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News & ViewsFAO/WHOMeeting Warn ofContaminatedInfant FormulaPeople caring for infants at high risk ofinfection should be warned thatpowdered infant formula is not a sterileproduct, a joint Food andAgricultural Organisation (FAO) and WorldHealth Organisation (WHO) meeting hasconcluded, and recently highlighted in a BMJnews piece 1 .Attended by experts, the joint FAO/WHOworkshop on Enterobacter sakazakii and othermicro-organisms in powdered infant formulafound that intrinsic contamination of powderedinfant formula with E sakazakii andSalmonella had caused cases of infection andillness in infants, including severe disease, andcould lead to serious developmental sequelaeand death.Neonates (up to 4 weeks of age), particularlythose born prematurely, with low birthweight,or immunocompromised babies, wereconsidered to be at greatest risk of E sakazakiiinfection. Infants of HIV positive mothers werealso at risk because they may require infantformula and may be more susceptible to infection.E sakazakii has been implicated in outbreakscausing meningitis or enteritis. In the fewoutbreaks reported, the death rate amonginfants who contracted the disease rangedfrom 20% to over 50%, while some survivorsexperienced severe lasting complications. Thebacterium has been detected in a range offoods, but only powdered infant formula hasbeen linked to outbreaks of disease. Its prevalenceis unknown.The expert meeting recommended thatcarers, particularly of high risk infants, shouldbe encouraged to use commercially sterileliquid formula or formula that has undergonean effective decontamination procedure, suchas using boiling water to reconstitute formulaor heating reconstituted formula.The meeting was called in response to arequest made by the Codex Committee onFood Hygiene for scientific advice to be used inthe revision of the Recommended InternationalCode of Hygienic Practice for Foods for Infantsand Children. On the basis of its findings, theworkshop recommended that the code shouldinclude microbiological specification for Esakazakii in powdered infant formula.A summary report of the joint FAO/WHOworkshop on E sakazakii and other microorganismsin powdered infant formula isavailable athttp://www.who.int/foodsafety/micro/meetings/feb2004/en/1News extra. FAO/WHO meeting warns of contaminationof powdered infant formula. BMJ 2004;328:426 (21February). See online athttp://bmj.bmjjournals.com/cgi/content/full/328/7437/426-d?etocDear EditorI was amazed, and greatly disappointed,to read the report of the workshopon Community Based Approaches toManaging Severe Malnutrition, and thepiece on this subject in Field Exchange,March 2004, pp 16-19. Why was there nomention, whatsoever, about any of themicronutrient deficiencies? These almostinvariably accompany severe proteinenergymalnutrition, and therefore constitutea very important part of "severemalnutrition". All those concernedshould surely know that deficiency ofvitamin A, iron, iodine, and zinc, andpossibly others, are responsible in largepart for the very high rates of mortalityand morbidity among young childrenand pregnant and lactating women, andothers, in developing countries. I find itironic that on the very next pages youhave printed an excellent article by DrAndre Briend, which rightly drawsattention to the scandal, and reflects anarea in which I was actively involved inover several decades, in trying to combatthe criminal micronutrient inadequacy ofmany refugee rations. The most startlingfeature of Table 1 in Dr Briend’s article isthe absence of both vitamins A and C.Even to this day, there are constantlyrecurring reports of frank scurvy andDear EditorThe targeting of food aid is widelyassumed to be the most effective andefficient way of ensuring that the limitedfood aid resources available in emergenciesreach those who need them most.Targeting is conducted at multiplelevels - from the selection of countries,down to the selection of individuals whowill receive it and those that won't. Foodaid targeting is a central aspect of thefood aid system, which is itself drivenby multiple objectives: shifting surpluses,keeping world prices high, humanitarian,political contract between countries,etc. This means that the quantityand quality of food aid at any givenemergency is unlikely to be commensuratewith the need experienced by thoseaffected by the emergency. Within thiscontext, humanitarian agencies are oftenrequired to target food aid to the householdsor individuals that need it most.In most emergency situations, it is notpossible to target food aid more specificallythan to geographical areas 1 . Thecontexts where within-community targetingof households is possible are veryfew, unless costly administrative systemsare put in place (which out-weigh thecost savings of targeting). Wide implementationof feeding programmes, oftenin the absence of a general householdration, can ensure that certain individualsreceive food (there are few guaranteesthat these individuals will consumethe food). These programmes rarelycontribute to the longer term viability ofthe household and targeted individualsnon-blinding and blinding xerophthalmia.Yours faithfullyDonald S. McLaren, MD, PhD, FRCPThe ENN would like to point out that thereport referred to in the letter above was theproceedings of a meeting summarised by theENN, and included with issue 21 of FieldExchange. While micronutrient deficiencieswere discussed at the meeting, the main focusof discussions was around the ‘new’ strategyof addressing severe malnutrition throughcommunity based care. It should also be notedthat all diets used in projects described in theDublin report used foods that were highlyfortified with all micronutrients (along theWHO recommendations for F100 rehabilitationdiets). Nonetheless, Dr. McLaren’s letter,and the article by Andre Briend to which herefers, do highlight how we can never becomplacent about micronutrient deficiencies.Sadly, the steady flow of articles about micronutrientdeficiency outbreaks in humanitariancrises received by the ENN and oftenpublished in Field Exchange bear testimonyto this.are likely to experience very low recoveryrates because, in fact, the targetinghas failed and food is shared or replacesthe normal diet. Food for work is rarelypractical in an emergency, because of theadministrative burden it carries.Targeting according to socio-economiccriteria can only feasibly be done usingcommunity managed approaches andonly then, in stable communities, whereneeds vary considerably between householdsand food is sufficient to addresshouseholds' food deficit.In practice, however, these approachesare applied in many emergencysituations. Monitoring and evaluation isvery poor and rarely documented.Inclusion and exclusion errors areundoubtedly huge in many contexts butgenerally ignored. Therefore, the mythof the appropriateness of targeting inemergencies continues.Isn't it time we challenged the perceivedwisdom, made a clear statement ofwhen it may be appropriate to targetfood aid in emergencies and when it islikely to fail, and began to explore otherways of targeting resources at individualsand households who need themmost, e.g. cash, market intervention, etc?Anna TaylorNutrition Advisor, SC UK1See ENN Special Supplement on Targeting FoodAid in Emergencies, Taylor and Seaman, 2004Letters19