Use of case definitions and awareness of micronutrient deficiencies

Summary of Unpublished Study^*

Afgani boy with swollen and bleeding gums typical of scurvy.

Micronutrient deficiencies have been reported in emergencies in populations who are dependent upon food aid, particularly refugees and IDPs. A review was recently carried out by a WHO intern to determine the awareness and progress in the field in detecting and/or preventing these outbreaks. Questionnaires were sent out to approximately 80 contacts, including academics, NGOs, aid agencies and individuals to gather information about activities and knowledge in the field. The results were analysed as follows.

Use of Case Definitions

Few agencies had defined case definitions. Agencies who had been in direct contact with and worked in areas with severe micronutrient deficiencies had developed case definitions on presentation of symptoms, but only for severe cases. No specific case definitions or risk assessment methods were specified to identify mild cases (symptoms are rarely obvious in mild and moderate cases anyway). Several organisations demonstrated an awareness of the classic symptoms of severe cases. MSF during their surveillance strategy, identified risk factors which would indicate the potential for micronutrient deficiencies. As expected, no agencies had the facilities to determine micronutrient deficiencies biochemically. Furthermore, many of the agencies contacted did not have any guidelines for assessing or recognising micronutrient deficiency disorders. Generally, there appeared to be a lack of awareness of micronutrient deficiencies, probably because many of the organisations had no direct experience of dealing with them.

Problems of Assessment

A major problem in detecting micronutrient deficiencies in the field is the occurrence of deficiencies in people of normal weight or those whose food rations are sufficient in quantity e.g. Nepal. An assessment in 2001 in Angola found that out of the 209 patients that were diagnosed with pellagra, none were wasted or oedematous, many were obese, and all were within the normal age height range.

Another problem with assessment is the variation in presentation and incidence between men, women and children. Much of the feedback and reports from the field suggest that micronutrient deficiency disorders are prevalent mainly in women of child bearing age and adolescent boys. This may be due to variations in symptom presentation. Variations in presentation of symptoms between adults and children also pose a problem for assessment through case definitions and none of the agencies recognised the potential for differences in symptoms or an awareness of the need to assess a 'new vulnerable group'.

Previous outbreaks of scurvy in refugee camps in Somalia and Sudan showed that the prevalence of scurvy was high in those who had been in the camp longest, adults, females and those over 45 years of age - very different from the traditionally 'vulnerable groups' with respect to general nutritional deficiencies. Other authors have highlighted the prevalence of micronutrient deficiencies among young women and adolescents. During the pellagra outbreak in Mozambican refugees in Malawi, there was a significant variation in the attributable risk for gender. Women were found to be at 7.8 times higher AR than males. Children under 5 also appeared to have a lower attributable risk than the general population. No agencies have separate specific case definitions or assessment methods for adults and children and nutritional assessments generally focus upon the general nutritional status of children under 5 (anthropometric assessment).

Training

Several field workers reported that training in assessing risk and awareness of micronutrient deficiencies was insufficient in NGOs and that experienced nurses, doctors and nutritionists missed the clinical signs of these deficiencies in the field, due to the expectation of 'text book' pictures. Field workers also stated that in retrospect they had seen cases in the field but were unaware at the time due to lack of training, resulting in deficiencies not being treated.

Monitoring of Food Baskets and Surveillance

Rations containing insufficient micronutrients are consistently a major factor in the development of micronutrient deficiencies. It is vital that, due to the difficulty in diagnosing mild micronutrient deficiencies that other methods of assessment are used to determine risk before severe cases present. The need for assessment and monitoring of the nutritional content of food baskets was acknowledged to be critical for early warning of potential micronutrient problems as far back as the outbreaks in 1980s in Somalia and Sudan. However, the development of health information systems within refugee camps, to systematically assess ration content at a household level is often not embarked upon. Assessment of risk factors, e.g. insufficient food rations, lack of fresh vegetables and fruit, insufficient ration to enable exchange of food stuffs, high prevalence of protein-energy malnutrition, length of time dependent upon food aid, should suggest the potential for micronutrient deficiencies. Several NGOs in the study undertake food basket monitoring and household food security assessments but with no specific analysis of the potential for micronutrient deficiencies.
There was also criticism from some individuals in the study, that prevention of micronutrient deficiencies was not a priority amongst some aid agencies and NGOs, specifically relating to fortification of food, and that co-ordination and interest was limited. The fact that the major incidences of scurvy, pellagra and beriberi have recently occurred in populations solely dependent upon food aid suggests that problems still remain in determining and/ or supplying food sufficient in micronutrients to maintain the nutritional status of the population.

Conclusion

Due to the fact that clinical signs are often difficult to determine before severe cases are present, ration content and household food security should be monitored on a regular basis. There needs to be an assessment strategy developed between agencies to ensure that assessment can be easily carried out to determine risk, but can also be easily interpreted by the WFP and others to provide appropriate response. The development of universal assessment and surveillance methods would help in ensuring that all NGOs and others involved know what to look for. However, every crisis is different and presents varying arrays of difficulties. Improved communication between relief agencies and NGOs is vital to ensure that co-ordination in detection and surveillance of nutritional status of populations takes place.
Training of personnel in detecting cases and using information from food security/household assessments, may be an effective strategy to ensure early detection of risk. However, further research is required. Increased awareness of the risk associated with 'traditionally less vulnerable populations' is also required.

^*Unpublished study by Helen Mitchell, WHO intern, Sept.- Dec. 2001. For more information contact: Zita Weise Prinzo, WHO HQ, Geneva (weiseprinzoz@who.int)