ACF Emergency Nutrition Handbook EN FV 2

ACF INTERNATIONAL NETWORK
EMERGENCY NUTRITION
A HANDBOOK FOR DEVELOPING AN EMERGENCY NUTRITION
INTERVENTION STRATEGY
FRANCE
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2 EMERGENCY NUTRITION
EMERGENCY NUTRITION
A handbook for developing an
emergency nutrition intervention strategy
Technical and scientific department

Nutrition and Health sector
Action Contre la Faim – International
EMERGENCY NUTRITION
3
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4EMERGENCY NUTRITION
INTRODUCTION
USER GUIDE
This document provides a better understanding of the issues and clarifies ACF’s stance in emergency
nutrition response. It is intended for all people working at the headquarters as well as in the field,
regardless of their level of expertise.
Over the years, as the emphasis on preventing acute malnutrition has grown, significant changes have
been made to emergency nutrition programmes, particularly in the development of new products..
More specifically, ACF is working in partnership with healthcare structures, in order to strengthen
their systems to reduce the number of ACF nutrition programmes. ACF also intends to develop its
work in emergency preparedness, to ensure the fastest, most effective response possible.
These changes, however, raise issues about how to best guide these emergency preparedness and
nutrition responses.
To address these concerns, this handbook was developed to guide ACF’s emergency response
strategy, as well as upstream preparedness, and provide a grid to be used as a decision-making aid.
This handbook helps place emergencies into a general context and time continuum, because ACF’s
ability to develop a nutrition response to an emergency depends greatly on:
 Its relations with the Ministry of Health and with the various stakeholders active in nutrition
and health within the country; and on
 Its ability to articulate emergency preparedness, response and rehabilitation smoothly.
This handbook will prove useful for Country Directors and Field Coordinators, to enhance their
knowledge of ACF’s stance on emergency nutrition response. They may also find it useful as ad hoc
support for tasks such as preparing a meeting with a funding source or authority that may ask
questions about our approach to emergency nutrition response. In this particular case, this handbook
will offer a clear overview of ACF’s issues, references and stance in this matter.
Heads of nutrition and health departments may also find it useful as a tool to assist them with the
development of emergency nutrition preparedness and response strategies. We therefore
recommend systematic use of this tool when drafting emergency response projects as well as projects
to strengthen healthcare systems. It is also recommended that the handbook be used during the
development and/or revision of country strategies.
At the start of this handbook, you will find a list of acronyms to help you understand the technical
vocabulary used within ACF.
To facilitate the reading of this handbook, you may also refer to the “ESSENTIAL IN NUTRITION AND
HEALTH” published by the nutrition health sector in late 2012, which provides more information on
some of the topics covered.
EMERGENCY NUTRITION
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ACRONYMS
ACF Action Contre la Faim
ALNAP Active Learning Network for Accountability and Performance
CSB Corn-Soy Blend
EPRP Emergency Preparedness and Response Plan
FAO Food and Agriculture Organisation
FSL Food Security and Livelihoods
GAM Global Acute Malnutrition
GNC Global Nutrition Cluster
HIV/AIDS Human Immunodeficiency Virus /Acquired Immunodeficiency Syndrome
HSS Health System Strengthening
IASC Inter-Agency Standing Committee
IYCF Infant and Young Child Feeding
MAM Moderate Acute Malnutrition
MHCP Mental Health Care Practices
MoH Ministry of Health
MUAC Middle Upper Arms circumference
NGO Non-Governmental Organisation
RUSF Ready-to-Use Supplementary Food
RUTF Ready-to-Use Therapeutic Food
SAM Severe Acute Malnutrition
SCUK Save the Children United Kingdom
SMART Standardized Monitoring and Assessment of Relief and Transition
UNHCR United Nations High Commissioner for Refugees
UNICEF United Nations Children’s Fund
UN-SCN United Nations Standing Committee on Nutrition
WASH Water supply, Sanitation and Hygiene Promotion
WFP World Food Programme
WHO World Health Organization
TABLE OF CONTENTS
DEFINITIONS ........................................................................................................................ 13
I. INTRODUCTION TO THE MANUAL ........................................................................................ 15
1.1 Aim and Approach ................................................................................................... 15
1.2 Target Audience ...................................................................................................... 15
1.3 Warning.................................................................................................................. 15
II. EMERGENCY RESPONSE IN A GLOBAL CONTEXT or THE MALNUTRITION MANAGEMENT
CONTINUUM ....................................................................................................................... 17
2.1 ACF and health system strengthening (HSS) ................................................................ 17
2.2 Preparation for emergency ....................................................................................... 19
2.3 Once the emergency occurs ...................................................................................... 24
2.4 Emergency response ................................................................................................ 24
2.5 Rehabilitation.......................................................................................................... 25
III. HOW TO DETERMINE THE EMERGENCY RESPONSE STRATEGY .............................................. 28
3.1 Determining the most suitable type of programme ..................................................... 29
3.2 Determining the modus operandi and programmatic elements ............................ 33
IV. THE NUTRITION CLUSTER: BASIC NOTIONS ......................................................................... 44
4.1 The Humanitarian Reform and the Cluster Approach ................................................... 45
4.2 Roles and Responsibilities ......................................................................................... 47
4.3 Nutrition Cluster’s spheres of operation ..................................................................... 51
4.4 Perspectives ............................................................................................................ 55
V. TAKING THE CAUSES OF UNDERNUTRITION INTO ACCOUNT .................................................. 57
5.1 Health .................................................................................................................... 58
5.2 Mental Health and Care Practices .............................................................................. 60
5.3 Food Security and Livelihoods ................................................................................... 60
5.4 Water, Sanitation and Hygiene .................................................................................. 61
REFERENCES ........................................................................................................................ 63
ANNEXES ............................................................................................................................. 65
EMERGENCY NUTRITION
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THE HISTORY OF EMERGENCY RESPONSE
Emergency nutrition interventions have considerably improved since the late 1970s, specifically
through the development of protocols and directives for therapeutic programmes1 effective foods for
treating severe acute sub-nutrition (F75 and F100 milk, ATPE), as well as standardised methods for
nutrition studies2
The multiple lessons learned from various crises3 resulted in enhancing the quantity (kcal) and quality
(micronutrients) of rations distributed as food assistance. Between 1986 and 1990, the daily ration for
refugees rose from 1500 to 1900 kcals a day, and then up to 2100 kcals per person per day, from
1996-1999. At the same time, epidemics of pellagra, scurvy or beriberi among populations
dependent on food assistance demonstrated the need to round out rations with micronutrients and
supplements, especially vitamin A. An agreement was finally signed in the late 1990s to include
fortified grains in daily rations.
During this same period, a link was established between the prevalence of acute sub-nutrition in
children under five and the mortality rate. A connection was also gradually drawn between children’s
nutritional status and pathologies such as measles (1984-1985 measles epidemic among Ethiopian
refugees in the Sudan, with fatality exceeding 30 per cent, especially among malnourished children)
or diarrhoea (1991 diarrhoea epidemic among Kurdish refugees in Iraq, resulting in increased acute
sub-nutrition among children under 24 months). Prevention of these pathologies therefore became a
key component of nutritional programmes.
In parallel with the programme aspects, humanitarian coordination has also advanced over the
past 30 years. Humanitarian coordination is the effective and consistent delivery of humanitarian
assistance focused on saving lives and reducing suffering. Coordination is indispensable to make the
most efficient use of available resources, with minimum delay and through actions that comply with
existing standards. An IASC review in 2005 showed that until that time, there were significant
shortcomings in humanitarian response: fragmented response, duplication, and insufficient
involvement by national governments and stakeholders. In response, a “Humanitarian Reform” was
proposed, to improve funding predictability and response leadership, accountability to the
populations affected, and partnership between UN and non-UN humanitarian agencies. The
development of the Cluster Approach gradually strengthened humanitarian response, by defining and
implementing partnerships and accountability in key sectors (cf Chapter 4 on basic cluster concepts).
Despite the progress achieved in humanitarian response over the past 30 years, the most recent
major catastrophes’4 response mechanisms’ assessment shows that inappropriate responses continue
in the areas of:
 Emergency infant and young child feeding;
 Timely response to crises; and
 Considering the causes of malnutrition.
1
Directives on emergency nutrition (MSF), selective feeding programmes (WFP/UNHCR), estimating emergency
nutrition needs (WFP/UNHCR), and treating severe malnutrition (WHO) were all published between 1995
and 1999.
2
There previously were considerable differences between sampling methods, anthropometric indexes and
definitions of acute malnutrition used in various studies.
3
UN-SNC, Report of the Meeting of the Working Group on Nutrition in Emergencies, April 1998
4
Horn of Africa drought in 2011, Haiti earthquake in 2010, Cyclone Nargis in Myanmar in 2008, China
earthquake in 2008, Lebanon conflict in 2006, Indonesia earthquake in 2006, Ethiopia drought (2003, 2006,
2008), Niger drought (2003, 2005, 2008, 2010)
EMERGENCY NUTRITION
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Emergency infant and young child feeding (IYCF)
The study of IYCF responses to emergencies in recent years shows that, instead of protecting infants
and young children, they actually increase their vulnerability to undernutrition, disease and death.
Following the 2010 earthquake in Haiti for example, several reports pointed out that products
distributed as humanitarian aid included powdered infant formula, nursing bottles, nipples and
powdered milk. These were handed out by various humanitarian agencies (either local or
international non-governmental organizations, including UN agencies), sometimes through national
health structures, without checking the age of the recipients or ensuring the preparation conditions
were safe and long-term needs covered. These activities were encouraged by massive donations (of
products and materials by the general public or by the companies’ marketing these products), which
were in turn promoted by the media. These types of interventions are not only in breach of
international recommendations5 and procedures6 but they also violate the International Code of
Marketing of Breast-milk Substitutes (adopted by a resolution at the World Health Assembly in 1981).
Following the earthquake in Haiti, a nutrition cluster was set up in order to address a joint declaration
to all operators advocating for good emergency IYCF feeding practices and compliance with
international recommendations and procedures. This consequently raised awareness among
humanitarian aid providers in terms of the importance of IYCF interventions to protect infants and
young children.
However, a recent study conducted by Save the Children-UK7 indicated that, although most players
recognize that IYCF interventions should be a priority to protect infants and young children, they are
still rarely implemented on a broad scale in emergencies,. The reasons most often cited to explain this
status quo are the difficulty to obtain funding for these interventions (especially if not backed by
another programme), the lack of human resources and expertise in the field, the missing linkage with
other technical fields, and the lack of evidence of the impact of these interventions (especially for
funding agencies). As a result, if IYCF interventions are actually implemented, they most often are
fragmented and on a small scale.
Timely response to crises

According to an article by Peter Hailey and Daniel Tewoldeberha8 the management of severe acute
malnutrition (SAM) is traditionally considered as an emergency intervention, with external aid coming
almost exclusively from donors, UN agencies and NGOs. The result is that this external aid is provided
and withdrawn based on the reported or perceived level of nutrition emergency, despite the constant
presence of severely malnourished children throughout the year. This means that programmes open
when the prevalence of acute malnutrition reaches emergency levels and close once the situation
improves, often only to reopen in the next hunger season. This method of intervention results in a lag
between the assessment of the situation and the moment when malnourished children are actually
taken care of on the ground - the time required to declare an emergency and mobilise resources.
During this initial delay, the state of an increasing number of children becomes critical as part of the
crisis has been underway. In addition, there is a second lag between the moment when a new survey
indicates the situation is improving and the moment when aid ceases.
This situation is even more pronounced in areas of chronic nutritional emergency where cycles tend
to overlap.
5 WHO recommendations: breast feeding only up to 6 months and continuous nursing up to 24 months
6 Operational Guidance on IFE for Emergency Relief Staff and Programme Managers, February 2007
7 SCUK, Infant and Young Child Feeding in Emergencies: Why are we not delivering at scale?, October 2012
8 Peter Hailey & Daniel Tewoldeberha, Suggested New Design Framework for CMAM Programming, Field
Exchange n°39, September 2010
This phenomenon was evident9 during the Horn of Africa drought of 2011 where, despite early
warnings of a pending crisis (the first forecasts came in August 2010), a large scale response only
began in June-July 2011, after acute malnutrition rates had already reached critical levels.
The challenge is therefore to trigger an early enough response so that the maximum level of
resources coincides with the peak time of need, particularly with slow-onset crises. This raises
questions about preparation and continuum plans.
Considering the causes of malnutrition

Slow-onset disasters such as the droughts in Niger and in Ethiopia are generally characterised by
acute malnutrition rates exceeding emergency levels. These nutritional emergencies are
predominantly managed via the provision of emergency food aid. However, evaluations10 show that
improvements in nutritional status have a better chance of being attained through an integrated
response based on a thorough understanding of the causes of malnutrition at a local level, and not
simply through food aid. This is particularly true when malnutrition is a chronic or structural problem
– not only related to inadequate food consumption but also related to poor public health and
sanitation systems and inappropriate care practices.
In addition, disasters are often perceived as an interruption in development rather than can be
prepared for and mitigated. This is particularly problematic in countries which have experienced
multiple droughts. Often the result is emergency programmes are duplicated and working in parallel.
These may save lives in the short term but the gap between emergency assistance and development
means the original causes of the disaster are barely addressed.
9 Oxfam & SCUK, A Dangerous delay. The cost of late response to early warnings in the 2011 drought in the
Horn of Africa. January 2012
10 USAID 2003, SCUK 2004, REDSO 2004, CARE 2005, IRAM 2006
EMERGENCY NUTRITION
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DEFINITIONS
An emergency is a sudden and unforeseen event that calls for immediate measures to minimise its
adverse consequences.11
A disaster is a serious disruption of the functioning of society, causing widespread human, material or
environmental losses which exceed the ability of the affected population to cope using only its own
resources. Disasters are often classified according to their cause (natural or man-made12)13.
A rapid-onset disaster could be defined as resulting from a unique, distinct and unforeseeable event
such as an earthquake or a flood.
Conversely a slow-onset disaster unfolds gradually over time and is often the result of a concordance
of various events such as drought.
The Importance of Emergency Food Aid

It is crucial to protect the nutritional status of vulnerable groups affected by emergencies. Individuals
suffering from acute malnutrition are more likely to fall ill and die. Also, sick people are more likely to
become malnourished. Emergencies impact a wide range of factors which can increase the risk of
malnutrition, sickness (morbidity), and death (mortality).
Who are the most vulnerable?
Children under the age of five present an increased mortality risk linked to acute malnutrition. In
particular, infants aged six months or less are in immediate danger. Infants over the age of six
months will see their nutritional status worsen in the medium term. It is therefore fundamental to
protect children under the age of five and, as a priority, babies under the age of six months, through
preventative action while simultaneously preparing a remedial response.
At what point does an emergency become a nutritional emergency?
While there is no universally accepted definition of the term nutritional emergency, various attempts
have been made to grade the severity of an emergency by using acute malnutrition or emaciation in a
population as an indicator. Such a system implies emergencies could be divided into stages, as for
example the Integrated Food Security Phase Classification of the FSAU/FAO14, the WHO's decision
tree concerning the implementation of nutritional programmes15, or the IPC's integrated framework
of food security classification presented in Annexes 1, 2 and 3.
These varying classification systems show how difficult it is to grade the severity of an emergency
situation. However, what these systems have in common is they all use quantifiable figures such as
malnutrition or mortality rates, and they link these figures with qualitative (or descriptive) indicators
such as food security.
As for the matrix presented in this manual, it is based on the classification proposed in the Moderate
Acute Malnutrition: A Decision Tool for Emergencies, drawn up by the MAM Task Force on Global
Nutrition Cluster.
11 UNOG/DHA, Internationally agreed glossary of basic terms related to Disaster Management, 1992
12 Relative to human activity
13 UNOG/DHA, Internationally agreed glossary of basic terms related to Disaster Management, 1992
14 IASC Global Nutrition Cluster, Introduction to nutrition in emergencies
15 WHO decision tree for implementation of selective feeding programme, WHO: The Management of Nutrition
in Major Emergencies. 2000
EMERGENCY NUTRITION
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I. INTRODUCTION TO THE MANUAL
1.1 Aim and Approach
The Nutrition in an Emergency manual aims to:
 Guide staff 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 staff 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.
 Guide staff in preparing for emergencies.
The aim of the manual is to help staff develop a full understanding of the environment in which the
emergency response will be taking place, and to understand that an emergency response is not an
isolated event but part of a continuum. The manual has also been designed to help decision-making
regarding the type of nutritional programme to implement (diagnostic, prevention, treatment), the
choice of programme, the groups to target, the duration of the programme and the modus operandi
(health system support vs. substitution). Lastly, it highlights the key points of preparation.
1.2 Target Audience

This tool is primarily aimed at ACF nutrition-health staff whether on the ground or in the
headquarters. The manual should guide them in drawing up a global nutrition response strategy to an
emergency.
In the absence of a nutrition-health team, it may also be used to help all ACF staff involved in
responding to an emergency, particularly country directors or on-the-ground coordinators.
Lastly, the manual will enable ACF to present its emergency response approach to various
stakeholders, especially donors.
1.3 Warning
The matrix and the manual are a guide; however in-depth discussions and the analysis and
interpretation of the context are still required in developing a response strategy to a particular
emergency. One should still bear in mind that an emergency response is not an isolated event but
part of a continuum. The notion of a continuum is further developed in Chapter 2 and the drawing up
of an emergency response strategy is covered in Chapter 3.
An emergency response cannot be developed in an isolated way. External coordination with others
involved must be improved, and in particular relations with the Public Health Ministry as well as other
health operators must be strengthened. Chapter 4 takes a closer look at the basic notions of nutrition
clusters.
In the same way, in an emergency situation acute malnutrition cannot be managed in isolation.
Consequently, the decision-making process put forward in this manual must be considered as one
element in a multi-sectoral response. Links with mental health, healthcare and food security
EMERGENCY NUTRITION
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intervention or with water, sanitation and hygiene action are also important in ensuring the diverse
causes of malnutrition are addressed simultaneously. In order to do that, internal coordination must
be improved. Some of these potential links are put forward in Chapter 5.
This matrix constitutes a guide for selecting interventions to set in motion in the first month of an
emergency. The nutritional response should however be adapted as the emergency situation evolves.
So the matrix can also be used to re-evaluate the context and adjust the programmes accordingly.
The matrix may be used for different kinds of emergency, rapid or slow-onset, prolonged or acute in a
chronic emergency situation. However, the extent of the disaster and the context in which it occurs
will influence the location of the response (prioritisation of intervention zones) and the modus
operandi if nothing else.
© ACF, Roselyne Monin – Ethiopia, 2011
II. EMERGENCY RESPONSE IN A GLOBAL
CONTEXT or THE MALNUTRITION MANAGEMENT
CONTINUUM
An emergency is not an isolated event. This means the emergency response cannot be isolated from
the global context: it is part of an environment and a continuum.
2.1 ACF and health system strengthening (HSS)16

The scaling up of access to treatment for SAM is the goal that ACF has set in its International Strategy
2015 framework (pillar I). To reach this goal in situations where the health ministry is the primary
access provider, ACF has been implementing health system support actions for many years. It should
be noted ACF started out with little knowledge of the health system and therefore little
understanding. After having worked to improve its knowledge, it is now easier for ACF to intervene to
strengthen the healthcare systems without risking weakening it.
Developing the health system strengthening (HSS) approach is an absolute necessity in the treatment
of SAM. We can no longer act in a vertical way. We have to build a solid base within primary
healthcare systems in order to develop access to SAM treatment.
At every level of the healthcare pyramid, ACF aims to strengthen the technical and organisational
capacity of healthcare professionals so they are able to include SAM treatment in their minimum
healthcare services. ACF now operates in each of the building blocks of the health system: quality
care, human resources, supply systems, healthcare information systems, management and finance.
A good understanding of the healthcare system, how it works as well as how to take into account
its weaknesses when building its strategies are essential prerequisites.
Based on an initial systemic analysis of the healthcare system, ACF staff must work together with
local operators, including the health ministry in the heart of deliberations, towards strategies that
will strengthen each pillar. The strategies must take three elements into consideration:
A. Substitution Strategy/ Gap filing strategy. This strategy is based on the healthcare
system's initial capacity to cope with the number of acute malnutrition cases => the
teams must devise a strategy ensuring the best possible access to treatment for those
not covered. We will broadly identify the difference between the total number of
patients expected and the number the structure can accommodate. This strategy
supposes a certain level of substitution as a complement to the following strategy. It
must not become an ongoing state. It should fade out as the system's capacity increases
(progress in Strategy B).
B. Strengthening Strategy. This strategy is based on an initial pillar-by-pillar diagnosis of the
health system. ACF will think through its contribution to the strengthening of the system
depending on the established role of all operators present. In this way, strengthening
strategies drawn up by ACF will not necessarily attack each of the six pillars but will be a
complement to other initiatives already in place (systematic approach). This strategy
should not only target the delivery of SAM-related care but the entire minimum
healthcare package and can work in conjunction with strategies A and C should the
situation require.
16 Health System Strengthening, Essential Health and Nutrition, ACF 2012

EMERGENCY NUTRITION
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C. Crisis Management Strategy: Seasonal peaks should be identified and give rise to the
preparation of a specific strategy in addition to the previous two strategies. Crisis
situation support mechanisms should be predefined with operators present and
negotiated with donors. They should aim to handle the number of cases caused by the
crisis without destabilising strategies A and B. The Multisectoral Seasonal Calendar tool
may provide further analysis.
Strategy C
The response to an emergency is at the level of crisis management strategy (Strategy C) and can be
broken down into a number of sequences, which make up a continuum (illustrated below). In order to
ensure that the response to the emergency is as relevant and efficient as possible so that it meets the
needs of the affected population in good time and in the best manner without endangering the
ongoing development strategies, it must be integrated into a continuum strategy. A certain number of
key action points must be implemented in each of the 4 phases: preparation for emergency,
occurrence of the emergency, response to the emergency and rehabilitation. These action points are
summarised in the Continuum presented at the end of the chapter (figure 3) and are developed in the
following paragraphs.
Figure: The Continuum
2.2 Preparation for emergency

Today, a large number of humanitarian emergencies can be foreseen because they happen on a
recurring basis and/or because they occur in a progressive manner. If an emergency is foreseeable,
this means it is possible to prepare for it. Furthermore, certain tools have recently been developed
which allow emergencies to be anticipated and prepared for. That is why it is now an absolute
obligation for every ACF mission to develop a multi-sectoral seasonal Calendar and to draw up an
Emergency preparedness and response plan as part of a development process.
An Emergency Preparedness and Response Plan (EPRP) is an emergency operations planning and
preparation tool which allows a permanent intervention capacity to be established to respond to
humanitarian emergencies.
The operational advantages of an EPRP are the following:
 The humanitarian risks are identified clearly by ACF missions
 ACF staff (national and expatriate) are trained and prepared to respond to an emergency
 All evaluation and emergency response tools are provided
 Partnerships and contacts are formalised with the Ministry for Health
 Partnerships with other operational stakeholders are identified and formalised
 Contacts are formalised with sponsors (signature of pre-contracts)
 Concrete deployment capacity is in place, even in cases of remote management
 ACF emergency stocks (if necessary) or access to emergency stocks belonging to partner
agencies are pre-positioned and formalised (e.g. UNICEF, PAM, Red Cross, etc.)
The main areas covered by an emergency preparedness programme are: regulation (law, authorities),
management (policies, procedures, directives) and execution (plans, resources, knowledge, skills,
awareness and attitude). The quality of the work carried out in each of these areas determines the
level of preparation for managing an emergency.
EMERGENCY NUTRITION
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INDICATORS TO COLLECT
In terms of emergency preparedness, it is important to know
and analyse the previous situation (indicators and The following indicators are to be
information to be collected), to anticipate the occurrence of collected and routinely monitored:
the crisis (surveillance) and to prepare the response (pre-  GAM and SAM rates
negotiations, evaluation, coordination).  Mortality rate
 Incidence of measles, malaria,
The different steps involved in the development of an diarrhea and acute respiratory
emergency preparedness plan include: infections
 Identifying the vulnerable areas and groups within  Measles vaccination coverage
the population  Infant and Young child feeding
 Assessing the number of expected cases practices, particularly the
 Monitoring the prevalence and number of cases of exclusive breastfeeding rate
acute malnutrition
 Analysing the capacity of the ministry of health to Knowing the level of these
cope with an increase in the number of cases indicators upstream of the crisis
 Developing the crisis management strategy provides a baseline and a yardstick
 Defining the “thresholds” for the emergency for measuring the development of
response the situation. It is also useful for
estimating the risks of the
situation worsening.
2.2.1 Vulnerable areas and groups within the population

The various vulnerable groups within the population during an emergency must be identified. They
can be categorised based on:
 Their physiological vulnerability: infants and young children, pregnant and breastfeeding
women, people living with a chronic disease such as HIV/AIDS;
 Their geographical vulnerability: people who live in areas that are subject to drought or
flooding, or in areas of conflict;
 Their political vulnerability: oppressed populations; and/or
 Their status as refugees or internally displaced persons.
2.2.2 Number of cases expected / Monitoring the prevalence and number of cases
of acute malnutrition
The seasonality factors need to be analysed as the number of SAM cases can greatly fluctuate. This
can be done using the Multi-Sectoral Seasonal Calendar,17 an ACF tool which illustrates and explains
seasonal peaks of acute malnutrition.
The seasonal variations of acute malnutrition are caused by the deterioration of one or several major
risk factors related to access to food or food consumption, care and feeding practices, diseases,
access to health services and/or inadequate sanitary conditions. The seasonal fluctuations can also be
caused by environmental and climatic factors (e.g. seasonal flooding) or by human or socio-economic
factors (e.g. increases in the price of foodstuffs).
Finally, existing micronutrient deficiencies must be monitored in order to anticipate the risks of
possible epidemics.
17 ACF, Nutrition Multi-sectoral seasonal calendar, March 2012
2.2.3 The capacity of the ministry of health to cope with an increase in the number
of cases
An analysis of the health system encompassing the six building blocks must be carried out at
a national, regional and local level (see questions to be asked in the Table 1 below) in order
to evaluate the capacity of health structures to cope with an increase in the number of cases.
2.2.4 The crisis management strategy

The crisis management mechanism must be predefined through cooperation with the
stakeholders involved (ministry for health and other stakeholders in the nutrition and health
sectors): the type and level of support required shall be determined for each pillar (see
examples in Table 1), with the objective of taking responsibility for additional cases without
destabilising the substitution (A) and reinforcement (B) strategies in the process.
Lastly, this crisis management strategy should be pre-negotiated with the donors.
2.2.5 The “thresholds” for emergency response

This aspect involves determining, together with the Ministry of Health, the threshold beyond
which the healthcare system can no longer manage cases without additional support.
Normally, this threshold should increase over the years as the capacity of the health system is
reinforced.
Tools to analyse the healthcare system's capacity for coping with an

emergency / managing a response strategy
How to use Table 1
The table below is designed to give guidance in analysing the six building blocks of the healthcare
system with the aim of assessing that system's capacity for coping with an increase in the number
of acute undernutrition cases.
First, the table sets out, for each building block, a series of questions to ask in order to identify
the initial situation.
Next, for each building block, proposals are given for what can be done in an emergency. Each of
the points mentioned must be discussed with the health ministry and, where possible,
implemented during the emergency preparedness phase.
Ideally, this analysis should be conducted in collaboration with the different nutrition and health
actors interacting with the health ministry.
This table is designed to help clarify thinking, however it makes no claim to be exhaustive.
Adaptations should be made according to the context.
EMERGENCY NUTRITION
21
Table 1: Tool for analysing the capacity of the health system for managing an emergency and the response strategy
Building Blocks What is the initial situation? What can be done if an emergency arises?
Management and Are there laws, policies, plans and procedures that are relevant to the Regulation of health-related emergency assistance:
governance national management of multi-sectoral emergencies?  Provisions related to the entry of international health workers into the
country to offer emergency assistance
Is there an operational body at national/regional level for managing multi-  Medical products exempted from import taxes
sectoral emergencies which coordinates and supervises a national  Provisions related to medical products
preparation plan that involves all partners concerned?
Coordination mechanisms and formation of partnerships:
Are there provisions for registering foreign and national humanitarian  Health authorities involved at all levels within the coordination
agencies for the implementation of humanitarian operations and logistical mechanisms
mechanisms?  Agreements signed with bodies within the public and private sectors as
well as civil society
Health workers Are enough qualified workers with the appropriate skills available to Training and education
respond to a crisis?
Cartography/database of available resources: qualified workers who have
Is there an appropriate educational and further training programme? the appropriate skills.
Is there a database containing details of workers trained in emergency Procedures for integrating national and international volunteers into the
response? provision of services in emergency situations.
The procedures to be followed for mobilising workers and the information

on the roles, responsibilities and authority of the people involved should
be communicated to all departments and organisations concerned.
Medication and Are there standard lists of emergency medical inputs and equipment Mechanisms for ensuring speedy delivery of products at a local level
vaccines (connected with the national directives and policies)?
Procedures for exceptional access to medical products that are not included
Is there an inventory process for ensuring that a minimum stock of on the list of standard equipment
essential inputs and medication?
Health Is reliable, up-to-date information available which would allow for risk Determination of thresholds for transition from routine reporting to
information assessment and for planning of emergency preparedness? emergency reporting (adaptation of frequency and content)
system Are there protocols and procedures for the collection, analysis and Emergency reporting system : data collected from all partners involved
dissemination of data?
Is there a monitoring system in place?
Is there an early warning system in place?
Financing Are there funds available for emergency preparedness and response at Financial mechanisms including contingency funds for emergency response
national and regional level? and recovery
Does the ministry of health’s financial strategy cover emergency Financing of activities aimed at determining the level of resilience of the
management activities, including risk reduction and emergency critical medical structures (hospitals, warehouses, etc.) and making the
preparedness activities? necessary improvements
Provision of Are there regional emergency response plans in place, based on the Mechanisms for rapid mobilisation of additional resources (workers,
services national plan? equipment and materials)
Are these plans based on the available resources? Procedures for the pre-positioning of essential inputs for the recipients of
services and the affected population
Are these plans revised with regard to lessons learned?
Temporary health structures or additional workers, the local health
Are these plans communicated to all partners? structures if local health structures are overloaded
Are there directives and procedures concerning temporary health The health structures / temporary workers may substitute or complete the
structures? Is the role of mobile clinics clearly defined? health system.
Have transportation and fuel costs been taken into account? Agreements with partners and/or private companies for the provision of
logistical services so as to ensure the continuity of essential activities
EMERGENCY NUTRITION
23
2.3 Once the emergency occurs
2.3.1 Collection of secondary information
The collection of secondary information begins in the first hours after an emergency. This is most
often carried out remotely and enables to illustrate a preliminary scenario.
The type of documents and secondary sources of information vary which allows information to be
cross-checked:
 Specialised sources: remote collection of information, media reports, etc.
 Monitoring and tracking systems
 Basic data, datasheets: country profile, lessons learned from past disasters, investigation reports,
etc.
The collection and analysis of the secondary information then continues during the response phase,
which allows an up-to-date analysis of the situation.
2.3.2 Collection of primary information

The collection of primary information (evaluation of the needs amongst the population) takes place in
several phases:
 The initial evaluation must be implemented during the first 72 hours. This evaluation
(MIRA18) is multi-sectoral and gives a first impression of the priority needs; the report should
be finalised and published within no more than 2 weeks. The amount of the initial emergency
funding will be assessed on the basis of this evaluation and will then be communicated to the
donors (Flash appeal).
 Following the publication of the MIRA report, each cluster/sector shall undertake a detailed
sectoral evaluation in order to determine the needs more precisely.
At this point, it is important to organize these evaluations at the cluster (or any other coordination
mechanism) level, so as to prevent gaps and duplications. Similarly, sharing the results of the
evaluations will facilitate the launching of a global nutritional response to the emergency.
2.4 Emergency response

2.4.1 Response strategy
To develop a solid response strategy, both the situation and the risks of its deterioration must be
considered and analysed. Chapter 3 of this manual explains the decision-making process and the
factors to be taken into account in elaborating the response: selection of the type of assistance (using
the matrix), choice of modus operandi and determination of the programme components.
The response strategy must be:
 Based on local structures and give prominence wherever possible. The objective is to build on
what exists (even if it isn't perfect) in order to reinforce local capabilities.
 Viewed in a long-term perspective, looking to early recovery, in order to not undermine long-
term programmes or national structures. In other words, rehabilitation considerations should
be addressed.
Wherever a mission has elaborated an emergency preparedness plan and a crisis-management
strategy (with the health ministry), the scheduled response plan should be adjusted as necessary.
18 Multi-cluster / sector Initial Rapid Assessment
2.4.2 Coordination
Coordination is key to an international global response to humanitarian emergencies. The lack of
coordination causes delays and hinders the coverage of needs.
The cluster approach is designed to strengthen humanitarian response by defining and reinforcing
partnerships and accountability in key sectors. The cluster approach is not designed to undermine
national authorities or supplant them . National authorities are ultimately responsible to provide
humanitarian relief. They must be involved in discussions about activating the cluster approach and
decide what commitments they are ready to make within the cluster.
Depending on the commitment they wish to make, three partnership options are available:
 The government is the cluster Lead or Co-Lead;
 The government is willing to provide coordination but chooses to delegate its coordinating
authority to the Cluster Lead Agency while maintaining the power to make decisions. This is the
most common situation;
 The government is unwilling or unable to provide coordination, but is kept regularly informed of
the progress of the cluster.
As a rule, the more the cluster’s structure is able to reflect and reinforce the national authorities'
coordinating mechanisms, the less likely programmes will be duplicated. This interoperating approach
also works in favour of transferring the coordinating function to the national authorities when the
emergency phase has ended.
It is essential not to confine the approach to the nutrition-sector coordinating mechanisms, but to
work in with the health-care sector as well. Nutrition and health interact at all stages in the
continuum: health indicators are collected and used during the preparation phase (see page 20),
optional assistance in the health field (parasite-disinfestations and immunisation campaigns), etc.
2.5 Rehabilitation
Knowing when to bring an emergency response to an end can be just as important as knowing when
to start it since as aid ceases, underlying causes of vulnerability may and often do persist.
The rehabilitation (or recovery) phase after an emergency provides the opportunity for improved
reconstruction (i.e. working towards an appropriate, sustainable health system, developing
preparedness systems, constructing the capacity for managing future crises, and instituting measures
to reduce vulnerability). Improving the resilience of populations and institutions (particularly those of
the health ministry) provides them with capacities for recovering better and sooner after a disaster.
Reinforcing response capabilities is the only means of ensuring that resources, processes and
procedures are in place to save lives in an emergency, particularly in the earliest days when external
aid is not yet available.
After an emergency, the experience must be capitalised-on to highlight the lessons learnt. The
capitalising exercise must analyse the strengths / abilities, weaknesses / vulnerabilities, risks and
opportunities, and lead to recommendations. Lastly, the preparedness plan must be adapted to take
account of the foregoing.
EMERGENCY NUTRITION
25
In conclusion
Including the response in a continuum means that catastrophes can be anticipated, and lessons learnt
from past experience. With the increasingly high frequency of catastrophes, their causes and
consequences have become better known; hence, this method of operation will improve the
adaptation and effectiveness of an emergency response, with its impact maximised.
© ACF, Roselyne Monin – Ethiopie, 2011
Figure 3: The Continuum
III. HOW TO DETERMINE THE EMERGENCY RESPONSE
STRATEGY19
3.1 Determining the most suitable type of programme
With the aim of determining the best-suited type of emergency-response programme, the
matrix set out in Annex 4 divides the factors to consider into two levels:
1) The previous situation, and

2) The risk of deterioration.
On completion of this analysis, a programme recommendation can be formulated.
3.1.1 Analysing the situation
The first points of information to consider are

Prerequisites
those which shed light on the previous situation,
particularly pre-crisis vulnerability. Present and
Various information and data are required
previous GAM prevalence in the population
to use the manual and its matrix: affected provide a key indicator of vulnerability.
 GAM prevalence in the zone
 Information on the nature and
severity of the crisis For decision-making purposes, a GAM prevalence
 Health data on the affected area above 15% will be considered high; a prevalence
and expected impact of the crisis between 8 and 15%20 will be considered medium,
 Food security analysis in the and below 8%, prevalence will be considered low.
affected area and expected impact To classify an emergency's severity, it is also of
of the crisis utmost importance to analyse trends, and to
 Population density and population have a clear grasp of GAM seasonality in the
movement risk analysis population affected by the emergency.
GAM prevalence may be corroborated by the

number of children in the GAM and SAM
treatment programmes if the coverage is known, and if the needs are covered. If this information is
unavailable or insufficiently recent, old data or screening data may be used to gain an idea of GAM
prevalence. If no data are available, the decision-making process may be started by analysing the risk
of deterioration.
19 According to Moderate Acute Malnutrition: A decision tool for emergencies, developed by the MAM Task
Force of the Global Nutrition Cluster
20 The MAM Task Force recommends 8% in preference to the 10% usually used.
3.1.2 Risk of deterioration
3.1.2.1 Risk assessment
Four key factors must be taken into consideration that can predict a risk of the situation deteriorating
and hence, point to a probable increase in GAM prevalence:
 The morbidity trend,
 The food security trend,
 Population displacements, and
 Population density.
Increase in morbidity – Diarrhoea, acute respiratory infection (ARI), malaria and measles in un-
vaccinated populations are the most common diseases affecting children, and their incidence is liable
to rise during an emergency. These diseases may additionally have a major impact on infant mortality
and under-nourishment. Some types of emergency are more markedly liable to cause increased
morbidity, such as floods or earthquakes: these situations promote, among others, the development
of water-borne diseases, for example by polluted-water contamination of drinking-water sources, or
the proliferation of various kinds of parasites in stretches of stagnant water. The type of habitat
(vulnerability, capacity) in which the catastrophe occurs may also heighten the risk of morbidity (for
example, an urban area where health conditions are already poor). Previous data on vaccination
coverage, or the coverage of vitamin A supplement administration, may give an indication of
increased probability of both the morbidity risk, and its impact on GAM. Assessing access to health
services, access to water (quantity and quality), water-treatment and hygiene services, and
population density, is also a key component in determining the risk of morbidity. The assignment of a
score to increased risk of morbidity must be based on the probability of an increase in the incidence
or outbreak of an epidemic. The three expected-risk categories are defined as follows:
 Epidemic: high score (2)
 Increasing incidence / high incidence: medium score (1)
 Stable incidence / low incidence: low score (0)
Decline in food security – A crisis adversely impacting food production, markets, households'
incomes or foodstuff prices may have a significant impact on GAM. The amplitude, extent, severity
and duration of the impact on food insecurity must be assessed using available data on the food
security of households, their consumption, and market information. The expected trend in food
security must be considered, including the proportion of households liable to suffer moderate or
severe food insecurity. The three expected-risk categories are defined as follows:
 Major shortages in food consumption, decrease in households' assets, and irreversible
adaptation strategies: high score (2)
 Significant shortages in food consumption, incipient decrease in households' assets, and
irreversible adaptation strategies: medium score (1)
 Lowered food consumption but no nutritional deficiency, no irreversible adaptation
strategies: low score (0)
Significant population displacements – Population displacement modes are another factor that
can influence the type of programme to implement. Displacements may overstep national boundaries
(in the case of refugees) or take place within the country (in the case of internally-displaced people).
Types of shelter resorted-to also vary: dispersed shelters, collective shelters at centres (such as
schools or religious buildings) or in dormitories, reception and transit camps, or improvised camps,
which may or may not be recognised by the host government. Cases may also arise in which refugees
or displaced persons mingle with the host population, who may or may not be relatives. The 2
expected-risk categories are defined as follows:-
 Population displacements are increased and concentrated: high score (1)
 No displacement, or no increase in displacements, or sparsely populated area: low score (0)
Population density – Population density is an important decision-making factor since first, it often
influences the risk of epidemic and secondly, the number of cases may be indicative of GAM
prevalence. This is why population density must be factored-in when defining programme
implementation mechanisms. For example, contexts exist in which, despite a low GAM prevalence,
the number of cases to treat will be high, affecting resources required and liable to overburden the
health system. Therefore, where population density is very high, despite the low GAM prevalence at
the outbreak of the emergency, the number of children requiring treatment may be very high. The 2
expected-risk categories are defined as follows:-
 Urban area, high concentration of population: high score (1)
 Other area: low score (0)
3.1.2.2 Risk evaluation

Each of the risks described above is evaluated independently and assigned a score; the total
score is then determined (see table 2).
Table 2: Evaluating the risk of deterioration.

Risk of deterioration Analysis Score Total score Risk category
High 2
Increase in morbidity (diarrhoea, ARI,
Medium 1
measles, malaria)
Low 0
High 2
Unavailability of or disrupted access to food Score 4-6: High
(markets, prices, production) Medium 1 Score 2-4: Medium
Low 0 Score <2: Low
Yes 1
Significant population displacements
No 0
Yes 1
Dense population
No 0
3.1.3 Programme recommendation

The programme recommendation is based on the prevalence of GAM (high, medium or low) and on
the calculated risk of deterioration (high, medium or low) as explained above.
The matrix of different possible recommendations based on the analysis of the situation and the risk
of deterioration is presented in Annex 4.
The various proposed interventions in the matrix represent the range of nutrition interventions that
ACF may implement in an emergency situation. They are categorized according to the nutrition and
health sector priority axis21.
21 For further details on the priority sections, see the essential in Nutrition-Santé (ACF-International, 2012)
Table 3: Emergency nutrition interventions based on the priority sections of the Nutrition-Health sector
AXIS INTERVENTIONS
AXIS 1: Diagnosis and analysis Surveillance
SMART survey
Rapid nutrition evaluation
AXIS 2: Management of acute Treatment of severe acute malnutrition
malnutrition Treatment of moderate acute malnutrition
Active screening
AXIS 3: Prevention of acute Infant and young child feeding
malnutrition Food assistance
Blanket feeding
Optional interventions*
* Optional interventions constitute an integral part of ACF’s mandate, but are less commonly implemented. The
conditions required for their implementation are explained further on.
As emergencies are not homogeneous (they don’t affect all regions of a country or all
population groups in the same way), the analysis and decision-making process must be
developed zone by zone and according to the needs of key target populations. Moreover,
the analysis must take into account different vulnerabilities and as a result the various
potential impacts on women, girls, boys and men as well as on different ethnic and economic
groups. This must then be integrated into the programme definition in terms of geographic
targeting and target groups.
Finally the importance of working in coordination cannot be understated. The situation must
be analysed jointly with nutrition and health partners (including the Ministry of Health) at
the level of the cluster or any other
coordinating mechanism existing at the
national, regional or local level.
3.2 Determining the modus operandi and programmatic elements
The onset of the emergency (rapid or slow) does not influence the selection of response programmes
to be implemented except in a few cases. Instead, the difference takes place in the choice of modus
operandi.
Selecting a programme is also influenced by other factors such as the number of expected
malnutrition cases, the existence of a health system and its ability to completely or partially manage
these cases, pre-existing nutrition programmes and their own modus operandi.
The choice of modus operandi can be depicted as a curser on a scale that runs from total substitution
(direct implementation by ACF) to total integration (implementation by health facilities without ACF’s
support); the intermediary steps consist of all the types of support offered to ACF to address gaps:
Substitution Integration
To determine the modus operandi, it is essential to analyse the capabilities of the health system in
order to find its gaps. This must be completed jointly with the Ministry of Health. It is also critical to
work in collaboration with various nutrition and health partners to ensure that ACF’s support is not
duplicated by other interventions or inversely that significant gaps are missed.
Some interventions may also be implemented by a local partner such as a local NGO or the national
office of the Red Cross. This possibility must not be overlooked because in some cases it provides a
continuity of interventions, or easier access to affected populations particularly in zones where
security is not assured.
The analysis required to choose a modus

operandi must be completed for each of
the selected interventions. As a result, the Emergency response: Choosing the
implementation of these interventions will right approach- Chad example-2012
take place in the most suitable manner
possible. Since 2008 ACF implements nutritional
programs in the Kanem region, with a health
Once the interventions have been selected system strengthening (integration)
and their modus operandi decided, certain approach.
programmatic elements must be
determined: A strategy has been developed to cope with
 Target group the increasing incidence of MAS due to the
 Choice of product (if necessary) crisis, without destabilizing the existing
 Duration of the intervention support in health centers. It was therefore
 Implementation mechanism decided to implement a temporary mobile
teams composed of ACF staff (direct
The decisions relative to these elements implementation), with the aim of extending
are influenced by the type of emergency support to areas with little or no coverage,
and the context of the affected zone, as is decongesting health centers already
outlined above in this document (prior supported.
situation, vulnerabilities leading to the
crisis and risk of deterioration).
3.2.1 Programmes section 1: Diagnosis and analysis
3.2.1.1 Modus operandi
The diagnosis and analysis of a situation can be determined to varying degrees by three
interventions:
 Surveillance
 Rapid nutrition evaluations
 SMART nutrition surveys
Surveillance consists of collecting certain amounts of data on a routine basis. The primary data to be
collected pertains to nutrition and sanitation: admissions into nutrition programmes, screening data
(active and passive), morbidity data, etc. The sources are varied: ACF programmes or other
organizations and health facilities (health information system). Data collection regarding food security
is also important (from institutions or from ACF’s FSL teams) in order to analyse the situation on a
global scale particularly in the case of slow-onset disasters: crop prospects, market price variations,
household vulnerabilities, etc. In short, surveillance provides visibility to the evolution of nutrition,
sanitation and food security.
When an early warning system is operative in a country, it is critical to monitor analyses in order to
more efficiently foresee disasters and their probable impact. Maximum involvement serves to
reinforce and improve the system.
Rapid nutrition evaluations are most relevant concerning rapid-onset disasters when little is known
about the initial situation, or concerning slow-onset
disasters when access is difficult (open only a few days). ! QUICK AND ESSENTIAL!
In fact, in the case of rapid-onset disasters, the In order for the rapid nutrition
nutritional situation does not deteriorate significantly assessments to retain relevance and
within the space of a few days. On the contrary, it takes a interest, the results should be
couple of weeks. If the nutritional situation of the zone known very quickly. The report
or the affected population is already known when the should be finalized and
disaster takes place, this evaluation is not required. If, disseminated within 3 days of the
however, the situation is not known, a rapid nutrition end of the data collection.
evaluation must be conducted.
In the case of slow-onset disasters, it is more relevant to plan for a bona fide nutrition survey to
obtain more precise data. Rapid nutrition evaluations prove to be more suitable in cases where
access to the zone or the population is complicated (unpredictable and/or short-term) because they
provide a better understanding of the situation.
SMART nutrition surveys provide a very clear idea in an instant of the situation of the selected zone.
These surveys provide the most precise and reliable information, but they require more resources
(time, financial support and technical expertise).
3.2.1.2 Programmatic elements
Selecting a target group
Surveillance can apply

to all population CAUTION : INFANT LESS THAN 6 MONTHS
groups depending on Infants less than 6 months do not currently receive
the data that is sufficient attention in terms of diagnosis and analysis.
collected.
Rapid nutrition  Monitoring data on them are few, if any, as they are
evaluations target not routinely collected;
children aged from 6 to  They are excluded from rapid nutrition assessments
59 months and/or insofar as they are not eligible for MUAC;
pregnant and lactating  They rarely investigated nutritional SMART.
women. These
populations are both
However, as explained previously infants less than 6
the most susceptible to
malnutrition and those months are in immediate danger during an emergency.
for which the MUAC They must imperatively be evaluated and monitored.
can be measured. ©
ACF, Roselyne Monin – Ivory Coast, 2011
SMART nutrition surveys normally target children aged from 6 to 59 months; infants under 6 months
can also be included or be subject to a survey where relevant.
Estimating the duration of the intervention

Surveillance is a long-term intervention that must exist leading up to the disaster, be in effect during
the emergency response and be maintained during the rehabilitation phase.
Rapid nutrition evaluations are quick to prepare (a couple of days) and to implement. They can be
conducted as part of the primary data collection during the in-depth sectorial assessment, that is to
say, in the two weeks following the disaster (see Chapter 2.3.2).
SMART nutrition surveys require six to eight weeks from preparation to report completion. In light of
the necessary time to prepare, a nutrition survey cannot be
undertaken in a few days. In the case of slow-onset disasters, it is
possible to foresee and plan the implementation of a nutrition
survey. When it comes to rapid-onset disasters, the nutrition
survey must be planned a couple of weeks or months after the
emergency, taking into account the situation’s risk of
deterioration.
Determining the implementation mechanism

As explained previously, access to the affected population/zone
determines, among other things, whether a rapid evaluation or a
nutrition survey will be used. Furthermore, the area of the
affected zone and/or the heterogeneity of the affected
population must be taken into account during the planning: a
very large zone or a very heterogeneous population requires a
number of evaluations/surveys; otherwise the results cannot be © ACF, Roselyne Monin – Côte
used. d’Ivoire, 2011
3.2.2 Programmes section 2: Management of acute malnutrition
The management of acute malnutrition consists of three interventions:

Treatment of severe acute malnutrition
Treatment of moderate acute malnutrition
Active screening of cases
For the most part, the management of acute malnutrition is overseen either directly by the NGOs
(international or local) or by the healthcare system. The degree of involvement varies depending on
the context. In this case, international NGOs are responsible for developing capacity within the
healthcare system and/or local NGOs for looking after its management. This leaves ACF to evaluate
the need for support in different areas (see 6 pillars of the health system), in so-called normal
situations and in crisis situations (see Strategies A, B and C, Chapter 2.1). The role ACF assumes
positions itself on the curser of the “substation-integration” scale. This positioning must take into
account not only the healthcare systems’ capabilities, but also the effectiveness and alignment of the
other actors for each of the interventions.
For example, the following combination could be possible:

 Management of SAM cases by health facilities with support from ACF for input delivery
 Training and supervision of a local NGO to treat MAM
 And active screening of cases within the community by an ACF team
As explained in the Emergency Preparedness chapter (2.2), in cases where ACF is already working to
reinforce the healthcare system, the crisis management strategy (Strategy C) will have been
determined in advance with the Ministry of Health and will have been subject to pre-negotiations.
Selecting a target group

Standard target groups for the treatment of acute malnutrition are the following:
Malnourished infants under 6 months (only in programmes for the treatment of SAM)
Children aged from 6 to 59 months, acutely or moderately malnourished (following the
programme)
Children aged from 6 to 59 months, recovered and released from the treatment of SAM (for
MAM programme)
Pregnant women and malnourished lactating women
In certain exceptional circumstances other groups can be included such as children aged from 5 to 10
years old or the elderly. Their need must be justified by the results of the survey, evaluations or
screening data. This was the case for the Somali refugees in Ethiopia and Kenya during the Horn of
Africa drought of 2011.
In the case of active screening, since it is based on the measurement of the mid-upper-arm
circumference and the diagnosis of oedema, eligible groups are children aged from 6 to 59 month or
who measure 65 to 110 cm, and pregnant and lactating women.
Focus on infants under six months
In the absence of official recommendations, and while awaiting the findings
of research in progress, ACF gives the following indications:
ALARM SIGNALS for case detection
 If the infant's mother mentions problems with breastfeeding;
 In the event of recent weight loss;
 Where there are visible signs of malnutrition.
ANTHROPOMETRIC CRITERIA for SAM ADMISSION

 Weight-for-height index < -3 z-score;
 Middle Upper Arm circumference < 110 for infants aged 2 to 6 months.
Selecting the correct product

The type of product selected depends on the nature of the programme, the target group,
and the food security situation. Principal factors to consider when selecting products are:
Type of intervention and target group: products designed to treat GAM and MAM are
different and very specialised; products can also differ across the same programme
depending on the target group (RUTF vs therapeutic milk to treat SAM; RUSF vs
CSB/CSB+/CSB++ to treat MAM) ;
Food preparation facilities: fortified flours like CSB (+/++) require access to a heat
source, clean water and cooking materials; if these conditions cannot be fulfilled it is
preferable to use ready-prepared foodstuffs;
Cultural practices and food preferences: available fortified flours are wheat or maize
based; a rice flour is being developed. Ready prepared food products are peanut
based, however alternatives with a chickpea or milk base have been developed.
Community preferences should be taken into account as much as possible, balanced
against the time it will take for the selected food product to become available.
Detailed advice about the products to use to prevent and treat moderate acute malnutrition
can be found in a document produced by the MAM Task Force, Moderate Acute Malnutrition:
A decision tool for emergencies, which can be found in Annex 5.
A detailed guide to the different types of nutritional products available as well as the position
of ACF regarding the problems of using these products is available in summary form in the
article Nutritional Products in Nutrition-Health Essentials 2012, or reproduced in full in the
ACF positioning brief Products are not enough: putting nutrition products in their proper
place in the treatment and prevention of global acute malnutrition.
Estimating the timescale of the intervention

A classic emergency acute malnutrition programme is carried out over at least six months.
Scaling back or even ending these emergency programmes can be considered when the GAM
rate has dropped, when there is no longer a risk of the situation deteriorating, and when the
number of participants has dropped. However, stopping an emergency programme does not
always lead to the cessation of all programmes dealing with acute malnutrition: returning or
transitioning to a programme of healthcare system support is desirable, to ensure that
treatment for severe malnutrition is available all year round.
Deciding how the intervention should be carried out

A certain number of factors should be taken into account when deciding how to respond to a
situation, such as access to the population, the extent of the catastrophe (number of zones
affected etc.), the number and capacity of other agents, and the population density. For
example, in densely populated areas, it may be necessary to increase the number of sites
and/or the number of days these sites are operational in order to reduce waiting lists. Some
interventions can be shared between them or offered on adjacent sites.
3.2.3 Programmes section 3: Prevention of severe malnutrition

Infants and Young Child Feeding (IYCF)22

Breastfeeding is undoubtedly the best method to ensure optimal growth and development in infants;
it also has important consequences for the health of the mother and the mother-child bond. In an
emergency situation, breastfeeding can mean the difference between life and death. Studies prove
that insufficient breastfeeding contributes massively to morbidity and mortality rates in infants
(Lancet 2008).
Experience shows that breastfeeding can become difficult in emergency situations. This is due,
amongst other reasons, to trauma, stress and other problems which interfere with milk production,
but also to widespread myths and beliefs, lack of time on the part of the mothers, insufficient
22 ACF, Care Practices in Emergencies Guidelines (to be published)
maternal support, and to the distribution of free samples of breast-milk substitutes, bottles and other
materials. However in emergency situations, and with the right encouragement, most mothers can
continue or recommence breastfeeding if appropriate technical and psychosocial support is
provided, and a favourable environment is created.
The objective of IYCF interventions is to protect infants and children within the family unit in an
emergency situation, by optimising care and nurturing the mother and family psychosocial resources .
Specific objectives include:
 Preventing an increase in acute malnutrition, morbidity and mortality rates;
 Helping families adapt the care they give in emergency and post-emergency situations;
 Improving the well-being of beneficiaries (infants, young children and those who care for
them, pregnant women) by taking into consideration past life experiences and past and
present sufferings, as well as emerging needs;
 Showing families how to support the infant’s development and increase its chances of
survival;
 Warning against or decreasing the negative impact of distribution of free breast-milk
substitute samples; and
 Providing appropriate and sustainable solutions in cases where maternal feeding is not an
option.
IYCF can be supported in different ways, which must always be adapted to suit the local culture, to
the identified needs and the technical ability of the team. Different IYCF interventions can
complement each other in an emergency situation: Baby-Tents, breastfeeding areas, mobile
counselling services, integration of healthcare practices (in a SAM treatment programme, for
example), and community healthcare practices.
In emergency situations, breast milk substitutes are even more dangerous than normal due to a
lack of hygiene in storage facilities or in preparation and administrative practices, and a long-term
lack of availability of age specific products labelled in local languages. The cessation of breast milk
production (brought on by the distribution of substitutes) means an impoverished immune system,
and a loss of nutritional value and well-being, all happening during a time where there is increased
risk of infection, reduced availability of good quality food supplements, and increased risk of
emotional problems brought on by the emergency situation. This proves that distribution of free
samples of breast milk substitutes causes morbidity and mortality rates to rise.
ACF, in its position as signatory of the International Code of Marketing of Breast Milk Substitutes,
must be actively involved in preventing distribution, following up and reporting on any violations of
the code, as well as dealing with confiscated products. These interventions are generally carried out
by Cluster Nutrition.
FOCUS ON READY-TO-USE INFANT FORMULA (RUIF)
The Haiti experience

Why distribute RUIF? The reasons for this strategic choice are: the low breastfeeding rate ahead
of the earthquake; an urban environment with substitutes already widely present in the markets;
a large number of orphans expected; the lack of acceptance of wet-nursing.
For what indications? The infants eligible for RUIF were infants aged under 12 months who had
no possibility of being breastfed, for the following reasons: mother away from home long-term,
or deceased; mother receiving treatment incompatible with breastfeeding; mother re lactating;
mother an HIV carrier not breastfeeding before the earthquake; mother not breastfeeding before
the earthquake.
What are the risks? The attractiveness of RUIF, which is liable to hinder breastfeeding ("false
orphans"); misuse (new product, instructions had to be generated from scratch); the exit strategy
(this type of distribution is not supposed to continue indefinitely).
Operating instructions
In the early emergency stages, RUIF has the advantage of not needing reconstitution with water.
Its use can limit health risks while awaiting the establishment of services capable of supporting
the use of powdered infant milk. RUIF is not a guarantee of safety – proper use, equipment
hygiene and proper storage conditions remain essential. RUIF procurement is very costly, and the
storage implications entailed need careful consideration in each context. Where RUIF is indicated,
supplying it to infants aged under six months should be given priority.
Food Aid23
Food aid interventions are varied and aim to prevent deterioration in the affected population’s
nutritional state, by guaranteeing access to specially adapted sources of nutrition.
Food aid can take different forms, such as general food distribution targeted at the whole population
of a given zone, targeted distribution to a given group within that population (i.e. under 5s, pregnant
or breast-feeding women, see Blanket feeding), work-for-food programmes, or food coupons which
allow recipients to purchase food in designated shops. The ration can be comprehensive, covering all
the energy needs of an adult, or complementary (to complement existing food sources, only
responding to some needs). In both cases the foodstuffs must correspond to the nutritional needs of
the target population.
However, given that these foodstuffs are often “dry”, containing no fresh products such as vegetables,
fruits or animal products, they are virtually free of key micro-nutrients. Foodstuffs are sometimes
prepared and distributed in canteens (see blanket feeding).
Monetary interventions are recognised to have great potential to improve nutrition and in preventing
the deterioration of the nutritional state. They take a wide range of forms, including cash-for-work
programmes, direct transfers and coupon schemes.
Experience has shown several times that monetary transfers increase considerably food consumption
and food diversity in households.
23 ACF-International, Optimiser l’impact nutritionnel des interventions sécurité alimentaire et moyens

d’existence – Manuel pour les professionnels de terrain, Décembre 2011
Coupon usage aiming to promote access to certain types of foodstuffs and services is appropriate in
every environment where these goods/services are readily available, but where access is limited or
out of reach to those with poor buying power. Coupons can be used to ensure access to fresh food
rich in micronutrients (fruit, vegetables, animal products) which are expensive and difficult to include
in food programmes. Food coupons can also be used to access fortified products and complementary
foodstuffs available in the local market.
Blanket feeding24
Blanket feeding is a targeted aid intervention which can be added to other food aid operations, or
rolled out separately. It can be a part of the first stages of an emergency response, as it can be set up
more quickly than a general distribution, programme and targets the most vulnerable (under 5s,
pregnant and breast-feeding women).
The foodstuffs, distributed dry or ready-mixed, are calculated to meet the nutritional needs of a 5
year old (1250 Kcal/day) taking into account the risk (high) that it will be shared with the rest of the
family; it contains thus 1500 Kcal.
In situations where families are not able to cook, or where we wish to be certain that the target
populations are properly benefitting from the foodstuffs, it is possible that these foodstuffs will be
distributed via canteens.
Optional interventions
Optional interventions are those which play an integral part in the ACF mandate, but which are less
frequently carried out. They will be implemented if the following conditions are present:
Distribution of micro-nutrients: if the population is dependent on a general food distribution
programme;
Targeted food supplement distribution (vitamin A, vitamin C or zinc) : 1) an endemic vitamin
A deficiency, 2) there is an epidemic or risk thereof of the following diseases: measles, scurvy
or diarrhoea, 3) no medical agents are present to ensure supplementation ;
Anti-parasite campaign : 1) serious problems with water access, 2) endemic anaemia, 3)
endemic parasitosis ;
Immunisation campaign: 1) immunisation coverage is low 2) there is risk of epidemic, 3) no
medical agent present to ensure the success of the campaign.

Selecting the target group
IYCF interventions target infants and young children up to the age of two and their immediate family
(parents, brothers and sisters, etc.) and pregnant women. Certain interventions, such as Baby-tents,
specifically target breastfeeding women with children under the age of two, as well as pregnant
women. Non-targeted food aid interventions benefit the general population, whereas monetary
interventions benefit a section of the population, chosen according to vulnerability criteria.
Blanket feeding targets the most vulnerable groups in a population suffering from severe
malnutrition, meaning children aged between six months and five years of age, pregnant and breast-
feeding women. Depending on the situation, participation can be limited to children under three.
Target groups in optional interventions are specific to each intervention, and can vary according to
the situation.
24 ACF-International FSL, Food Aid Interventions, Programming … A blanket distribution intervention &
Programming … Canteens interventions
Selecting the right product
The selection of products is intrinsically linked to the nature of the programme, the target group and
the context of food safety. The main factors to take into consideration for the selection of products
are:
The intervention and the target group: the products aimed at a general distribution of
food or the distribution of cover are different; on the other hand, for the same
programme the products can differ according to the target group (RUSF vs.
CSB/CSB+/CSB++ for blanket feeding for example);
The abilities of the households to cook: for the enriched flours such as CSB (+/++), you
need to have access to some kind of fuel, clean water, cooking utensils; if these
conditions are not fulfilled, it would be better to use some readymade food (RUSF or
energy biscuits for example);
The cultural practices and the food preferences: enriched flours that are already available
are wheat- or corn-based, and a type of rice-based flour is being developed. On the other
hand, the ready-made foods are for most of them peanut-based, but alternatives which
are chickpea- or milk-based are being developed. The preferences of the communities
have to be taken into account as much as possible, but should be balanced taking into
account the time necessary for the food to be available.
Detailed recommendations on the products to use for the prevention and the treatment of
moderated acute malnutrition (MAM) can be referred to in the document produced by the MAM Task
Force, Moderate Acute Malnutrition: A Decision Tool for Emergencies (Annex 4).
On the other hand, a detailed briefing on the various types of nutrition products as well as on the
position of ACF about the problems surrounding the latter are available in a summary form in the
paper Nutritional Products from The Essentials on Nutrition-Health or a full version in the document
from the briefing and the views of ACF: Products are not enough: putting nutrition products in their
proper place in the treatment and prevention of global acute malnutrition.
Finally and generally speaking, the composition of the food intakes distributed is calculated to cover
the energy needs of the targeted population, keeping in mind their composition in micro-nutrients.
Those calculations can be easily done thanks to the software NutVal of the PAM.
Estimating the length of the operation

Usually, an emergency program for the prevention of acute malnutrition is often put into place for at
least three to six months. The reduction or even the closing of the emergency programmes can be
considered when the levels of GAM have diminished, that there is no risk of worsening and that the
number of cases has diminished in the health care programmes.
However the stopping of an emergency intervention does not mean the disappearance of all the
programmes to prevent acute malnutrition: a transition towards longer-term programmes is
desirable, so that the prevention of malnutrition can be provided all year around with programmes
addressing the causes of undernutrition.
Determining the setting-up mechanism
A number of factors have to be taken into account when determining the setting-up mechanism for
the answer, such as the access to the population, the spread of the disaster (number of affected
areas, etc.), the number and abilities of the actors and the population density. For example in areas
where the density is high, it will be necessary to multiply the sites and/or the opening days so as to
reduce the waiting time. Some interventions can be integrated between themselves or delivered in
adjacent sites.
© ACF, Roselyne Monin – Côte d’Ivoire, 2011

IV. THE NUTRITION CLUSTER: BASIC NOTIONS
Humanitarian emergencies can have various forms. They can be the result of natural disasters, such
as flooding or earthquakes, or of conflicts. The beginning of an emergency can happen very quickly, or
evolve over time.
The humanitarian answer is a progressive and dynamic field, guided by fundamental humanitarian
principles.
4.1 The Humanitarian Reform and the Cluster Approach

In response to the increasing complexity of the humanitarian contexts, a Journal of the Humanitarian
Answer was finalised in 2005 by the IASC25. This Journal pointed out the significant gaps: particularly
fragmented responses and an insufficient involvement of governments and national stakeholders.
The development of a Humanitarian Reform has been advised in order to improve the predictability
of the financial situation, the accountability towards the affected populations, and the partnership
between the UN and non-UN humanitarian actors.
figure 3: the 4 pillars of the Humanitarian Reform
4.1.1 Aims of the Cluster Approach

The development of the Cluster Approach is aimed at reinforcing the humanitarian response, through
the strengthening of partnerships between organizations and ensuring that key sectors are held
accountable.
 At the global level: reinforcement of the preparation and technical ability to answer
humanitarian emergencies.
 At the country level: ensuring a more coherent and efficient response through mobilising
agencies in such a way that they are able to respond in a more strategic manner, with a
leading agent: “the cluster” (Cluster Lead Agency) designated at the level of the
country.
25 Inter-Agency Standing Committee: forum involving UN and non-UN key actors, in charge of coordination,
development of policies and decisions making. The IASC determines who is in charge of doing what in the
humanitarian answer, identifies the gaps and makes recommendations for the setting up of internetional
humanitarian principles. The IASC is managed by the Emergency Relief Coordinator (ERC).
The Cluster Approach allows more strategic responses and a more effective system in prioritizing
available resources while clarifying how work is shared between organisations, and better defining
the roles and responsibilities of the humanitarian organisations within the sector.
4.1.2 Where/When activating the Clusters?
When a humanitarian emergency exceeds the limits of an agency’s mandate, when the needs are of
such complexity that a multi-sectorial approach and the commitment of a large range of actors is
justified.
4.1.3 Mechanism for the activation of the Clusters
The process to activate the Clusters was developed by the IASC in 2007.
Figure 4: Mechanism for activation the Clusters
Acronyms
HC (Humanitarian Coordinator): (S)he has the responsibility to ensure that the
international response is strategic, well planned, coordinated and efficient.
HCT (Humanitarian Country Team): the equivalent of the IASC at the country level;
managed the HC.
ERC (Emergency Relief Coordinator): is at the head of the OCHA, manager of IASC,
and reporting to the Secretary General of the United Nation, the ERC is responsible for
the global coordination of the humanitarian assistance.
CLA (Cluster Lead Agency): For nutrition, UNICEF is the Cluster Lead Agency
4.1.4 When does the Nutrition Cluster need be activated?
The activation of specific clusters depends on the humanitarian emergency and on the abilities to
respond at the national level. Clusters are supposed to be activated only in sectors where existing
mechanisms of coordination are insufficient. The activation of a cluster will depend on the decision of
the national authorities (see below).
As Cluster Lead Agency at a global level for Nutrition, UNICEF has the responsibility to facilitate the
discussion, the analysis and the recommendation on whether or not to activate the nutrition cluster.
At the same time, the actors in nutrition at the country level as well as the GNC-CT26 can bring forth
their own contributions.
Questions to ask oneself to know whether a Nutrition Cluster is necessary:

 Are there gaps between the availability of the treatment programmes and the prevention of
malnutrition because of the emergency?
 Are the preparation and response to the nutrition emergency already coordinated in a proper
manner by the national authorities?
 Is there a coordination mechanism in the nutrition sector that has the ability to prepare and
answer emergencies?
 Do other sectors plan to activate the Cluster Approach?
 Are there indicators to measure an increase of the nutritional risk linked to the emergency,
and would one surpass present capacities in order to respond?
4.2 Roles and Responsibilities

4.2.1 Government
The role of the government is defined in the resolution 46/182 of the General Assembly of the UN:
“Each State has the responsibility first and foremost to take care of the victims of natural disasters
and other emergencies occurring on its territory. Hence, the affected State has the primary role in the
initiation, organization, coordination and implementation of humanitarian assistance within its
territory”
Humanitarian assistance is provided in case the national authorities have the will or ability to give it
themselves.
According to the will of the national authorities to take part to the Cluster, there are three
possibilities of partnership:
 The government is the lead or co-lead of one cluster;
 The government wishes to coordinate, but delegates the power of coordination to the CLA,
and the opportunities for taking decisions are given in a regular manner (the most common
situation);
 The government cannot or does not want to coordinate and is being kept informed of the
progresses of the cluster at regular intervals.
4.2.2 Cluster Lead Agency

An agency is designated as CLA in each technical sector.
26 Global Nutrition Cluster – Coordination Team

At the global level, the CLA in Nutrition is UNICEF. At the country level, UNICEF, is for the most part
also the CLA, although there are other relationships as well. At the country level, the CLA can be any
member organization of the IASC if it has the resources and necessary expertise to qualify for the
terms of reference. ACF has acted as the CLA in some countries: South Sudan, as one example.
The intervention fields of the CLA are:
 Standards and policies: development, consolidation, dissemination
 Construction of a ability to answer: trainings, stocks, HR
 Operational back up
ACF INVOLVEMENT
 Operational presence: it would be unrealistic for ACF to position itself as a CLA with
a limited operational presence in the field.
 HR implications: the CLA must provide sufficient numbers of senior, experienced
personnel to perform the coordination, information-management and
administrative-support functions throughout the duration of the emergency and
during the transitional period.
 Financial implications: costs of personnel and coordination activities (meetings,
logistical support, administrative support, printing, etc.).
 Working relations with the national authorities: the different organisations (UN,
NGOs, institutions) may be treated differently by the national authorities (e.g. for
travelling permits and work permits). To act as a CLA would require resolution of this
type of problem.
 Accountability: as a provider of last resort, the CLA is accountable to the
humanitarian coordinator where gaps are identified.
To know more
Last resort Supplier: At country level, the CLA is responsible to supply the necessary
services in order to fill any gaps during the emergency response. Conditions to
consider are access, security and availability of funds.
4.2.3 The Cluster coordinator
The role of the Nutrition Cluster Coordinator (NCC) is to ensure a coherent and efficient
answer to a nutrition emergency. His/her terms of reference cover 13 fields of intervention:
 Inclusion of all the key partners;
 Establishing and maintaining appropriate coordination mechanisms;
 Ensuring the link/coordination with the national authorities, the institutions and the
civil society;
 Ensuring the participative approach and the involvement of the community in the
assessments, analysis and answers;
 Ensuring that the transverse questions are taken into account (gender, HIV,
environment, etc.);
 Ensuring the efficiency and coherence of the assessments and analysis, and involving
the appropriate partners;
 Preparation for the emergencies;
 Elaboration of a strategy;
 Implementation of the standards: ensuring that the answers are in line with the
national policies;
 Follow up and reporting: ensuring that the mechanism are implemented;
 Plea and mobilisation of the resources;
 Training and development of the abilities of the partners;
 Supplier in last resort: request to the CLA to fill in the gaps.
The credibility of the NCC depends on the manner in which (s)he can demonstrate his/her
impartiality, autonomy and independence regarding his/her CLA.
4.2.4 Participants to the Cluster
The Nutrition Cluster is open to all organisations taking part to a nutrition response, as long
as they are in line with the good practice standards and wish to take part in reinforcing
nutrition resources in a specific country. They must also be committed to the Nutrition
Cluster strategic priorities.
ACF INVOLVEMENT
 Approving the global objectives and coordination mechanisms of the cluster;
 A proactive approach to exchanging information, identifying needs and gaps,
mobilising resources and strengthening local capacities;
 Sharing coordination responsibilities: using working groups to assess needs, develop
response plans and guidelines, etc.; developing responses aligned with the defined
objectives and priorities;
 Complying with principles, policies, priorities and standards.
It is important to make clear that the Cluster Nutrition participants are not accountable
to the CLA, except where contractual obligations exist (e.g. as implementing partner).
4.2.5 Global Nutrition Cluster (international level)
4.2.5.1 Composition
The Global Nutrition Cluster (GNC) is made up of a large range of participants each with a different
role and responsibilities:
 Coordinator of the GNC: in charge of the general management of the GNC, helped by a team
(GNC-CT: GNC-Coordination Team);
 Main partners of the GNC (Core Partners): individuals or agents being formally part of the
GNC, and bringing their technical expertise. (ACF is part of this);
 Resource persons of the GNC: network of NCC and regional staff of the CLA which are called
on for specific contributions;
 Observers of the GNC: individuals or agencies which take part in the GNC only to share
information (for example: MSF, CICR)
 Large network of the GNC: students, professionals having an interest in the information
shared by the GNC but are not involved in the work.
4.2.5.2 Strategic lines of the GNC

 Coordination, plea and mobilisation of resources internationally speaking;
 Policies, standards, international guidelines;
 Development of the abilities to give a humanitarian answer;
 Preparation;
 Assessment, monitoring and management information; and
 Best practices and lessons learnt.
4.2.5.3 The GNC and country Cluster

There is no hierarchy between the GNC-CT and the NCC. The NCC shares its resources
(documentation) and gives technical support to the NCC, on demand.
The GNC also ensures a link between other initiatives which deals with nutrition, such as the IFE27
Core Group, SCN28, SUN29, NUGAG30 and REACH31.
4.2.6 UNHCR ant the Nutrition Cluster
In 2005 the UNHCR took the role of CLA for the Protection and Shelter Cluster for internally displaced
persons, as well as the coordination and management of the displaced camps. On the other hand,
there are not directives on how the UNHCR and the Nutrition Cluster should cooperate in the case of
refugees.
In summary:
 For displaced people, outside the camps: nutrition is the responsibility of the Nutrition
Cluster;
 For displaced people, inside the camps: nutrition is the responsibility of the Nutrition
Cluster;
 For refugees, inside and outside the camps: nutrition is the responsibility of the UNHCR.
27 Infant Feeding in Emergency

28 Standing Committee on Nutrition
29 Scaling Up Nutrition
30 Nutrition Guidance expert Advisory Group
31 Ending Child Hunger and Undernutrition
4.3 Nutrition Cluster’s spheres of operation
4.3.1 Information management
Managing information efficiently is fundamental to coordinating effectively. This is an essential factor
for improving the planning, integration and implementation of an emergency nutrition response.
Information management is comprised of four areas: collecting, processing, analysing and
disseminating.
Who is involved?
 The CLA: provides the resources: IM staff and software required;
 The IM manager;
 The NCC: produces the data and ensures their proper use;
 Cluster participants: proactively exchange information and contribute to producing standards
and guidelines for the IM; and
 OCHA: compiles the information from the various Clusters.
4.3.2 Evaluation
Information provided by evaluations represents the basis for planning, delivering and following up on
the Nutrition Cluster’s response. It generates a picture of the pre-emergency situation, including
areas of vulnerability, as well as a picture of the situation during the crisis, highlighting the impact of
the emergency and the people affected.
Who is involved?
 The NCC and IM: identify information available and any gaps;
 The HC and OCHA: coordinate inter-cluster emergency evaluations; and
 Cluster participants (implement evaluations and identify specific needs).
4.3.3 Cluster’s strategic response

The Cluster’s strategic response represents the global framework of the response to the nutrition
emergency. It supplies the vision and the action plan for a collective and comprehensive response.
The Nutrition Cluster strategic response:
 Defines shared objectives,
 Identifies priorities,
 Draws up a coherent and comprehensive action plan, clearly defining the roles and
responsibilities, and
 Defines the mechanism for monitoring implementation of the response.
The strategic response must be based on an analysis of the information available, take account of the
cross-cutting issues, establish links with other Clusters where relevant and take account of the
priorities and the capacities available.
The strategy must be regularly reviewed and updated to remain relevant.
Who is involved?
 The NCC: facilitates development and updating of the strategy with clear quality control and
revision methods; and
 Cluster participants: contribute via their information and ideas.
4.3.4 Promoting standards and developing capacities
Promoting standards
Standards must be put in place to promote a quality response and to ensure the Nutrition Cluster
objectives are attained, by undertaking planned activities that are implemented and monitored in an
appropriate way.
Who is involved?
 The NCC: facilitates the identification, revision, development and promotion of standards,
 Cluster participants: identify and prioritise areas where standards are required and undertake
developing/revising,
 Institutions or organisations outside the Cluster: develop training materials or other aspects.
Developing capacities
The capacities of the Cluster participants are developed in such a way as to better equip them to
safeguard the nutritional status of populations.
Who is involved?
 The NCC: supports efforts to strengthen the capacities of national authorities and civil
society; and
 Cluster participants: help identify and prioritise capacities that need to be developed.
4.3.5 Advocacy and communication

Advocacy
In practice, advocacy in emergency situations is aimed at:
 Gaining acceptance and support for nutrition in emergency situations;
 Mobilising resources;
 Increasing awareness.
Who is involved?
 The NCC: ensures the Nutrition Cluster’s advocacy issues are identified and facilitates the
joint advocacy process);
 IM: collects and analyses information used in advocacy messages;
 Cluster participants: prioritise problems, develop evidence, implement advocacy and
determine its parameters: who speaks on behalf of the Nutrition Cluster and the conditions
that apply;
 The CLA: the representative of the CLA is responsible for advocating on behalf of the
Nutrition Cluster, using every opportunity presented and basing the advocacy on input from
the NCC.
Communication
Communication is an important advocacy tool particularly in relation to the media.
Who is involved?
 The NCC: facilitates the definition and presentation of the Nutrition Cluster’s point of view
and ensures that the messages represent the Nutrition Cluster’s position and not that of just
one partner);
 The IM: collects and analyses information used in communication material;
 Cluster participants: define the parameters of external communication based on the Cluster’s
Terms of Reference: who speaks on behalf of the Nutrition Cluster, the conditions that apply
and how sensitive information is handled;
 The CLA: communicates the Nutrition Cluster’s needs and problems at higher-level forums,
provides technical support and facilitates contact with the media and
 OCHA: important communication role for all Clusters.
4.3.6 Mobilising resources

Fundraising
Fundraising is aimed at ensuring the humanitarian partners have sufficient financial resources to
enable the Nutrition Cluster’s response strategy to be implemented.
Who is involved?
 The NCC: ensures that the Nutrition Cluster mobilises the necessary funds to address priority
needs and that the funds obtained through the Nutrition Cluster are prioritised for the most
critical and underfinanced problems;
 The CLA: advocates on behalf of the Nutrition Cluster’s financial needs and aims this action at
the HC, donors and the humanitarian community;
 Cluster participants: share information with the NCC to ensure that all financial needs are
covered, help prioritise projects within the Cluster and mobilise funds from their side;
 OCHA and the HC: manage the fundraising process for Clusters; determine the process, tools,
time assigned to drawing up funding priorities and project selection.
More details on funding mechanisms…

Funds What is it? Who is eligible? Who prepares it?
FLASH APPEAL Gives an overview of all urgent UN agencies Coordinated and
needs, the Cluster’s response NGOs compiled by the HC and
strategies and agency projects for OCHA with input from
the first 3 to 6 months. NO national authorities cluster coordinators and
Usually revised at the end of 1 unless as part of a UN or HCT.
month depending on additional NGO project In 5 to 7 days from
information. emergency.
CERF Rapid Response Supplies a starting-point for UN agencies NCC in collaboration with
Grant launching ‘life-saving’ programmes IOM Nutrition Cluster
(Central Emergency developed in the Flash Appeal but
Response Fund) not yet covered by other donors. NO NGOs and national
authorities except as part
of a UN project
CAP Developed if an emergency goes UN agencies HC directs the process
(Consolidated on beyond the 6 months of the NGOs with the HCT, cluster
Appeal) Flash Appeal. IFRC coordinators and the
Comprises the CHAP (Common other humanitarian
Humanitarian Action Plan) which is National authorities can organisations.
the strategic emergency response only be an implementing
+ the package of projects needed partner
for this strategy.
Pooled Funds: ERF Small-scale funds covering needs Often NGOs
(Expanded not included in the CAP but in line
Humanitarian with the CHAP objectives; short-
Response Fund) term projects (max 6 months).
Pooled Funds: CHF Covers CAP priority projects. Consultative process
(Common involving all the clusters
Humanitarian Fund)
4.3.7 Mobilising inputs and equipment
The capacity to implement nutrition interventions requires having sufficient inputs and equipment in
the right place at the right time.
The type and quantity of products required for the response should be included in the nutrition
response strategy.
Inputs used to treat SAM and MAM are often categorised as foodstuffs and are subject to regulations
at the national level. Establishing and respecting quality control standards associated with nutritional
inputs are also crucial matters for the Nutrition Cluster.
Who is involved?
 The NCC: ensures that all necessary input and equipment needs relating to the emergency
response are identified and that the Nutrition Cluster can identify and resolve pipeline issues;
 The IM; manages information relating to inputs and equipment;
 The CLA:advocates for all the Nutrition Cluster’s resources;
 Cluster participants: share information concerning input needs and stocks to identify
potential disruptions.
4.3.8 Monitoring and evaluation

Monitoring
The aim of monitoring within the Nutrition Cluster is to:
 Oversee changes in the emergency situation and evolving needs;
 Evaluate progress and coverage of the response;
 Facilitate accountability;
 Identify and resolve problems as they appear;
 Highlight successes.
An effective monitoring system is essential to make better use of the resources available.
Who is involved?
 The NCC: ensures the monitoring system is in place;
 The IM: designs the monitoring system and strengthens partners’ capacities relating to
monitoring;
 Cluster participants: define and use the monitoring system; and
 OCHA: coordinates monitoring data from all clusters.
4.3.9 Evaluation and lessons learned

Evaluations within the Nutrition Cluster may be done at two levels:
 Partners can evaluate their own programmes (no obligation to share the results with the Cluster);
 Overall evaluation of the Cluster’s performances.
Who is involved?
 The NCC: coordinates evaluations at Cluster level and ensures information is disseminated
and used;
 The IM: provides technical support to define the methodology and conduct the evaluation
analysis);
 Cluster participants: identify and prioritise the need for evaluations for the Cluster and for
their own agencies; and
 OCHA: carries out inter-cluster coordination.
4.4 Perspectives
4.4.1 Transformative Agenda
Weaknesses are always identified in the multilateral humanitarian response.

Three priority areas for improvement are the following:
 Leadership: Rapid deployment of an experienced, top-level HC;
 Coordination: Trained and experienced Cluster coordinators and inter-cluster coordination;
 Accountability: Improvements in mutual accountability between HC/HCT/Cluster
coordinators/Cluster participants.
In summary, what can bring the Nutrition Cluster

 Access to technical support, and clarity of the standard response;
 Reduced risk of duplication or conflict between agencies, or beneficiaries;
 Improved network and means to discuss with governments and donors;
 Power collective advocacy, resource mobilization, etc.. ;
 Sharing resources and expertise;
 Decreased risk of decision-making and accountability solo.
V. TAKING THE CAUSES OF UNDERNUTRITION
INTO ACCOUNT
Undernutrition is the result of the interaction of multiple complex factors. The immediate causes are
linked to inadequate intake of food and diseases. Food insecurity, inappropriate care and unhealthy,
inadequate environment (limited access to healthcare services and to water supply and sanitation)
are the underlying causes of undernutrition.
Crises characterised by levels of acute undernutrition above emergency thresholds are predominantly
managed by providing emergency food aid. However, nutritional statuses are more likely to be
improved through an integrated response based on a thorough understanding of the causes of
undernutrition at local level, and not solely as a result of food aid.
Figure: Conceptual framework of the causes of undernutrition
The fight against maternal and infant undernutrition requires a twofold approach: implementing
large-scale direct nutritional interventions and ‘nutrition sensitive’ indirect and multi-sectoral
interventions.
5.1 Health
A vicious circle: common infectious diseases increase the probability that a weakened child will be
affected by acute malnutrition (a sick child loses appetite and weight). From the period of
conception until the end of early childhood, undernutrition increases the frequency and intensity of
infectious diseases. Due to this interaction, severe acute malnutrition is thus directly responsible for 1
million deaths a year, while undernutrition is now considered to cause 3.5 million deaths.
Epidemiology confirms these observations. This science allows us to quantify the link between
nutrition and health. Thus, by aggregating the data obtained from several different contexts, it is now
possible to estimate that a malnourished child has, due to the single aggravating factor of his/her
nutritional state, about six times higher a risk of dying from diarrhea, nine times higher from
pneumonia, two times higher from an acute malaria attack, and six times higher from measles.
Overall, severely malnourished children die nine times more frequently than healthy children.
Children with a deficiency in iron, zinc, vitamin A or iodine (simple nutritional deficiencies), are more
at risk of dying than others if they develop an infectious disease. The causal role of pathologies in the
appearance of acute malnutrition is more complicated to demonstrate. It is very well- known with
regard to chronic malnutrition. The impact of chronic undernutrition on quality of life and life
expectancy is also generally recognized. The juxtaposition between the prevalence maps of chronic
and acute malnutrition is also very well-known. It has also been shown that malarial episodes during
pregnancy lead to acute malnutrition of the baby (low weight-for-age). Common sense tells us that in
areas inhabited by poor populations who are struggling to provide themselves with good nutrition,
falling ill can set off a fatal episode of malnutrition among the most vulnerable, i.e. children under the
age of three.
Among the medical factors contributing to undernutrition, the following are preventable:
 Routine pediatric consultations
• Treatment of common pathologies before they result in weight loss
• Early detection of nutritional problems (dynamic analysis)
 Vaccination
• Against the immunizing viral childhood diseases (measles, diphtheria, polio)
• Against particularly serious pathologies of early childhood (hemophilus)
• Against banal viral diarrheas of childhood (rotavirus: ROTARIX; ROTATEQ)
• Against serious diseases recurrent in a given area:
o meningitis
o cholera
o yellow fever
 Prenatal and neonatal care:
• Fight against nutritional deficiencies of the mother
• Early screening of puerperal infections, including malaria
• Prevention of vertical HIV transmission
• Promotion of breastfeeding
 Routine de-worming
 Correction of latent micronutrient deficiencies
Thus, a preventive medical strategy disposes of many arms that should be used judiciously in line with
the local health analysis. The following are important to consider as they will each influence the type
and intensity of the prevention strategy in development:
 The annual incidence of undernutrition;
 The state of stress and capacities available for resilience of persons affected by
undernutrition; and
 Results from the epidemiological analysis performed locally (and at the departure point for
migrants) as well as that of the different resources available through the current healthcare
system.
FOCUS ON CHOLERA
PUNSH AND SHIELD STRATEGY
To minimize the risk of cholera epidemic disease control in endemic areas and reduce the number
of deaths, it is necessary to develop a multidisciplinary approach based on prevention,
preparedness and response, systematically associated with an effective surveillance system.
POSITIONING ACF
For ACF, cholera prevention activities are a priority. These activities are most effective when
accompanied by EAH programs associated with psychosocial and care practices approach. This is
why ACF focuses primarily on preparedness and prevention, in order to limit the spread of
cholera. ACF currently does not perform medical procedures in the Cholera Treatment Centres,
although it may be considered in the future.
Further reading
ACF-International, ACF & La Santé, L’Essentiel Nutrition et Santé, 2012
ACF-International, Document de positionnement opérationnel sur le choléra, Décembre 2012
ACF, Boîte à outils choléra : http://www.missions-acf.org/kitemergency/HTML/5.5-washFR.html
5.2 Mental Health and Care Practices

Care practices are defined as “the behaviours and practices of persons in charge of care (mother,
father, brothers and sisters, the people who take care of the child) to provide food, medical care,
stimulation and emotional support necessary to allow the child to live, grow and develop in a healthy
manner. These practices, combined with food security and health care, have an impact on the well-
being of the child. It is not only the practices themselves, but also the ways they are carried out (with
affection and receptivity towards the child), that are essential to the survival, growth and
development of the child. It is impossible for people responsible for the child’s care to provide the
latter without adequate resources, such as time and energy”32
Six care practices were identified by Engle and presented in the manual published by Unicef33 in 1997:
care for women, breastfeeding practices and complementary feeding, psychosocial care, food
preparation, hygiene practices and household health practices.
Adequate care practices are all the more important when the environment is poor because they
make it possible to optimize available resources. Humanitarian emergencies such a natural disasters,
wars or other emergency situations can cause deterioration of the environment and place the
children in even more danger, since there may be deterioration not only of food security and health,
but also of care practices.
Experiences such as traumatic events, the loss of loved ones, the loss of social support,
displacements, deterioration of living conditions, inadequacy of food supplies, an uncertain future
and the loss of possessions may impact the capacity of the entourage to care for children, which will
increase their risks of malnutrition, illness and death. Those families for whom childcare has
become difficult should benefit from technical, pyschosocial and psychological support in such a
way as to reinforce good practices and encourage adaptation of practices in order to promote the
well-being and development of the child.
Further reading
IASC, Directives du CPI concernant la santé mentale et le soutien psychosocial dans les situations
d’urgence, 2007
ACF-International, Politique santé mentale et pratiques de soins, Décembre 2009
ACF-International, Holistic approach for pregnant, lactating women and their children in emergency
(Baby friendly tent): guidelines and practical handbook. To be published in 2013
OMS, Santé mentale et bien-être psychosocial des enfants en situation de pénurie alimentaire sévère
UNICEF & WHO, Integrating early childhood development activities into nutrition programs in
emergencies. Why, what and How (2012)
5.3 Food Security and Livelihoods

The links between food security, livelihoods, nutrition and health are complex, global and subject to
rapid change. Food security and livelihood programs have the potential to prevent and reduce the
scourge of undernutrition. At the minimum, FSL programs should not jeopardize the nutritional status
of beneficiaries. If that occurs, attenuation measures (preventive or corrective) must be
implemented.
32 Engle, P.L., M. Bentley, and G. Pelto, The role of care in nutrition programmes: current research and a
research agenda. Proceedings of the Nutrition Society, 2000. 59(1): p. 25-35.
33 Engle, P (1997) The Care initiative : assessment, analysis and action to improve care for nutrition. Unicef
Further reading
ACF-International, Optimiser l’impact nutritionnel des interventions de sécurité alimentaire et moyens
d’existence, Décembre 2011
5.4 Water, Sanitation and Hygiene

Undernutrition is responsible for about 35% of worldwide deaths among children under five. It is
thought that a high proportion of this undernutrition is associated with diarrhea or recurrent
infections with intestinal nematodes because of unclean water, inadequate sanitation or
unsatisfactory hygiene conditions.
Diarrhea that is already affecting patients is in itself a particularly important aggravating factor for
malnutrition because it reduces the capacity to absorb nutrients by alteration of the intestinal wall,
and those who suffer from malnutrition are at high risk for diarrhea. That creates a vicious circle
hindering the child’s growth and development.
Water supply, sanitation and improved hygiene can contribute to the fight against undernutrition by
integrating the nutrition issue with improvement of the state of health. Ensuring access to drinking
water, a healthy environment and good hygiene practices remains extremely important in the
prevention of undernutrition, especially in contexts of survival and/or socioeconomic development.
Link between precarious WSH conditions, disease and undernutrition
Translation of text in chart

Absence de toilettes Lack of toilets
Environnement contaminé Contaminated environment
Ressource non protegée… Unprotected, contaminated resource
Mouches Flies
Mains contaminées Contaminated hands
Aliments contaminées Contaminated foods
Eau potable contaminée Contaminated drinking water
Stockage Eau potable contaminée Storage of contaminated drinking water
Diarrhées intermittentes Intermittent diarrhea
Enthéropatie tropicale Tropical Enteropathy
Moindre absorption de nutriments Reduced absorption of nutrients
Capacité de défense immunitaire diminuée Reduced immune defense capacity
Effet = Sous-nutrition Effect = Undernutrition
Augmentation de la mortalité infantile Increase of infantile mortality
Autres maladies Other diseases
Special attention must be given throughout the treatment chain, starting from the therapeutic
feeding centres to the domicile of the “mother/accompanying person – malnourished child” couple.
Interventions such as treatment of water at home to guarantee the potability of drinking water stored
in the home and consumed by the malnourished child also offer the opportunity to target the most
vulnerable.
Further reading
Strategy « Wash in Nut », Regional Emergency Cluster Advisor (RECA) project, WCARO
© ACF, Roselyne Monin – Ivory Coast, 2011
REFERENCES
 ONUG/DHA, Glossaire international multilingue agréé de termes relatifs à la gestion des

catastrophes, 1992
 IASC Global Nutrition Cluster, Introduction to nutrition in emergencies, 2008
 MAM Task Force du Global Nutrition Cluster, Moderate Acute Malnutrition : A decision tool
for emergencies, 2012
 ACF-International, Products are not enough : putting nutrition products in their proper place
in the treatment and prevention of global acute malnutrition, 2011
 ACF-International, L’Essentiel Nutrition-Santé, 2012
 Kit urgence ACF : http://www.missions-
acf.org/kitemergency/HTML_STATIC/homepageFR.html
 UN-SCN, Report of the meeting of the working group on nutrition in emergencies, Avril 1998
 ALNAP, Slow-onset disasters: drought and food and livelihoods insecurity. Learning from
previous relief and recovery responses
 OMS, Distribution of infant formula during the Lebanon Crisis, Décembre 2006
 SCUK, Infant feeding in emergencies – Indonesia & Lebanon responses, Décembre 2006
 Fitsum Assefa, Sri Sukotjo, Anna Winoto & David Hipgrave, Increased diarrhea following
infant formula distribution in 2006 earthquake response in Indonesia, Field Exchange n°34
 ACF-International, Breastfeeding assessment report, Java, Indonesia, June 2006
 Victoria Sibson, Putting IFE guidance into practice: operational challenges in Myanmar, Field
Exchange n°36
 Karleen Gribble, Media reports on IFE in relation to cyclone Nargis and the Wenchuan
earthquake: an analysis, September 2009
 Carmen Dolan & Mija Ververs, The Haiti earthquake, Country and global level Cluster
coordination experiences and lessons learnt, Field Exchange n° 39
 SCUK, Infant and young child feeding in emergencies: Why are we not implementing at scale?
A review of global gaps, challenges and ways forward, October 2012
 Peter Hailey & Daniel Tewoldeberha, Suggested new design framework for CMAM
programming, Field Exchange n° 39
 Oxfam & SCUK, A dangerous delay. The cost of late response to early warnings in the 2011
drought in the Horn of Africa, January 2012
 OMS, Strengthening health system emergency preparedness – Toolkit for assessing health
system capacity for crisis management. 2012
 Global Nutrition Cluster, Nutrition Coordination Handbook version1
 ACF-International, Optimiser l’impact nutritionnel des interventions de sécurité alimentaire et
moyens d’existence, Décembre 2011
 ACF-International, Care Practices in Emergencies Guidelines; to be published.
ANNEXES
Annex 1 – FSAU / FAO Integrated Food Security Phase Classification
Strategic Response Framework

Key Reference Outcomes (current or imminent
Phase (mitigate immediate outcomes,
outcomes on lives and livelihoods; based on
classification support livelihoods, and address
convergence of evidence)
underlying/structural causes)
Crude Mortality Rate <0.5 / 10,000 / day.

Acute Malnutrition <3 % (w/h <-2 z-scores).
Stunting <20% (w/age <-2 z-scores).  Strategic assistance to pockets of
Food Access/Availability Usually adequate food insecure groups.
(>2,100 kcal ppp day), stable.  Investment in food and economic
Dietary Diversity Consistent quality and quantity production systems.
Generally food of diversity.  Enable development of livelihood
secure Water Access/Avail. Usually adequate (>15 litres systems based on principles of
ppp day), stable. sustainability, justice, and equity.
Hazards Moderate to low probability and  Prevent emergence of structural
vulnerability. hindrances to food security.
Civil Security Prevailing and structural peace  Advocacy.
Livelihood Assets Generally sustainable
utilization (of 5 capitals).
Crude Mortality Rate <0.5/10,000/day;

U5MR<1/10,000/day.  Design and implement strategies to
Acute Malnutrition >3% but <10 % (w/h <-2 z- increase stability, resistance.
score), usual range, stable.  and resilience of livelihood
Stunting >20% (w/age <-2 z-scores). systems, thus reducing risk.
Food Access/ Availability borderline adequate  Provision of ‘safety nets’ to high
(2,100 kcal ppp day); unstable. risk groups.
Chronically Dietary Diversity chronic dietary diversity deficit.  Interventions for optimal and
food insecure Water Access/Avail. Borderline adequate (15 sustainable use of livelihood assets.
litres ppp day).  Create contingency plan.
Hazards recurrent, with high livelihood  Redress structural hindrances to
vulnerability. food security.
Civil Security Unstable; disruptive tension.  Close monitoring of relevant
Coping ‘insurance strategies’ Livelihood Assets outcome and process indicators.
stressed and unsustainable utilization (of 5  Advocacy.
capitals).
Crude Mortality Rate 0.5-1 /10,000/day, U5MR  Support livelihoods and protect
1-2/10,000/dy. vulnerable groups
Acute Malnutrition 10-15 % (w/h <-2 z-score),  Strategic and complementary
>than usual, increasing. interventions to immediately
Disease epidemic; increasing. increase food access/availability
Food Access/ Availability lack of entitlement; AND support livelihoods.
Acute food and 2,100 kcal ppp.  Selected provision of
livelihood crisis Dietary Diversity acute dietary diversity deficit. complementary sectoral support,
Water Access/Avail. 7.5-15 litres ppp day, eg water, shelter, sanitation,
accessed via asset stripping health, etc.
Destitution/Displacement Emerging; diffuse  Strategic interventions at
Civil Security Limited spread, low intensity community to national levels to
conflict. create, stabilize, rehabilitate, or
Coping ‘Crisis strategies’; CSI > than reference; protect priority livelihood assets.
EMERGENCY NUTRITION
65
increasing.  Create or implement contingency
Livelihood Assets accelerated and critical plan.
depletion or loss of access.  Close monitoring of relevant
outcome and process indicators.
 Use ‘crisis as opportunity’ to
redress underlying structural
causes.
 Advocacy.
Crude Mortality Rate 1-2 / 10,000 / day, >2x  Urgent protection of vulnerable
reference rate, increasing; U5MR > /10,000/day. groups.
Acute Malnutrition >15 % (w/h <-2 z-score), >
 Urgently increase food access
than usual, increasing
through complementary
Disease Pandemic.
interventions.
Food Access/ Availability Severe entitlement
 Selected provision of
gap; unable to meet 2,100 kcal ppp day.
complementary sectoral support,
Dietary Diversity Regularly 2–3 or fewer main
eg water, shelter, sanitation,
Humanitarian food groups consumed.
health, etc.
emergency Water Access/Avail. < 7.5 litres ppp day
 Protection against complete
(human usage only) r.
livelihood asset loss and/or
Destitution/Displacement Concentrated;
advocacy for access.
increasing.
 Close monitoring of relevant
Civil Security Widespread, high intensity conflict.
outcome and process indicators.
Coping ‘Distress strategies’; CSI significantly >
than reference.  Use crisis as opportunity to redress
Livelihood Assets Near complete & irreversible underlying structural causes.
depletion or loss of access.  Advocacy.
Crude Mortality Rate > 2/10,000 /day (example:

 Critically urgent protection of
6,000 /1,000,000 /30 days).
human lives and vulnerable groups.
Acute Malnutrition > 30 % (w/h <-2 z-score)
 Comprehensive assistance with
Disease Pandemic.
basic needs, eg food, water,
Food Access/ Availability Extreme entitlement
shelter, sanitation, health, etc.
Famine/ gap; much below 2,100 kcal ppp day.
 Immediate policy/legal revisions
Humanitarian Water Access/Avail. < 4 litres ppp day (human
where necessary.
catastrophe usage only).
 Negotiations with varied political-
Destitution/Displacement Large scale,
economic interests.
concentrated.
 Use crisis as opportunity to redress
Civil Security Widespread, high intensity conflict.
underlying structural causes.
Livelihood Assets Effectively complete loss;
collapse.  Advocacy.
Source: Food Security Analysis Unit – Somalia. Integrated Food Security and Humanitarian Phase Classification: Technical Manual Version
I. Technical Series Report No. IV. 11. May 2006
Annex 2 – WHO Decision Tree for the Implementation of Nutritional Programs
Finding Action required

Food availability at household Unsatisfactory situation
level below 2,100 kcal per  Improve general rations until local food availability and access can be
person per day. made adequate.
Serious situation
Malnutrition rate 15% or more
 General rations (unless situation is limited to vulnerable groups) plus
or
 Supplementary feeding generalized for all members of vulnerable groups
10–14% with aggravating
especially children and pregnant and lactating women
factors.
 Therapeutic feeding programme for severely malnourished individuals.
Risky situation
Malnutrition rate 10-14%  No general rations; but
or  Supplementary feeding targeted at individuals identified as malnourished
5–9% with aggravating factors. in vulnerable groups
 Therapeutic feeding programme for severely malnourished individuals.
Acceptable situation
Malnutrition rate under 10%  No need for population interventions
with no aggravating factors  Attention for malnourished individuals through regular community
services.
Aggravating factors
 General food ration below the mean energy requirement
 Crude mortality rate more than 1 per 10 000 per day
 Epidemic of measles of whooping cough (pertussis)
 High incidence of respiratory or diarrhoeal diseases
Source: WHO. The Management of Nutrition in Major Emergencies. 2000
EMERGENCY NUTRITION
67
Annex 3 – Reference Table for Integrated Food Security Classification
Framework
Source: Integrated Food Security Classification Framework – Technical Manual
Annex 4 – The matrix
Annexe 5 – Nutrition product sheet (Adapted from GNC MAM Task Force Product sheet)
Objective Treatment of Severe Acute Malnutrition Treatment of Moderate Acute Malnutrition
Generic Term Therapeutic Therapeutic Milk Ready-to-Use Ready-to-use Fortified Blended Foods
Milk F-100 Therapeutic Supplementary
F-75 Foods Foods
(RUTF) (RUSF)
High quantity*
Products*
SuperCereal/oil/sugar
Supercereal Plus
Purpose Treatment of Treatment of Treatment of Supplement to Supplement to treat

complicated complicated uncomplicated treat moderate moderate acute
severe acute severe acute severe acute acute malnutrition malnutrition with
malnutrition with malnutrition with malnutrition with with continued continued breastfeeding
continued continued continued breastfeeding
breastfeeding breastfeeding breastfeeding
Target Group 6-59 months 0-59 months 6-59 months 6-59 months 6-59 months:
Older children Older children Older children Others PLW SuperCereal Plus
and adults and adults and adults including HIV+ Others including PLW,
including HIV+ including HIV+ including HIV+ adults HIV+ adults: SuperCereal
Energy 75 kcal/100mL 100kcal/100mL 500 kcal 500 kcal 840kcal

/nutrient per 0.9g protein 12.5g protein 12.5g protein 32gprotein
100g 2g fat 32.9g fat 32.9g fat 18g fat
Packaging Sachet = 410g Sachet = 465g Sachet = 92g Sachet = 92g SuperCereal:
25 kg bag
SuperCereal Plus: 1.5kg
bag
Shelf life 18 months 18 months 24 months 24 months 12 months
Ration/dose According to According to According to One sachet/day 200g/day
weight: weight: weight: 92g/day
6-59m: 6-59m: 6-59m: (75kcal/kg/day)
100kcal/kg/day 200kcal/kg/day 200kcal/kg/day
Approximate 3-4 days 21 days 6-8 weeks 3 months 3-6 months
duration of
Intervention
Cost/dose/ 0.36/sachet 0.29/day Super Cereal: 0.17 / day;
day (USD) Super Cereal Plus 0.15/day
Manufacturer Nutriset (Fr) Nutriset (Fr) Nutriset (Fr); Vitaset Nutriset (Fr); Michiels fabrieken (Bel);
(DR); JB (Mad); Edesia (US); CerFar (It); ProRata, Somill,
Nutivita (Ind), Compact (India & J&C (SA) ;
Edesia (US); Diva Norway);
(SA); Com-pact (N, Export Trading, Rab (Mal) ;
Ind); Tabatchnick
Nutrivita (India);
(US);
Challenge (US),
Insta(Ke); local
production
Objective Prevention of Malnutrition
Acute malnutrition Micronutrient and chronic malnutrition
Generic Term Lipid-based Nutrient Fortified Blended Food Lipid-based Nutrient Vitamin & Mineral
Supplements Supplements (LNS) Powder
(LNS) Low quantity*
Medium quantity*
Products*
SuperCereal/oil/sugar
Supercereal Plus
Wawa Mum
Purpose Supplement to the local diet Supplement to the local Supplement to the Fortification of home
for prevention of acute diet for prevention of local diet with prepared foods, just
malnutrition with continued acute malnutrition with continued before consumption,
breastfeeding and prevent continued breastfeeding breastfeeding to with continued
micronutrient deficiency and prevent prevent micronutrient breastfeeding to prevent
and stunting micronutrient deficiency deficiency and stunting micronutrient
and stunting deficiencies
Target Group 6-23 months 6-23 months: 6-23 months 6-59 months
SuperCereal Plus
PLW: SuperCereal
Energy 247kcal 840kcal 108kcal Daily supplement: RDI:
/nutrient per 5.9gprotein 32gprotein 2.5gprotein A- 400ug, C- 30ug, D-
100g 16g fat 18g fat 7g fat 5ug, E- 5ug, B1- 0.5,
B2- 0.5 ug, niacin- 6ug,
B6-0.5ug, B12- 0.9ug,
folic acid-150ug, Iron-
10ug, zinc- 4.1, copper-
0.56, iodine- 90ug,
selenium-17ug
Packaging 325 gm pots or sachets of SuperCereal: Sachet = 20g Sachet = 1g
different quantities 25 kg bag
SuperCereal Plus: 1.5kg
bag
Shelf life 24 months 12 months 18 months 24 months
Ration/dose 47-50g/day 200g/day 20g/day One sachet/day

1g/day or 5g/day
Approximate 3-6 months 3-6 months Up to 18 months 6-12 months
duration of Up to 59 months
Intervention
Cost/dose/ 0.18/day Super Cereal: 0.17 / day 0.028/day
day (USD) Super Cereal Plus
0.15/day
Manufacturer Nutriset (Fr); Edesia (US); Michiels fabrieken (Bel); Nutriset (Fr); Edesia Global Health Initiative;
Compact (India, Norway); CerFar (It); ProRata, Somill, (US) DSM; Fortitech; Heinz;
Nutrivita (India) J&C (SA) ; Hexagon; Piramal
Export Trading, Rab (Mal) ; (India); Renata
(Bangladesh)
Objective Other
Generic High Energy Biscuit (HEB) Ready-to-Use Infant Formula

Term (RUIF)
Products*
Purpose Temporary meal replacement; Replacement of breastfeeding for infants

prevention for acute malnutrition and with no possibility to be breastfed:
micronutrient deficiencies prevention for acute malnutrition
for vulnerable groups
Target General population, vulnerable groups 0-11 months non-breastfeeding infants

Group
Energy 1,800 kcal/400g (biscuits) 100kcal

/nutrient per 2,300kcal/500g (BP-5, NRG-5) 2.1g protein
100g 5.3g fat
Age Bars
6 3-4
months-3
years
4-8 years 5-6
Adults 8-9
Packaging 400g packs (HEB) 118mL (4oz) bottle
500g packs (NRG-5, BP-5) 237mL (8oz) bottle
946mL (32oz) bottle
Shelf life 5 years 12 – 24 months
Ration/dose Adults: 400g/day (HEB),500g/day According to weight

(NRG-5, BP-5) 150mL/kg/day
Approximat 1 week as full diet At least up to the age of 6 months
e duration 1 month for children
of
Intervention
Cost/dose/ 2.84/day
day (USD)
Manufacture NRG-5/BP-5: MSI (D), Compact (N), Abbott (US)
r
Biscuits:
Nuova Biscotti (I); Michiels (B); Insta
(Ke)
FRANCE
4 rue de Niepce
75662 Paris cedex 14 France
Tel: +33 1 43 35 88 88
[email protected]
www.actioncontrelafaim.org
ETATS-UNIS
ESPAGNE 247 West 37th Street, 10th Floor Suite
C/Caracas 6, 1° #1201
28010 Madrid, España New York, NY 10018 USA
Tel: +34 91 391 53 00 Tel: +1 212-967-7800
[email protected] Toll free: 877-777-1420
www.accioncontraelhambre.org [email protected]
www.actionagainsthunger.org
ROYAUME-UNI
First Floor, rear premises, CANADA
161-163 Greenwich High Road 1150, boulevard St-Joseph est
London, SE10 8JA, UK Bureau 302
Tel: +44 208 293 6190 Montréal, QC
[email protected] H2J 1L5, Canada
www.aahuk.org Tel: +514 279-4876
[email protected]
www.actioncontrelafaim.ca

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ACF INTERNATIONAL NETWORK

Technical and scientific department

Action Contre la Faim – International

Cover photo: © Roselyne Monin - Côte d’Ivoire, 2011

© Action Contre La Faim 2012, 4 rue Niepce 75662 Paris cedex 14

Timely response to crises

Considering the causes of malnutrition

The Importance of Emergency Food Aid

1.2 Target Audience

© ACF, Roselyne Monin – Ethiopia, 2011

2.1 ACF and health system strengthening (HSS)16

16 Health System Strengthening, Essential Health and Nutrition, ACF 2012

2.2 Preparation for emergency

2.2.1 Vulnerable areas and groups within the population

17 ACF, Nutrition Multi-sectoral seasonal calendar, March 2012

2.2.4 The crisis management strategy

2.2.5 The “thresholds” for emergency response

Tools to analyse the healthcare system's capacity for coping with an

The procedures to be followed for mobilising workers and the information

Is there a monitoring system in place?

Is there an early warning system in place?

2.3.2 Collection of primary information

2.4 Emergency response

18 Multi-cluster / sector Initial Rapid Assessment

© ACF, Roselyne Monin – Ethiopia, 2011

© ACF, Roselyne Monin – Ethiopie, 2011

1) The previous situation, and

On completion of this analysis, a programme recommendation can be formulated.

3.1.1 Analysing the situation

The first points of information to consider are

GAM prevalence may be corroborated by the

3.1.2.2 Risk evaluation

Table 2: Evaluating the risk of deterioration.

3.1.3 Programme recommendation

© ACF, Roselyne Monin – Ethiopia, 2011

The analysis required to choose a modus

Surveillance can apply

Estimating the duration of the intervention

Determining the implementation mechanism

The management of acute malnutrition consists of three interventions:

For example, the following combination could be possible:

3.2.2.2 Programmatic elements

Selecting a target group

ANTHROPOMETRIC CRITERIA for SAM ADMISSION

Selecting the correct product

Estimating the timescale of the intervention

Deciding how the intervention should be carried out

© ACF, Roselyne Monin – Ethiopia, 2011

3.2.3 Programmes section 3: Prevention of severe malnutrition

Infants and Young Child Feeding (IYCF)22

22 ACF, Care Practices in Emergencies Guidelines (to be published)

The Haiti experience

23 ACF-International, Optimiser l’impact nutritionnel des interventions sécurité alimentaire et moyens

3.2.3.2 Programmatic elements

Estimating the length of the operation

© ACF, Roselyne Monin – Côte d’Ivoire, 2011

4.1 The Humanitarian Reform and the Cluster Approach

figure 3: the 4 pillars of the Humanitarian Reform

4.1.1 Aims of the Cluster Approach