6
Conclusions and Recommendations

Conclusions

Programmatic approaches to provide displaced populations with adequate vitamin C must address two possible situations: (1) treatment of populations in which scurvy exists, and (2) provision of sufficient amounts of vitamin C to prevent scurvy in populations that are not currently deficient but are dependent to some degree on donated food commodities. The provision of sufficient amounts of vitamin C for other physiological purposes, such as maintenance of saturated tissue levels of ascorbic acid and enhancement of immune responses, was considered. However, these functions are less well documented, and appropriate levels to achieve such benefits are not known but are assumed to be much higher than those necessary for scurvy prevention. Thus, the committee concluded that assigning a priority to the addition of vitamin C in emergency feeding situations based on these roles, is not appropriate. The committee also estimated that adding additional vitamin C is not a cost-effective strategy for increasing the amount of iron absorbed from blended foods.

Assessment of Vitamin C Status and Risk of Deficiency

As a first step in determining the appropriate means of delivering vitamin C, it is necessary to assess the current situation of the population and the likelihood of future deficiency. Issues to be considered are (1) the current prevalence of scurvy, based on a specific case definition (e.g., presence of hemorrhagic skin lesions: or in nonedentulous children and adults, swollen, hemorrhagic gums, and either joint pain or muscle tenderness) and (2) access to vitamin C-containing foods.

Access to vitamin C-containing foods depends on the ability of the population to purchase food or engage in trade, the presence of local markets,



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--> 6 Conclusions and Recommendations Conclusions Programmatic approaches to provide displaced populations with adequate vitamin C must address two possible situations: (1) treatment of populations in which scurvy exists, and (2) provision of sufficient amounts of vitamin C to prevent scurvy in populations that are not currently deficient but are dependent to some degree on donated food commodities. The provision of sufficient amounts of vitamin C for other physiological purposes, such as maintenance of saturated tissue levels of ascorbic acid and enhancement of immune responses, was considered. However, these functions are less well documented, and appropriate levels to achieve such benefits are not known but are assumed to be much higher than those necessary for scurvy prevention. Thus, the committee concluded that assigning a priority to the addition of vitamin C in emergency feeding situations based on these roles, is not appropriate. The committee also estimated that adding additional vitamin C is not a cost-effective strategy for increasing the amount of iron absorbed from blended foods. Assessment of Vitamin C Status and Risk of Deficiency As a first step in determining the appropriate means of delivering vitamin C, it is necessary to assess the current situation of the population and the likelihood of future deficiency. Issues to be considered are (1) the current prevalence of scurvy, based on a specific case definition (e.g., presence of hemorrhagic skin lesions: or in nonedentulous children and adults, swollen, hemorrhagic gums, and either joint pain or muscle tenderness) and (2) access to vitamin C-containing foods. Access to vitamin C-containing foods depends on the ability of the population to purchase food or engage in trade, the presence of local markets,

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--> and the availability of vitamin C-containing foods in these markets or the ability of food donors to purchase and provide such foods. Because of seasonal variation in the availability of these foods and dynamic changes in the market situation, periodic assessments are needed. It is extremely unlikely that biochemical assessment of vitamin C status will be feasible in most field situations, although this might be of interest for research purposes. Ideally, systematic evaluation of the situation with regard to vitamin C should be included in the initial and subsequent periodic assessments of a population's general nutrition and health condition. It would be useful for international agencies and nongovernmental organizations to achieve some consensus on how this assessment might be accomplished and interpreted. In any situation where more than 0.1 percent of individuals are found to have clinical scurvy, therapeutic interventions should be initiated as quickly as possible. Because the appearance of any cases of scurvy is likely to indicate that the entire population is deficient to some degree, therapeutic approaches might be considered for all members of the population until adequate preventive measures are in place. Moreover, since there is generally a lag of two to three months between the onset of low vitamin C intake and the first appearance of clinical signs of scurvy, it can be assumed that if any scurvy is present in a population at the initial assessment, the incidence of new disease is likely to increase progressively unless the population has access to local food sources of vitamin C or other preventive measures are introduced. Occurrence of Scurvy There is evidence of scurvy outbreaks among refugee populations entirely dependent on emergency relief rations that provide less than 2 mg of vitamin C per day per person. The greatest number of outbreaks occurred in the 1980s in Somalia. Only four outbreaks have been reported since January 1994, when the World Food Programme (WFP) and the United Nations High Commissioner for Refugees (UNHCR) adopted a policy of providing fortified blended foods to populations wholly dependent on food aid, in an effort to preempt any micronutrient deficiencies. One outbreak occurred among Rwandan refugees in eastern Zaire in the spring of 1994 prior to the time at which the newly adopted food aid plan could be implemented. Recurring mild outbreaks of scurvy were reported among Bhutanese refugees in Nepal in 1994, 1995, and 1996, and moderate outbreaks were reported among Somali refugees in the Dadaab camp in Kenya in 1994 and 1996. However, the scurvy outbreaks in the Dadaab camp did not appear to be related to the presence or abscence of fortified, blended foods in the diet. Thus, the need for higher vitamin C fortification of corn-soy blend (CSB) and wheat-soy blend (WSB) would be sporadic and apparently localized.

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--> Treatment of Scurvy Scurvy is best treated by administering large daily doses of vitamin C, which are typically provided as pharmaceutical preparations available in many dosages. Single doses on alternate day schedules would be needed. Response times depend on the extent of depletion. Because young children are often unable to swallow pills, special liquid or powdered preparations may be necessary, or vitamin C tablets would have to be manipulated in the household. For example, vitamin C tablets can be crushed and added to a prepared food or drink. However, because of the lability of ascorbic acid once hydrated, these preparations should be consumed immediately after mixing. Vitamin C concentrations in fruits and vegetables vary widely. Since availability is not likely to be consistent in an emergency situation, this solution would not be applicable for acute cases. Oranges can provide 50–100 mg of vitamin C per serving, clearly a more-than-adequate source of the nutrient. Greens (such as collards or kale) would give about 20–30 mg per 1/2-cup serving. These foods would have to be supplied on a daily basis. Prevention of Scurvy Different approaches to prevent scurvy are possible in the short or long term. In the short term, prevention can be accomplished by (1) providing supplements of vitamin C, as described above for treatment of scurvy; (2) supplying vitamin C-fortified rations; (3) supplying vitamin C-containing foods as part of the ration package; or (4) ensuring access to local markets for acquisition of vitamin C-containing foods if they are available. It should also be recognized that breast milk is an excellent source of vitamin C (40 mg/L average; varies depending on vitamin C status of the mother), and efforts should be made to promote continued breast feeding of children. For situations in which the population is expected to be displaced for a long period, local food production might also be encouraged by providing seeds, tools, and appropriate training for establishing home or community gardens. Vitamin C-Fortified Rations If food commodities are adequately fortified with vitamin C and the vitamin is not destroyed during shipping, storage, or cooking, these rations should be adequate to prevent scurvy. The stability of vitamin C is discussed in Chapter 5. On the assumption that 6–10 mg per day would prevent scurvy, adequate intake of this minimum amount of vitamin C can be achieved from fortified rations by varying the amount of food provided. Regardless of the level of vitamin C in the ration, it is important to provide clear, simple instructions on appropriate

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--> cooking techniques to conserve vitamin C and on the desirability of consuming food as soon as possible following preparation. To avoid the unnecessary cost of increased fortification for those populations that do not require it and the commonly experienced four-to six-month lag time between ordering commodities and their delivery in country, alternative approaches could be used. Local Fortification This approach, which is already being used by the World Food Programme (WFP), fortifies certain foods with additional vitamin C within the country or region in which particular relief programs are being implemented, only after a specific need has been identified. This approach requires both the availability of a specially formulated micronutrient mix that can be shipped rapidly to sites that require it and a local or regional processing capability. The committee was informed that specially fortified food can be obtained locally or regionally within a reasonably short period of time, although costs may be elevated when extraordinary procurement or shipping procedures are necessary. Addition of Vitamin C-Containing Foods to Ration Packages Another approach is to provide fresh or processed food sources of vitamin C as a component of the ration package. Examples might include locally purchased fresh fruit or vegetables or imported packaged items such as tomato paste, enriched powdered fruit drinks, and sour candies. The committee did not have access to information about the procurement and shipping costs of these items in different parts of the world, but it seems likely that they would be less than the cost of increasing the vitamin C content of all blended products if the items could be appropriately targeted to only those populations in need. Examples of the amounts of foods that would supply 10 mg of vitamin C (ascorbic acid) include 20 g of fresh orange (1/4 of a small orange), 30 ml of fresh lemon juice (bottled lemon juice is much lower in vitamin C), 25 g of tomato paste, or 2.5 g of powdered orange drink (USDA, 1997). Ensuring Access to Market When local sources of vitamin C are available in the marketplace, relief programs can be designed to take advantage of these foods. In particular, either foods can be procured locally by the program and distributed as described above, or the program can ensure that individual households have physical and economic access to the market. The latter approach can be facilitated by providing a sufficient amount of the basic staples to permit their exchange for

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--> vitamin C-containing foods without jeopardizing the adequacy of macro-nutrients provided by the relief package (Reed and Habicht, 1997). Household Production of Vitamin C-Containing Foods To reduce the burden on food distribution programs and decrease the dependence on donated foods, efforts should be made as soon as possible to facilitate local food production in situations where populations are likely to be displaced for long periods of time (i.e., more than one growing season). The extensive available literature on technical inputs required for promotion of home gardens can be adapted to increase the local availability of vitamin C-containing foods, at least during some parts of the year. These foods will also supply other needed nutrients. Fortification of Title II Blended Commodities Only a small proportion (~7 percent) of U.S.-supplied CSB and WSB is designated for emergency feeding programs in East African countries where scurvy has occurred. Although the United States supplied approximately 84 percent of all blended, fortified foods used worldwide (249,200 metric tons [MT]), 82 percent of U.S.-blended commodities went to Asia and to South and Central America. The majority of this 82 percent (75 percent) went to India for development feeding programs. Only 18 percent of U.S.-supplied CSB and WSB went to Africa, and roughly half of these went to general relief and to maternal and child health (MCH) programs rather than emergency programs. Of the 9–10 percent of CSB and WSB that was used for emergency feeding situations, only 70 percent would likely have been used in East Africa, where scurvy has been reported. Thus, fully 93 percent of the cost of adding more vitamin C to blended, fortified foods as a strategy for preventing scurvy is wasted. If a fixed dollar amount is assumed available for the purchase of food aid commodities, increasing the vitamin C content to 90 mg/100 g at an estimated increased cost of $6.33/MT would mean that approximately 425,800 fewer recipients could receive fortified, blended commodities as emergency food aid. This situation is not conducive to improving the nutrition and health status of refugees. Even if total food aid funding were increased, the same tradeoff would exist in relation to the most effective use of increased funds. Furthermore, the results of SUSTAIN's survey of five of the seven plants producing CSB or WSB raise serious questions about the capability of these manufacturers to meet specified fortification levels. Three of the five plants sampled were outside specifications almost 60 percent of the time, and levels fell below specifications more often than above. None of the plants sampled had a process capability (Cp) equal to or greater than 1.0. Given the pervasive

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--> problem of lack of uniformity of vitamin C content during the production of CSB and WSB, it would seem inappropriate to increase any micronutrient fortification of these commodities without better manufacturing controls. The potential for fortified blends to prevent outbreaks of scurvy will depend on the extent of the losses of vitamin C that occur during transport, storage, and cooking. Information obtained from the pilot study indicates that vitamin C losses during shipment and storage are not a major concern. Conventionally fortified WSB shipped to Haiti indicated a small but significant loss of 13 percent, but vitamin C retention in the highly fortified WSB and conventionally fortified CSB was approximately 100 percent. SUSTAIN's study indicates that losses of vitamin C during cooking may be a major limiting factor. The data for vitamin C losses during cooking are not conclusive because of a number of variables introduced, particularly the variability in vitamin C concentration of the starting blends (especially CSB) and the temperature or time of holding before cooked samples were frozen. The conclusions that are drawn relative to the concentration dependence of vitamin C retention are reasonable but not fully validated by the pilot studies. In addition, cooking times observed in the SUSTAIN study are not representative of emergency situations where fuel for cooking is frequently limiting. Use of local food sources rich in vitamin C benefits the local economy and provides the additional nutrients in these foods; local foods can be obtained quickly to respond to the need for vitamin C in a timely way. Alternative approaches for the prevention of scurvy have to be explored where the availability of vitamin C-rich foods is low. Higher fortification of U.S.-provided blended foods is not the most efficient or cost-effective of these alternatives. In addition, although iron deficiency appears to be a much more widespread problem in emergency and development feeding situations, the use of higher levels of vitamin C fortification to enhance iron absorption is not a cost-effective method of improving iron status. More cost-effective strategies would target populations at risk of vitamin C deficiency by providing vitamin C-containing foods as part of the emergency ration package; supplying a larger ration size of blended, fortified foods; ensuring access to local markets; or for long-term situations, encouraging local food production. Recommendations Major Recommendations 1.   The level of vitamin C fortification of blended food aid commodities should NOT be increased to 90 mg/100 g but maintained at the current level of 40 mg/100 g. Based on the reported incidence of scurvy and the quantity of U.S.-supplied blended food commodities going to regions where scurvy has

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-->       been reported, increasing the vitamin C fortification of all CSB and WSB is not cost-effective. 2.   Strengthen health surveillance systems in refugee camps to monitor population risks of vitamin C deficiency and scurvy and to initiate a timely response. Risk factors for vitamin C deficiency and scurvy should be monitored at the community and/or camp level. Some of the risk factors that have been identified as potentially useful for such monitoring include: populations totally dependent on food aid (e.g., displaced and famine-affected populations [CDC, 1992]); duration of stay in a refugee camp (Toole, 1994); seasonality: dry season and inability to cultivate (Desenclos et al., 1989; Henry and Seaman, 1992); market failure, limited local supplies of fresh produce, or lack of resources to trade for other food sources (Magan et al., 1983; Toole, 1992); poor acceptance of donated foods, especially blended fortified foods, resulting from cultural preferences, (Mason et al., 1992; Toole, 1992); and difficult access for relief organizations because of war or remoteness (Mason et al., 1996). At the individual level, the risk factors include age and physiological status (young children, pregnant and lactating women, and the elderly have been found more susceptible). 3.   Target identified populations at risk for scurvy with appropriate vitamin C interventions. There are several possible strategies to achieve increased vitamin C supplementation, (1) increased access to local foods and markets; (2) local fortification of commodities in the country or region where the emergency is occurring, as is currently practiced in some regions; and (3) use of vitamin C tablets if scurvy is already present. Alternatively, an increased total daily ration of conventionally-fortified, blended food would be appropriate in an emergency feeding situation and would increase the intake of other important nutrients such as energy, protein, and iron, as well as vitamin C. Another possibility might be for The U.S. Agency for International Development's (USAID's) Bureau of Humanitarian Response to investigate the logistics of managing two supplies of CSB and WSB, the conventionally-fortified blends, and a small proportion of highly-fortified blends that would only be targeted as part of the general ration to situations where the risk of vitamin C deficiency is high and continues for several months. 4.   Improve the uniformity of blended food aid commodities by implementing specific product and process procedures. Delivery of vitamin and mineral fortification via food aid commodities to target populations depends on the manufacturing facilities' ability to comply with formulation and finished product specifications. To improve the uniformity of blended food, the following remedial initiatives are recommended: Formulation document—a formal reporting of the formulation and ingredients used to generate a particular product or blend.

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--> Product specifications—institute procedures for analytical quality control to monitor compliance with fortification levels defined by product specification. Inability of manufacturer to comply can result in loss of contract. Methods and Sampling Procedures—the list of all statistical process control procedures, all analytical procedures, test methods and the appropriate sampling protocols. Operating guide—a formal document that provides a blueprint for operating a process. It includes a process description for each step, a review of normal operating conditions, control actions (the set of steps necessary to maintain a quality operation), and a discussion of the impact of each process step on product quality. Control plan—a master document that keeps track of a plant's record keeping. It lists the specification or test to be performed, the source of the authority for the test, who is responsible for conducting the test, the test frequency, where the test is recorded, what action to take, and where to file or who must receive the report. HACCP (Hazards Analysis Critical Control Points) plan—a preventive system to identify key areas of process control to avoid food safety risks. Measurements of improvement include analytical sampling and analysis of key fortification nutrients, regular audits of plant performance, maintenance of calibration records for all metering equipment, and maintenance of usage records for all vitamin and mineral premixes. Research Recommendations The committee has identified several areas in which additional research would be most helpful in alleviating potential vitamin C deficiencies and evaluating the appropriateness of any overall vitamin C fortification of U.S. Commodities. 1.   Research the epidemiology of vitamin C deficiencies. Ascertain the incidence of scurvy in displaced populations and analyze this according to the amount of blended, fortified foods received. The incidence of scurvy among those receiving blended foods at currently prescribed levels will permit assessment of the need to increase fortification or seek alternative approaches. Develop and validate predictors of populations at risk of vitamin C deficiency among refugees so as to institute local fortification 2.   Research and develop means to increase consumption of local foods rich in vitamin C. This may also be achieved by purchasing such foods for refugees, but it may be done more cost-effectively by decreasing barriers to barter and trade in refugee camps.

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--> 3.   Research and evaluate appropriate ration sizes of blended foods. More information is needed on the amounts of blended foods that are distributed to those at risk for scurvy in displaced populations. Currently, no good information is available on actual quantities distributed. This information may also indicate that much higher levels of fortification than are currently being considered are necessary for those at most risk because they could be receiving smaller rations. 4.   Research and evaluate methods for campsite vitamin C fortification. This would be the most cost-effective approach to fortification because the need is rare and the cost of vitamin C is relatively high. 5.   Research alternative forms of vitamin C available for fortification. The limited data available on cooking losses using the current ethyl cellulose-coated product indicates a need to develop other vitamin C products that are more stable to heating in dilute solutions.

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