Nutrition in transit centres

Protection objectives

• To ensure that refugees in transit centres have access at all times to safe and nutritious food, sufficient to maintain a healthy and active life.
• To respect the right to food and the right to health.
• To ensure that refugees in transit centres receive appropriate treatment for moderate acute malnutrition (MAM) and severe acute malnutrition (SAM).
• To ensure adequate protection, promotion and support for breastfeeding of infants and young children are available in transit centres, that infants and young children have access to adequate complementary feeding and infants younger than 6 months who are not breastfed have access to alternative food that is appropriate and adequate.

Underlying principles and standards

UNHCR, Global Strategy for Public Health 2014-2018:
Food security and nutrition objective 2.

• Sets standards for treating acute malnutrition that ensure quality treatment and adequate coverage.
• Guides an effective food security and nutrition response in emergencies.

UNHCR has developed a comprehensive Public Health strategy that applies to emergency and non-emergency operations in camp and out-of-camp settings. To tailor its interventions more efficiently to emergency situations, UNHCR recommends the use of SPHERE standards during emergency operations.

Sphere, Management of malnutrition standard 2.1: Moderate acute malnutrition. Moderate acute malnutrition is prevented and managed.

Sphere, Management of malnutrition standard 2.2: Severe acute malnutrition. Severe acute malnutrition is treated.

Sphere, Micronutrient deficiencies standard 3: Micronutrient deficiencies. Micronutrient deficiencies are corrected.

Sphere, Infant and young child feeding standard 4.1: Policy guidance and coordination. Policy guidance and coordination ensure safe, timely and appropriate infant and young child feeding.

Sphere, Infant and young child feeding standard 4.2: Multi-sectoral support to infant and young child feeding in emergencies. Mothers and caregivers of infants and young children have access to timely and appropriate feeding support that minimises risks, is culturally sensitive and optimises nutrition, health and survival outcomes.

UNHCR, Global Strategy for Public Health 2014-2018: Food security and nutrition objective 1. Addresses the prevention of under-nutrition and micronutrient deficiencies through the provision of access to food, cash and/or vouchers to the general population, and special nutritional products for vulnerable groups, as well as promotion of and support to adequate infant and young child feeding and care practices.

UNHCR and Save the Children, Infant and Young Child Feeding in Refugee Situations: A Multi-Sectoral Framework for Action. 2018. Provides guidance on how to consider the particular vulnerabilities of children under 2 and pregnant and nursing mothers in a multitude of sectors.

Protection Risks

In emergency response operations, protection, food security and nutrition are closely linked.
 

• If refugees cannot obtain food in transit centres, they are likely to become food insecure and malnourished and may adopt unsafe coping mechanisms that endanger their security.
• If refugee new arrivals are not screened for acute malnutrition or malnutrition programmes are unavailable, individuals with acute malnutrition will not be identified or treated, making it more likely that they will die or that their nutritional status will deteriorate.
• If transit centres do not assist infants and mothers who have difficulty breastfeeding, those infants are at greater risk of serious malnutrition and death.
• If transit centres do not identify and support infants younger than 6 months who are not breastfed, those infants face a higher risk of serious malnutrition and death, as a result of eating inappropriate or contaminated food.

Other risks

Failure to provide adequate food or nutritional rehabilitation may generate indirect or longer term risks.
 

• The security of transit centres may be compromised, by riots, demonstrations, or violent behaviour.
• Refugees may take risks to acquire food, or adopt unsafe coping strategies.
• Malnourished individuals may suffer long-term effects, such as impeded growth or development.

Key decision points

Wherever required, UNHCR and WFP should provide appropriate food assistance, including fortified foods, to refugees in transit centres.

Wherever required, UNHCR and partners must ensure that transit centres offer appropriate treatment programmes for acutely malnourished persons, either by establishing facilities or making facilities in the host community available to refugees.

UNHCR and partners must ensure that transit centres and other institutions offer breastfeeding support or alternatives to breastfeeding for infants younger than 6 months with established needs.

Public health and nutrition interventions must always be:

• Evidence-based. Activities should be planned and implemented, based on the findings of the initial assessment.
• Needs-based. Interventions should be scaled and resources should be allocated to meet the needs of the population.
• Technically sound. Services should be based on current scientific evidence and operational guidance, and implemented by skilled staff.
• Impact oriented. UNHCR promotes the primary health care approach, which ensures that essential health services address the health and nutrition needs of the entire population.
• Priority-based. Emergency nutrition interventions and services should be prioritised to achieve maximum impact across the population. Interventions to address immediate health risks, such as disease outbreaks and malnutrition, must be priorities.
• Integrated. Avoid setting up costly parallel services. Assist the national health system to extend its services to refugees.

Key steps

1. Establish strong co-ordination to ensure the response covers all needs, and that referrals across services as well as individual follow-up are assured. At the very start of the emergency, make sure that arriving refugees immediately receive minimum food rations or food assistance, to prevent their nutritional status from deteriorating.

2. At the start of an emergency, conduct an initial rapid nutrition assessment to identify levels of malnutrition, in transit centres and other arrival points.

3. Continue to screen for acute malnutrition, both to monitor levels of nutrition and detect individuals who need treatment.

4. Where moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) are identified, establish treatment programmes. All malnourished individuals detected on arrival should be referred to them. Young children and pregnant and lactating women are especially vulnerable to malnutrition. Programme design should reflect needs and available resources.

5. Programmes to treat SAM should build on and support existing health provision, wherever possible. If transit centres cannot treat SAM, or treatment centres are inaccessible, make arrangements to refer cases rapidly to other treatment facilities (for example, in camps).

6. Supplementary feeding programmes to tackle MAM may be targeted or blanket. The choice should reflect the degree of malnutrition, the caseload, the risk that acute malnutrition will increase, available resources, and capacity to screen and monitor. Targeted supplementary feeding programmes generally require more screening and monitoring; blanket delivery usually requires less expertise but more food. Supplementary programmes may provide wet or dry rations. In most situations dry rations are to be preferred; but wet may be more suitable if transit centres are overcrowded or food is difficult to prepare. The choice should be made by an experienced nutritionist.

7. Infant feeding programmes at the start of an emergency can save many vulnerable infants and young children, and play a key role in preventing malnutrition and micronutrient deficiencies. Transit centres should provide basic infant feeding assistance, emphasizing protection, support and promotion of breastfeeding for infants aged less than 6 months. Staff should respond quickly to reports that infants in that age range are having difficulty breastfeeding or eating substitute foods. Infants younger than 6 months who are not breastfed should be identified, receive urgent support, and referred for assessment by skilled personnel. Ensure that rest areas in transit centres include secluded areas for breastfeeding and that skilled breastfeeding support is available to help stressed mothers and acutely malnourished infants. It may be necessary to refer trauma cases to psychosocial services.

8. Refugees with specific needs who require assistance to access or use nutrition services should be supported and prioritised.

Key management considerations

Nutrition programmes are normally part of the basic health services in the transit centre. Given the multitude of actors in transit centres, it is vital to ensure that the health and nutrition programmes are well coordinated.

UNHCR must ensure that transit centres provide adequate food assistance, programmes to treat acute malnutrition, and infant feeding support. These services are normally provided by NGO partners in collaboration with WFP and UNICEF.

Given that UNHCR has an overall accountability for the refugee response, UNHCR should ensure that public health or nutrition staff are available as soon as possible to support the assessment, relevant health and nutrition strategy and support the operational response. In situations where malnutrition is a severe problem, UNHCR should deploy nutrition staff directly.

It should also ensure that the nutrition situation of arrivals in transit centres is monitored and reported regularly, using the Basic Indicator Report format in iRHis, so that partners can respond quickly if the situation changes. The iRHis team is available to provide remote and direct support. Contact [email protected].

Infant feeding programmes in transit centres must respect the UNHCR´s standard operating procedure for breastmilk substitutes (BMS). UNHCR actively discourages inappropriate distribution and use of BMS, which are not to be included in general or untargeted distributions, and are only provided to specific infants after a professional assessment. UNHCR does not accept unsolicited donations of BMS. Inappropriate handling of milk products can negatively affect feeding practices and increase infant morbidity and mortality.

Resources and partnerships

Staff

• In cases of severe under-nutrition a UNHCR nutritionist should be present; a nutritionist from UNHCR or a partner organisation can lead in less severe situations; where under-nutrition and infant feeding problems are a minor feature of the response, the UNHCR public health officer will support the partners in this case.
• An experienced nutritionist should lead the nutrition response of the programme.
• Community outreach workers provide support in the surrounding community, and nutrition/health assistants in transit centres.

Partners

• Ministry of Health and/or nutrition partners in collaboration with UNHCR implement initial rapid nutrition assessments, screenings, and nutrition programmes. Partners include NGOs (international and national) and UN agencies such as WFP and UNICEF (for child and maternal health, vaccination, and nutrition)