Drought resistant 'banana' - Field Exchange - Emergency Nutrition ...
Drought resistant 'banana' - Field Exchange - Emergency Nutrition ... Drought resistant 'banana' - Field Exchange - Emergency Nutrition ...
Field ArticlePotential of Using QBmix to PreventMicronutrient Deficiencies inEmergenciesMSF/Epicentre, Angola, 2003Household survey on how QBmix is usedBy Evelyn Depoortere, EpicentreEvelyn Depoortere is currently a medical epidemiologistfor Epicentre. Previously she worked on severalMSF missions, including Southern Sudan during the1998 famine.The contributions of Sandra Simons (medical coordinator,Angola), Ann Verwulgen (field coordinator, Kuito), Dr. PaulinaSemedo (Coordinator of the National Nutrition Programme) andSophie Baquet (Nutrition Advisor, MSF-B) are gratefully acknowledged.Thanks to the MSF team of interviewers in Kuito, namely AldinoGilles, Amelia Vita, Azevedo Antunes, Custodio Albano, DanielAlfonso, Isabel Domingas, Manuel da Saudade, Maria do Ceu,Ventura Sozinho, and Veronica da Costa. Also, the assistance ofMs. Rita Kakwarta, Provincial supervisor for Nutrition, in thesupervision of the teams, is appreciated.Box 1A guide to PellagraPellagra is caused by Niacin (Nicotinic acid) deficiency. The condition can befatal and is often associated with other B vitamin deficiencies. Niacin (vitaminB3) is a water-soluble vitamin widely distributed in plant and animalfood, but in very small amounts. Rich sources of niacin include groundnuts,fish, meat and pulses. The body can synthesise niacin from the amino acidtryptophan.The recommended daily requirements range from 13 to 15 mg nicotinic acidequivalent for women and 16 to 19 mg for men. During pregnancy andlactation, an additional 2 and 5 mg nicotinic acid respectively, are required.For infants and children, 6 and 11 mg daily are recommended, respectively.The initial clinical features of pellagra are non-specific and include anorexia,prostration, weight loss, headache and a burning sensation in the mouth.The fully developed syndrome, described by the "three D's", consists ofdermatitis, gastrointestinal symptoms (diarrhoea), and finally mentalimpairment (dementia). The dermatological signs are usually most prominent,symmetrically affecting sun exposed areas like the arms (“pellagragloves”), the cheeks in a butterfly distribution, and the neck and upperchest (“Casal’s necklance”). Eventually the fourth 'D' can occur - death.When a niacin and/or tryptophan - deficient diet is consumed, the lead-timefor developing signs of pellagra is about 2 to 3 months.Populations consuming maize or sorghum and little else are at risk of pellagra.Niacin deficiency is now endemic at very low levels amongst the ruralpoor in Africa where maize is the principal cereal. Examination of ruralhealth centre records may show a few cases - especially during the 'hungryseason'. However, outbreaks of pellagra have only occurred in recent yearsamongst emergency affected populations, including Mozambican refugeesin Malawi, Bhutanese refugees in Nepal, emergency-affected populations inAngola, and refugee returnees to Mozambique.Strategies to prevent outbreaks of pellagra in emergencies include diversifyingthe general ration to include bioavailable sources of niacin, fortificationof foods when maize is a staple food in the ration, allocation of surplus foodsto allow food sale or food exchange for another food commodity, vitamintablet supplementation, and cultivation or production of foods by the affectedpopulation.Adapted from: Pellagra and its prevention and control in major emergencies.WHO/NHD/00.10 Available online at http://www.who.int/nut/documents/pellagra_prevention_control.pdfThis article describes an assessment by MSF of using a micronutrient-richfood product, QBmix, in Angola and outlines possiblestrategies for the future in preventing micronutrient deficiencyoutbreaks in emergency affected populations 1 .Since the 1990s, Médecins Sans Frontières-Belgium (MSF-B)have worked in Kuito, Angola, as well as in several IDP(internally displaced person) camps around Kuito town.One of these camps, Kaluapanda, was established in March2002 and has an estimated population of 4,400 people. During thisperiod, MSF have been involved in a number of large scale emergenciesin Kuito. However over the past year (2003), the situationhas become much more stable, with the displaced populationbeginning to return home. The current MSF programme focuseson treatment of malaria and TB. MSF have also been implementinga pellagra treatment programme, which at the time of thestudy described in this article, was receiving 20-30 new patientsevery week. Most of those in this treatment programme wereliving in the city.Between June 1999 and November 2002, there were fouroutbreaks of pellagra in Kuito town 2 . A total of 3859 cases wererecorded during this period. During the first two outbreaks in1999, the displaced population was the main group affected, withan attack rate of 4.7 per 1000 population. During the latter twooutbreaks (2001 and 2002), it was the resident population whowere most affected, with attack rates of 7.1 (in 2001) and 5.5 (in2002) per 1000 population. In all outbreaks, women aged 15 yearsand older were the largest affected group.Strategies to deal with micronutrient deficiency disease outbreakslike these, include food fortification, dietary diversificationand supplementation (see box 1). However, these strategies allhave inherent difficulties. For example, fortification requires that1Micronutrient supply in emergencies. Logistic feasibility and population acceptabilityof food supplementation with QBmix, Kuito, Angola. Evelyn Depoortere,January 20042See Field Exchange 10, A Pellagra Epidemic in Kuito, Angola, by Sophie Baquetand Michelle van Herp12
Field ArticleBox 2Profile of QBmixTable 1Acceptance of QBmix in pellagra patients and displaced familiesin Kuito, AngolaQBmix is manufactured by Nutriset. Ithas a shelf life of one year after manufacturingdate, but studies are ongoingto improve this. It is recommended tostore the product in a cool, dry place,below 30°C.Use: QBmix is added to the family meal,like a condiment, after cooking only (notto destroy the vitamins). Preparationguidelines state to prepare the meal asusual, add QBmix® to the dish and mixwell.Recommended dose: One 210 g sachetmeets the needs of 10 people for 2weeks. A daily intake is not necessary -21 g per person for a period of 2 weeksis sufficient (1.5 g/day) in 2 or 3 intakesper week. Overdosing is unlikely due tothe very salty taste.One 1.5 g dose of QBmix contains 7 mgiron, 400 mg folic acid, 34 mg selenium,7 mg zinc, 600 mg vitamin A, 1.2 mgvitamin B1, 1.3 mg vitamin B2, 16 mgniacin, 5 mg vitamin B5, 1.3 mg vitaminB6, 2.4 mg vitamin B12, 90 mg vitaminC and 10 mg vitamin D. The equivalentof the height of the screw top gives 1.5 gof QBmix.Adapted from the Nutriset QBmixguidelines for usageall people vulnerable to deficiency consume thefood ‘vehicle’, while the use of supplementtablets or capsules may place a considerablestrain on an already overworked local healthsystem.The recent development of QBmix 3 , a mineraland vitamin rich condiment, offers an alternativeto the above strategies (see box 2). In order toassess the feasibility and acceptability of usingQBmix in an emergency-affected and food aiddependent population, MSF-B and Epicentrecollaborated with the Nutrition Department inthe Ministry of Health to test the product out inAngola. Specific objectives of the study were to:• compare the overall cost involved of usingCorn Soya Blend (CSB) and QBmix 4• describe advantages and difficulties relatedto introduction and use of QBmix• describe the population’s perception andacceptance• make recommendations to MSF regardingthe integration of QBmix in their futureresponse to nutritional emergencies.Frequency of QBmix use• Every day• 2 or 3 times a week• OtherEasy to use QBmixEasy to add right quantityUsed screw top as measureAdded QBmix after cookingQBmix left overLike to useLike the sachet (packing)Easy to doseClottingLike the textureLike the colourLike the smellLike the tasteToo saltyRefused by familyFamily wants moreSomeone felt unwellnPellagra patients(n = 116)Displaced families(n = 232)*% n %10893.122998.77 † 6.12 ** 0.976.031.310.900.0109 †94.0232100.0111 †96.5228 ‡98.711296.622797.811599.122898.38069.05322.8115 †100.0232100.0114 †99.1232100.0111 †96.5232100.032 **27.831.311397.4232100.0116100.0232100.011296.6232100.0116100.0232100.054.300.010 †8.741.711094.8229 **99.6* The one family who did not use the QBmix is no longer included in the denominator† One missing value, ** two missing values, ‡ three missing valuesTable 2Comparison of CSB and QBmix needs for 1000 persons for 30 daysTotal quantity 1800 kg 3000 kg 45 kgVolumeBuying priceInternational transportNational transport (truck)• MSF truck• Rented truck60g CSB/p/d72 bags 120 bagsQBmix215 sachets738,72 euro 1231.2 euro 361.2 euro3600 euro 6000 euro 90 euro• 28 euro• 223.2 euro100g CSB/p/d• 16.8 euro• 372 euro• 0.42 euro• 5.58 euroSource: MSF-B logistics in Luanda, Feasibility and costs assessment, Kuito, Angola, October 2003Note: Prices originally given in US dollar, were converted to euro at the rate of 1.25 USD for 1 Euro.Study designTwo different groups were sampled for thestudy. The first group consisted of pellagrapatients admitted in the MSF treatmentprogramme, while the second group targetedrecently displaced families dependent on externalfood aid, and therefore at risk of micronutrientdeficiency disease.As the two target populations were different,they were treated as independent samples.Overall, 116 of the 168 pellagra patients who hadreceived QBmix, and a random selection of 233displaced families in Kaluapanda, were interviewed.Acceptability of QBmix was assessed througha questionnaire administered during a populationsurvey and was expressed as the proportionof families that used the product correctly andliked it. A total of 10 interviewers were trained toadminister the questionnaire. Questions addres-sed included confirmation that families receivedQBmix, verification of how it was used, whetherit was accepted by the family, and what was theperceived usefulness of the product.Feasibility was based on estimating themicronutrient needs of 1000 people for 30 daysand the weight, volume and transport costscompared to CSB. Caloric value (which is relevantfor CSB but not QBmix) was not considered.Accept ability and feasibility of usingQBmixBoth groups, in general, reacted positivelyand liked QBmix (see table 1). The large majorityused it correctly, adding it only after cooking,and using the screw top as a measure. Five pellagrapatients (4%) (but no displaced families) saidit tasted too salty, while seven (6%) said it madethem feel unwell or sick. A small proportion ofthe pellagra patients (12.9%, n=15) and displa-ced families (5.2%, n=12) said they wouldnot be prepared to buy it on the market, andvarious reasons were given for this (alsotable 1). Only one family did not use theQBmix at all because they did not like it.All pellagra patients and displaced familiesconsidered QBmix to be good for health.Between 15% (patients) and 27% (displaced)said they did not add salt to a meal withQBmix.Table 2 shows a comparison, in volumeand cost, between CSB and QBmix. In orderto meet micronutrient needs for a food aid3QBmix is a registered trademark and is part of arange of products patented by IRD/Nutriset4The World Food Programme (WFP) policy dictatesthat fortified Corn Soy Blend (CSB) is provided forpopulations completely dependent upon food aid and,therefore, at risk of micronutrient deficiency disease13
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<strong>Field</strong> ArticleBox 2Profile of QBmixTable 1Acceptance of QBmix in pellagra patients and displaced familiesin Kuito, AngolaQBmix is manufactured by Nutriset. Ithas a shelf life of one year after manufacturingdate, but studies are ongoingto improve this. It is recommended tostore the product in a cool, dry place,below 30°C.Use: QBmix is added to the family meal,like a condiment, after cooking only (notto destroy the vitamins). Preparationguidelines state to prepare the meal asusual, add QBmix® to the dish and mixwell.Recommended dose: One 210 g sachetmeets the needs of 10 people for 2weeks. A daily intake is not necessary -21 g per person for a period of 2 weeksis sufficient (1.5 g/day) in 2 or 3 intakesper week. Overdosing is unlikely due tothe very salty taste.One 1.5 g dose of QBmix contains 7 mgiron, 400 mg folic acid, 34 mg selenium,7 mg zinc, 600 mg vitamin A, 1.2 mgvitamin B1, 1.3 mg vitamin B2, 16 mgniacin, 5 mg vitamin B5, 1.3 mg vitaminB6, 2.4 mg vitamin B12, 90 mg vitaminC and 10 mg vitamin D. The equivalentof the height of the screw top gives 1.5 gof QBmix.Adapted from the Nutriset QBmixguidelines for usageall people vulnerable to deficiency consume thefood ‘vehicle’, while the use of supplementtablets or capsules may place a considerablestrain on an already overworked local healthsystem.The recent development of QBmix 3 , a mineraland vitamin rich condiment, offers an alternativeto the above strategies (see box 2). In order toassess the feasibility and acceptability of usingQBmix in an emergency-affected and food aiddependent population, MSF-B and Epicentrecollaborated with the <strong>Nutrition</strong> Department inthe Ministry of Health to test the product out inAngola. Specific objectives of the study were to:• compare the overall cost involved of usingCorn Soya Blend (CSB) and QBmix 4• describe advantages and difficulties relatedto introduction and use of QBmix• describe the population’s perception andacceptance• make recommendations to MSF regardingthe integration of QBmix in their futureresponse to nutritional emergencies.Frequency of QBmix use• Every day• 2 or 3 times a week• OtherEasy to use QBmixEasy to add right quantityUsed screw top as measureAdded QBmix after cookingQBmix left overLike to useLike the sachet (packing)Easy to doseClottingLike the textureLike the colourLike the smellLike the tasteToo saltyRefused by familyFamily wants moreSomeone felt unwellnPellagra patients(n = 116)Displaced families(n = 232)*% n %10893.122998.77 † 6.12 ** 0.976.031.310.900.0109 †94.0232100.0111 †96.5228 ‡98.711296.622797.811599.122898.38069.05322.8115 †100.0232100.0114 †99.1232100.0111 †96.5232100.032 **27.831.311397.4232100.0116100.0232100.011296.6232100.0116100.0232100.054.300.010 †8.741.711094.8229 **99.6* The one family who did not use the QBmix is no longer included in the denominator† One missing value, ** two missing values, ‡ three missing valuesTable 2Comparison of CSB and QBmix needs for 1000 persons for 30 daysTotal quantity 1800 kg 3000 kg 45 kgVolumeBuying priceInternational transportNational transport (truck)• MSF truck• Rented truck60g CSB/p/d72 bags 120 bagsQBmix215 sachets738,72 euro 1231.2 euro 361.2 euro3600 euro 6000 euro 90 euro• 28 euro• 223.2 euro100g CSB/p/d• 16.8 euro• 372 euro• 0.42 euro• 5.58 euroSource: MSF-B logistics in Luanda, Feasibility and costs assessment, Kuito, Angola, October 2003Note: Prices originally given in US dollar, were converted to euro at the rate of 1.25 USD for 1 Euro.Study designTwo different groups were sampled for thestudy. The first group consisted of pellagrapatients admitted in the MSF treatmentprogramme, while the second group targetedrecently displaced families dependent on externalfood aid, and therefore at risk of micronutrientdeficiency disease.As the two target populations were different,they were treated as independent samples.Overall, 116 of the 168 pellagra patients who hadreceived QBmix, and a random selection of 233displaced families in Kaluapanda, were interviewed.Acceptability of QBmix was assessed througha questionnaire administered during a populationsurvey and was expressed as the proportionof families that used the product correctly andliked it. A total of 10 interviewers were trained toadminister the questionnaire. Questions addres-sed included confirmation that families receivedQBmix, verification of how it was used, whetherit was accepted by the family, and what was theperceived usefulness of the product.Feasibility was based on estimating themicronutrient needs of 1000 people for 30 daysand the weight, volume and transport costscompared to CSB. Caloric value (which is relevantfor CSB but not QBmix) was not considered.Accept ability and feasibility of usingQBmixBoth groups, in general, reacted positivelyand liked QBmix (see table 1). The large majorityused it correctly, adding it only after cooking,and using the screw top as a measure. Five pellagrapatients (4%) (but no displaced families) saidit tasted too salty, while seven (6%) said it madethem feel unwell or sick. A small proportion ofthe pellagra patients (12.9%, n=15) and displa-ced families (5.2%, n=12) said they wouldnot be prepared to buy it on the market, andvarious reasons were given for this (alsotable 1). Only one family did not use theQBmix at all because they did not like it.All pellagra patients and displaced familiesconsidered QBmix to be good for health.Between 15% (patients) and 27% (displaced)said they did not add salt to a meal withQBmix.Table 2 shows a comparison, in volumeand cost, between CSB and QBmix. In orderto meet micronutrient needs for a food aid3QBmix is a registered trademark and is part of arange of products patented by IRD/Nutriset4The World Food Programme (WFP) policy dictatesthat fortified Corn Soy Blend (CSB) is provided forpopulations completely dependent upon food aid and,therefore, at risk of micronutrient deficiency disease13
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