Set
Cups/Tumblers Piece
Spoons Piece
Water Jug with lid Piece
Wooden Pallets Piece

57
Essential commodities for the management of OTP
Item or product Unit Quantity
Mebendazole or Albendazole Tablet
Amoxicillin Tablet
Thermometer Piece
RUTF Packet
OTP Card (0–69 months) Piece
OTP Card (0–6 months) Piece
Ration Card Piece
Referral Slip Piece
Registration Book for SAM Piece
Weighing Scale Piece
MUAC Tapes Piece
Length/Height Board Piece
WFH/WFL Reference Tables Piece
Quick Reference Guide Piece
Guidelines for the Management of Acute Malnutrition Piece
IEC Materials Set
Cups/Tumblers Piece
Spoons Piece
Water Jug with lid Piece
Wooden Pallets Piece

58
Essential commodities for the management of MAM

Item or product Unit Quantity

Specialised Nutritious Foods (RUSF or Super Cereal) Packet
TSFP Treatment and Follow-up Card Piece
Specialised Nutritious Food Ration Card Piece
Referral Slip Piece
Registration Book for MAM – children 6–59 months Piece
Registration Book for MAM – PLW Piece
Monthly Statistics Report for Acute Malnutrition Piece
Mebendazole or Albendazole Tablet
Vitamin A Tablet
Scorecard for the Management of Acute Malnutrition Piece
Weighing Scale Piece
MUAC Tapes Piece
Length/Height Board Piece
WFH/WFL Reference Tables Piece
Quick Reference Guide Piece
Guidelines for the Management of Acute Malnutrition Piece
IEC Materials Set
Cooking Demonstration Equipment Piece
Cups/Tumblers Piece
Spoons Piece
Water Jug with lid Piece
Wooden Pallets Piece

59
Annex 6. The UNICEF conceptual framework for undernutrition

Malnutrition, disability,
morbidity, and death
Manifestations

Inadequate Disease
Immediate
diet
causes

Inadequate Inadequate Inadequate services

Underlying
household food and unhealthy
security care environment
causes

Lack of capital: financial, human,

physical, social, and natural

Basic

causes
Social, economic, and
political context

60
Annex 7. The IPC reference table

Key Reference Outcomes Current or imminent outcomes on lives and livelihoods.

Phase classification Based on convergence of direct and indirect evidence rather than absolute thresholds.
Not all indicators must be present for classification.
Crude Mortality Rate < 0.5 / 10,000 / day
Acute Malnutrition <3 % (w/h <-2 z-scores)
Stunting <20% (h/age <-2 z-scores)
Food Access / Availability usually adequate (> 2,100 kcal ppp day), stable
1A Generally Dietary Diversity consistent quality and quantity of diversity
Food Secure Water Access / Availability usually adequate (> 15 litres ppp day), stable Hazards
moderate to low probability and vulnerability
Civil Security prevailing and structural peace
Livelihood Assets generally sustainable utilisation (of six capitals) Crude Mortality Rate
<0.5 / 10,000 / day; U5MR<1 / 10,000 / day
Acute Malnutrition >3% but <10 % (w/h <-2 z-score), usual range, stable
Stunting >20% (h/age <-2 z-scores)
Food Access / Availability borderline adequate (2,100 kcal ppp day); unstable
Dietary Diversity chronic dietary diversity deficit
Moderately / Water Access / Availability borderline adequate (15 litres ppp day); unstable
2 Borderline Hazards recurrent, with high livelihood vulnerability
Food Insecure Civil Security Unstable; disruptive tension
Coping ‘insurance strategies’
Livelihood Assets stressed and unsustainable utilisation (of six capitals)
Structural Pronounced underlying hindrances to food security
Crude Mortality Rate 0.5–1 / 10,000 / day, U5MR 1–2 / 10,000 / day
Acute Malnutrition 10–15 % (w/h <-2 z-score), > than usual, increasing
Disease epidemic; increasing Food Access / Availability lack of entitlement; 2,100 kcal
ppp day via asset stripping Dietary Diversity acute dietary diversity deficit Water Access
Acute Food
/ Avail. 7.5–15 litres ppp day, accessed via asset stripping
and
3 Destitution / Displacement emerging; diffuse
Livelihood
Crisis Civil Security limited spread, low intensity conflict
Coping ‘crisis strategies’; CSI > than reference; increasing
Livelihood Assets accelerated and critical depletion or loss of access
Crude Mortality Rate 1–2 / 10,000 / day, >2x reference rate, increasing;
Mortality Rate U5MR > 2 / 10,000 / day
Acute Malnutrition >15 % (w/h <-2 z-score), > than usual, increasing
Disease Pandemic
Food Access / Availability severe entitlement gap; unable to meet 2,100 kcal
Humanitarian
4 ppp day
Emergency
Dietary Diversity Regularly three or fewer main food groups consumed Water Access /
Avail. < 7.5 litres ppp day (human usage only)
Destitution / Displacement concentrated; increasing Civil Security widespread, high
intensity conflict
Coping ‘distress strategies’; CSI significantly > than reference

61
 Livelihood Assets near complete and irreversible depletion or loss of access
Crude Mortality Rate > 2 / 10,000 / day (example: 6,000 / 1,000,000 / 30 days)
Acute Malnutrition > 30 % (w/h <-2 z-score)
Disease Pandemic
Famine / Food Access / Availability extreme entitlement gap; much below 2,100 kcal ppp day
5 Humanitarian
Catastrophe Water Access / Availability < 4 litres ppp day (human usage only)
Destitution / Displacement large-scale, concentrated
Civil Security widespread, high intensity conflict
Livelihood Assets effectively complete loss; collapse

62
Annex 8. Standards for population nutritional requirements – for planning
purposes in the initial stages of an emergency

Nutrient Minimum population requirements*

Energy 2,100 kcal
Protein 53 g (10% of total energy)
Fat 40 g (17% of total energy)
Vitamin A 550 μg RAE
Vitamin D 6.1 μg
Vitamin E 8.0 mg alpha-TE
Vitamin K 48.2 μg
Vitamin B1 (Thiamine) 1.1 mg
Vitamin B2 (Riboflavin) 1.1 mg
Vitamin B3 (Niacin) 13.8 mg NE
Vitamin B6 (Pyridoxine) 1.2 mg
Vitamin B12 (Cobalamin) 2.2 μg
Folate 363 μg DFE
Pantothenate 4.6 mg
Vitamin C 41.6 mg
Iron 32 mg
Iodine 138 μg
Zinc 12.4 mg
Copper 1.1 mg
Selenium 27.6 μg
Calcium 989 mg
Magnesium 201 mg

*Expressed as reference nutrient intakes for all nutrients except energy and copper

Source: The Sphere Project (2011). Humanitarian Charter and Minimum Standards in Humanitarian
Response. Geneva: The Sphere Project.

Alpha-TE – alpha-tocopherol equivalents

RAE – retinol activity equivalents
NE – niacin equivalents
DFE – dietary folate equivalents

63
Annex 9. Bin Card
Bin Cards
…………………………………………………………………………………………………

Name of the Health Facility:

Product Name, Strength and Dosage Form

Unit of Issue:

Maximum Stock Level: Emergency Order Point:

Average Monthly Consumption:

Doc. No. Received Quantity Expiry

Date (Receiving from or Batch Remarks
or Date
issued to No.
Issuing)
Received Issued Loss/Adj Balance

64