NEWSLETTER 3/2005 31 SIGHT AND LIFE
HKI’s Tsunami Response – Supplementation with
vitamins and minerals for tsunami survivors in the
provinces of Nanggroe Aceh Darussalam (Aceh)
and North Sumatra (Nias Islands), Indonesia.
R Moench-Pfanner1, S de Pee1, E Martini2, J van Hees2, S Halati2, F Graciano1, MW Bloem1,3.
1Helen Keller International Asia-Pacific Regional Office, Singapore; 2Helen Keller International, Jakarta,
Indonesia; 3World Food Programme, Rome, Italy.
Introduction At a global experts’ meeting in United Nations. Several factors
late 2004, to which Helen Keller enabled HKI to rapidly initiate the
The overwhelming humanitarian International (HKI) was invited to SUM within weeks of the tsunami.
emergency facing countries af- contribute its expertise, the im- Firstly, HKI had access to and
fected by the Indian Ocean tsu- portance of vitamins and minerals knowledge on how to distribute,
nami on 26 December 2004, as (V&M) in emergency situations administer and promote vitamin
well as the Nias island earthquake was highlighted. It was concluded A capsules (VAC) through its
on 28 March 2005, led interna- that V&M offer an unparalleled years-long involvement in the na-
tional, regional and national-level combination of six key advan- tionwide mass media and social
groups to assist in short, medium tages as a first-line response in marketing campaign to promote
and long-term recovery from the disaster situations, where poor the national VAC supplementa-
disaster. Indonesia was hit hard- sanitation and limited food are tion program (3). HKI was also
est, particularly the provinces serious problems: 1) high impact, able to obtain a large donation
of Nanggroe Aceh Darussalam 2) low cost, 3) minimal storage of dispersible zinc tablets from
(Aceh) and North Sumatra (Nias needs, 4) minimal or no prepara- Nutriset for distribution to medi-
Islands). Indonesia’s victims tion, 5) easy transportation, and cal and other health personnel.
numbered nearly 230,000 (1), as 6) providing a gateway for assess- Another critical factor was HKI’s
documented in the months im- ment of additional need. previous work in conducting pilot
mediately following the tsunami. studies on iron fortified soy sauce
Relief operations were focused Recognizing this, HKI initiated as- and the multivitamin-mineral
on preventing a second wave of sistance focusing on Supplemen- sprinkles, testing their acceptance
casualties from disease and mal- tation with Micronutrients (SUM) among target groups and impact
nutrition among the displaced and (2) in Aceh and North Sumatra, on nutritional and health status,
homeless survivors (numbering Indonesia, to assist in the overall which allowed HKI to mobilize
over 750,000 (1) in Indonesia). relief, rehabilitation and recon- resources for using these inno-
struction effort led by the Govern- vative, new products to enhance
ment of Indonesia (GOI) and the the nutritional quality of survivor
Ruins in the city of Banda Aceh. Woman on Simeulue island.
SIGHT AND LIFE 32 NEWSLETTER 3/2005
populations’ food aid rations. bled HKI to provide assistance in the diet, which is largely based on
Furthermore, HKI’s partnerships the early phase of the emergency food aid, more palatable.
with Heinz ABC and Akzo Nobel in through its SUM relief initiative.
the above-mentioned pilot studies In January 2005, VACs, sprinkles
enabled local production of these Supplementation with and zinc tablets, together with
V&M preparations and their rapid micronutrients (SUM) informational materials and guide-
deployment to Aceh and North lines, were immediately made
Sumatra through partnerships The objective of HKI’s SUM relief available to tsunami-affected
with other NGOs. initiative (4) is to lower the risk and communities. Because these
severity of morbidity, to reduce V&M preparations were small and
Partnerships mortality, and to increase the light, they could be taken in large
ability to reconstruct and rebuild quantities as luggage on planes
HKI has worked in Indonesia for livelihoods in the tsunami-affected to Aceh and Nias Island by HKI
over 30 years and has had part- areas of the provinces of Aceh staff from Jakarta. Also, as these
nerships with many organizations, and North Sumatra. V&M preparations do not require
including the Ministry of Health, special containment, they could
UNICEF, Church World Service Vitamin A and zinc are two key nu- be stored in any available space,
(CWS), CARE, and WFP. With a trients for children under 5 years however limited.
mobile team consisting mainly of of age that are proven to reduce
experienced Indonesian staff, HKI mortality from diarrhea and mea- HKI teams conducting SUM ac-
was able to rapidly start up SUM sles by 30–50% (5),and to reduce tivities among the displaced and
operations in early January, assess the incidence and severity of di- homeless survivors administered
the situation in Aceh and begin arrhea, pneumonia, and malaria VACs to children aged 6 months
providing V&M preparations. The by 30–40% (6,7). Multi-micronu- to 12 years who had not yet re-
immediate funding support from trient sprinkles complement food ceived these from the Ministry of
its partners in the field as well as aid, improve health and prevent Health/GOI and UNICEF health
internationally, from governments V&M deficiencies (8). Iron fortified teams conducting combined
and private sector organizations soy sauce reduces anemia, espe- measles immunization and VAC
such as SIGHT AND LIFE ena- cially among adults, and makes supplementation.
Table 1. Supplementation with Micronutrients (SUM); distribution update until 28 September 2005.
Distribution Vitamin A Vitamin A Zinc Vitalita Iron fortified
capsules capsules dispersible Sprinkles soya sauce
(100,000 IU) (200,000 IU) tablets (20 mg) sachets sachets
by HKI 1,817 35,946 860 4,217,187 *7,965,280
via partners** 108,487 795,562 573,080 1,453,345 1,753,180
*to 235,276 households
Ministry of Health, Republic of Indonesia; Provincial Health Offices, Nanggroe Aceh Darussalam and North Sumatra; District
Health Offices of Banda Aceh, Aceh Besar, Aceh Selatan, Kota Lhokseumawe, Bener Meriah, Aceh Tengah, Pidie, Nagan
Raya, Bireun, Aceh Jaya, Aceh Utara, Aceh Timur, Aceh Tamiang, Kota Langsa, Aceh Timur, Aceh Barat, Simeulue, and Nias;
Terre des Hommes; SurfAid; CARE; Plan International; CWS; UNICEF; IOM; Indonesian Medical Association (IDI); Tengku
Fakinah Hospital; Clinic Bantuan Kesehatan Dinas Kesehatan DKI Jakarta; Forum LSM; PMI Sragen; Relawan Bogor; IDI
Batam; Clinic Walubi; Clinic Pangkalan TNI; PCC; Clinic Posko FUI Makassar; Clinic Kosgoro TM Budaya; Clinic TVRI Mata
Ie; Clinic PT Sampoerna; Clinic Japan Lambara; Tim Bantuan Propinsi Sumatra Selatan; Indonesian Midwives Association
(IBI); Zainul Abidin Hospital; various Puskesmas (Community Health Centers) in tsunami-affected areas; Indonesian Red
Cross (PMI); Clinic Secapa Matai; Harapan Bunda Hospital; Malahayati Hospital; PKS; Clinic Posko Tenggala; Gerakan
Kemanusiaan Indonesia; Habibi Center
• Close collaboration with partners and a system of marking children with ink on the finger prevents double dosing with vitamin
• Zinc supplements are distributed to health facilities for administration as part of treatment for diarrhea, as per the WHO/
UNICEF guidelines and as supported by MOH.
• Guidelines and/or educational materials in Bahasa Indonesia are distributed along with all vitamin A, zinc, Vitalita Sprinkles
and iron-fortified soy sauce
• Training and promotional materials have been produced in collaboration with MOH and are being provided to all partners
who are distributing micronutrients.
NEWSLETTER 3/2005 33 SIGHT AND LIFE
The HKI teams also provided of assistance, HKI has continued treatment for diarrhea, to health
zinc tablets to medical and other to provide VACs, zinc tablets and personnel and medical teams.
health staff for use as an adjunc- multivitamin-mineral formulations In addition, social marketing and
tive treatment for diarrhea, in line (sprinkles and iron-fortified soy training materials in Indonesian,
with international recommenda- sauce) to partners involved in the which had already been devel-
tions from the WHO and UNICEF post-tsunami/earthquake assist- oped for HKI’s ongoing vitamin
(9). Furthermore, HKI teams ance in Aceh and North Sumatra. A program, were available for
distributed sachets of multimicro- HKI has also trained substantial immediate distribution in the tsu-
nutrient sprinkles, which are in a numbers of its staff to distribute nami-affected districts.
form that is ready for consump- the V&M preparations, according
tion and can be sprinkled over to strict safety guidelines, to af- In collaboration with the Ministry
children’s food. fected populations being reached of Health, HKI also developed
by their services. Table 1, below, extensive guidelines, and training
The implementation of HKI’s SUM summarizes HKI’s distribution of and promotional materials to raise
relief initiative has been very quick vitamin A capsules, zinc tablets, awareness and educate health
and effective, aimed particularly sprinkles and iron-fortified soy personnel, mothers and their chil-
at addressing the need for V&M sauce sachets until 28 September dren about the V&M preparations,
preparations to enhance the 2005. its benefits and good nutrition
compromised nutritional status practices. Guidelines, brochures,
of the tsunami survivors living in Capacity building and and flyers provide explanations
camps and host households. This training about dehydration, diarrhea, vita-
was made possible through HKI’s min A and iron deficiency anemia,
expertise in the field of V&M, as Among the major impacts of the as well as their causes, conse-
well as its specific and techni- ‘tsunami’ was the collapse of the quences and ways to combat
cal knowledge of the health and health structure in the affected them. They also provide informa-
nutrition situation in Indonesia areas as well as a reduction in tion on who should receive V&M
acquired through its partnership the number of health personnel. preparations, how these should
with the GOI in operating the Nu- HKI’s SUM relief initiative strongly be given and how frequently.
trition & Health Surveillance Sys- emphasizes capacity building by Flipcharts using graphics and text
tem (GOI/HKI NSS) from 1988 providing knowledge and train- were developed to be used for
to 2004. During this period, over ing on the importance of V&M in training and provide information
1,000 employees were trained reducing morbidity and mortality not only on V&M preparations, but
to collect health, nutrition and among children. During the initial also on child health, nutrition and
related data from 160,000 house- emergency phase, while visiting development, exclusive breast-
holds annually in eight provinces hard to reach areas in particular, feeding, complementary feeding,
of Indonesia (10). HKI teams provided written inter- consumption of iodized salt and
national guidelines in Indonesian vitamin A-rich foods. Other ma-
With the transition of the emer- on vitamin A supplementation terials carry key messages and
gency relief phase of assistance and the use of oral rehydration benefits to introduce and promote
to longer-term rehabilitation – and salts (ORS) solutions, together the V&M preparations among the
eventually reconstruction – phases with zinc tablets as an adjunct target groups. HKI was able to
HKI field worker giving a vitamin A capsule to a child. Training and promotion materials.
SIGHT AND LIFE 34 NEWSLETTER 3/2005
Table 2. Guidelines, training and promotion materials that have been designed, developed and produced
from April until August 2005. Number of materials about the various topics.
Materials Vitamin A Zinc tablets Sprinkles Iron fortified Health, nutrition, SUM
capsules and oral re- soy sauce vitamins and relief
hydration salts minerals initiative
Guidelines 1,000 1,000 1,000
Brochures 30,000 30,000
Flyers 150,000 150,000
Flipcharts 1,500 1,500
Stickers 30.000 30.000 30,000
Posters 13,000 13,000 13,000
Banners 500 500 500
T-Shirts 500 500 1,000
Balloons 5,000 5,000
rapidly design and produce the Movement, hospital staff, gov- diarrhea and discussed the im-
guidelines and materials as in- ernment officials, and local and portance of providing zinc tablets
house expertise had been devel- international NGO staff. to children suffering from diarrhea
oped in promoting good nutrition in tsunami-affected areas. The
practices over years of technical As the SUM relief initiative con- recommendations resulting from
assistance to the GOI vitamin A tinues, HKI has raised more this meeting are summarized in
program and other nutrition pro- awareness and conveyed greater Table 3.
grams (Table 2). knowledge in Indonesia on the use
and benefits of zinc tablets. A zinc SUM program
From January to September experts’ meeting was organized in monitoring
2005, a total of 2,767 people from Jakarta by HKI, in collaboration
provincial to sub-district levels with the Directorate General for HKI closely monitors and evalu-
were trained by HKI in 13 tsuna- Communicable Disease Control ates its program to determine the
mi-affected districts in both Aceh and Environmental Health, Min- coverage and need for micronutri-
and Nias islands, including Banda istry of Health, Government of ents among various target groups
Aceh, Pidie, Bireun, Aceh Utara, Indonesia (CDC&EH) (11). Par- who have been most affected by
Lhokseumawe, Aceh Timur, Aceh ticipants, who were specifically the tsunami, and to assess the
Jaya, Aceh Barat, Nagan Raya, experts in nutrition and diarrhea impact of the distribution of mi-
Aceh Selatan, Simeulue, Nias, control and prevention, represent- cronutrients on their health status.
and Nias Selatan. These included ed government and UN agencies In tsunami-affected districts, HKI
staff from government health divi- (UNICEF and WHO), academia visits camps, barracks and host
sions (doctors, nutritionists and and associations of health profes- communities where internally
midwives), health volunteers from sionals. The participants reviewed displaced persons (IDPs) are
clinics and village health posts, the evidence for zinc as an ap- accommodated, and adminis-
staff from the Family Welfare propriate adjunct treatment for ters questionnaires to mothers,
Table 3. Recommendations of the zinc experts’ meeting
• The participants endorsed the implementation of the WHO/UNICEF recommendation for diarrhea cases
in tsunami-affected areas: Daily dose of 20 mg zinc supplements for 10–14 days for children aged 6
months to 12 years with acute diarrhea, and 10 mg per day for infants aged 2–5 months, to curtail the
severity of the episode and prevent further occurrences in the ensuing 2–3 months.
• HKI was encouraged, in conjunction with CDC&EH and Health Promotion/MOH, to continue with the
development of guidelines as well as educational and promotional materials for the use of zinc as an
adjunct treatment for diarrhea among children.
• Participants recommended the formation of a working group (including MOH, HKI, UNICEF and WHO)
to carry out operational research on the benefits and effects of zinc. Based on the outcomes of such
research, the MOH will consider including zinc supplementation as adjunct therapy for diarrhea in its
national health policy.
NEWSLETTER 3/2005 35 SIGHT AND LIFE
HKI field worker providing guidelines and zinc tablets HKI field staff collecting data from a mother and her
to a health volunteer. children.
caretakers and the heads of shel- coverage was not increased to Conclusions and
ters, camps, barracks and clinics. more than 95% in all districts. In Recommendations
Anthropometric measurements three districts – Aceh Jaya, Aceh
are also collected from mothers Utara and Lhoseumawe – HKI’s • HKI’s response to the tsunami
and their children. sweeping activities increased disaster was very rapid and ef-
VAC coverage to only 54–68%. fective because V&M prepara-
Monitoring of the program also This may have been caused by tions were in stock and could
provides a gateway to assess ad- the postponement of sweeping in be produced locally, and due
ditional needs. For example, HKI’s these districts from July to Sep- to HKI’s strong technical exper-
recent monitoring data show that tember, because of district health tise in micronutrient programs,
the prevalence of severe wast- officials’ concerns about children large-scale health and nutri-
ing, particularly among children receiving a second dosage during tion surveillance, and social
aged 6–23 months affected by the national vitamin A distribution marketing.
the tsunami and earthquake near effort in August. • For the first time, supplemen-
Nias Island is very high and had tation with V&M preparations
increased from January until Au- was employed as a first-line
gust 2005 (1). For that reason,
current efforts such as therapeutic
feeding and the provision of com-
plementary foods to IDPs need
to be continued, intensified and
expanded urgently, in addition
to supplementation with V&M
Figure 1 shows the VAC coverage
by HKI and others among children
aged 6 months to 12 years in elev-
en affected districts, 4–8 months
following the tsunami. Coverage
by others, mainly the Ministry of
Health/GOI and UNICEF health
teams, was 12–66%. After sweep-
ing by HKI in camps and host
communities, coverage increased
to 77–99 % in the majority of the
districts. Due to the fact that older
children have returned to school Figure 1. Coverage of VAC supplementation among children aged 6 months
and therefore were likely to have to 12 years in 11 tsunami-affected districts, as assessed 4–8 months after
missed VAC distribution, VAC the tsunami, and whether from others or from HKI (n=22,896).
SIGHT AND LIFE 36 NEWSLETTER 3/2005
Hees J, Foote D and Bloem MW.
Tsunami relief operations: the role of
vitamins and minerals. Proceedings
of the 18th ICN, 19–23 September,
2005, Durban, South Africa
5) Beaton GH, Martorell R, Aronson KJ,
et al. (1993). Effectiveness of vitamin
A supplementation in the control of
young child morbidity and mortality in
developing countries. United Nations:
ACC/SCN state of the art series: nutri-
tion policy discussion paper no 13.
6) Bhutta ZA, Black RE, Brown KH,
Participants in a course held in the district of Lhokseumawe. Gardner JM, Gore S, Hidayat A, Kha-
tun F, Martorell R, Ninh NX, Penny
emergency response in the tions of Aceh and North Sumatra are ME, Rosado JL, Roy SK, Ruel M,
aftermath of a natural disaster addressed. We are especially grateful Sazawal S and Shankar AH. (1999)
to the families and internally displaced Prevention of diarrhea and pneumo-
(i.e. the tsunami and the later persons who agreed to participate in
earthquake in Nias): this should nia by zinc supplementation in chil-
the assessment. The distribution of
dren in developing countries: pooled
be applied to future emergency V&M preparations and the assessments
analysis of randomized controlled tri-
situations. Further research is conducted until August were funded
by donations from CARE Indonesia; als. Zinc Investigators’ Collaborative
needed to design and improve PLAN Indonesia; SurfAid International; Group. J Pediatr;135(6):689–97.
similar programs adaptable to Terre des Hommes, Netherlands; Akzo 7) Bhutta ZA, Bird SM, Black RE, Brown
various situations. Nobel Chemicals; Mees Pierson, Asia KH, Gardner JM, Hidayat A, Khatun
• Guidelines and promotional Pacific; the Ministry of Foreign Affairs, F, Martorell R, Ninh NX, Penny ME,
Royal Netherlands Government; HJ Rosado JL, Roy SK, Ruel M, Sazawal
materials, as well as training Heinz Company Foundation; SIGHT
and capacity building, are very S and Shankar AH. (2000). Thera-
AND LIFE; the Government of Taiwan; peutic effects of oral zinc in acute
important when introducing Nutriset; Kimia Farma; Brother’s Brother and persistent diarrhea in children in
V&M preparations among vari- Foundation; and the Michael and Su-
developing countries: pooled analysis
san Dell Foundation. Donors had no
ous target groups in order to involvement in the design, development, of randomized controlled trials. Am J
ensure their acceptance and analysis, interpretation or reporting of the Clin Nutr.72(6):1516–22.
successful distribution. content of this paper. 8) Martini E, Foote D, de Pee S, van
• Monitoring and evaluation is of Hees J, Halati S, Moench-Pfanner R,
utmost importance to assess Yeung D, Kosen S and Bloem MW
References (2004). Efficacy of ‘Sprinkles’ home
coverage, need for V&M, and fortification to reduce anemia and
1) Helen Keller International (2005).
the impact of V&M on health Prevalence of wasting among 6–23- micronutrient deficiencies in young
and nutrition status, as well month-old children affected by the children in Indonesia. Poster pres-
as to provide a gateway to af- tsunami warrants additional efforts entation 2004 INACG Seminar, Lima,
fected communities in order to such as therapeutic feeding and com- Peru. Helen Keller International.
determine additional needs. plementary food. Program Fact Sheet 9) WHO/UNICEF. 2004. Clinical man-
Findings should be provided Supplementation with Micronutrients agement of acute diarrhoea. WHO/
(SUM) / Aceh / North Sumatra www. UNICEF Joint Statement. (http://www.
widely to support decision mak- hkiasiapacific.org/tsunami/tsunami_ who.int/child-adolescent-health/pub-
ing based on sound evidence. wasting.htm lications/CHILD_HEALTH/JS_Diar-
M&E is also vital to assure the 2) Helen Keller International (2005). rhoea.htm
quality and effectiveness of Vitamins and minerals are crucial 10) De Pee S, Martini E, Moench-Pfanner
program activities and docu- components of first line emergency R, Firdaus MA, Stormer A, Halati S,
ment lessons learned. response because they markedly Sari M, Palmer J, Kosen S and Bloem
reduce mortality and severity of MW (2004). Nutrition and health
disease. Indonesia Tsunami Relief trends in Indonesia 1999–2003. Nutri-
Acknowledgements Bulletin. Year 1, Issue 1 January 2005 tion & Health Surveillance System An-
We are very grateful to the heads and (http://hkiasiapacific.org/Resources/ nual Report 2003. Jakarta, Indonesia:
volunteers of the camps; the heads of Downloads/bulletins_indonesia. Helen Keller International.
villages (Kepala Desa) in the affected htm). 11) Helen Keller International (2005).
areas of Aceh and North Sumatra; the 3) Helen Keller International/Indonesia The importance of dispersible zinc
Head of the Provincial Health Office, (2001). National vitamin A supple- tablets to treat diarrheal disease
NAD; and the heads of the District Health mentation campaign activities: August among children in Aceh and North
Offices for their cooperation and support. 2001. Indonesia Crisis Bulletin. Year Sumatra. Indonesia Tsunami Bulletin,
We also thank the national-level MOH, 3, Issue 2. Jakarta: Helen Keller Year 1, Issue 2 July 2005 (http://hkia-
HKI staff, collaborating agencies and Worldwide.
other organizations working to ensure siapacific.org/Resources/Downloads/
that the nutrition and health as well as 4) de Pee S, Moench-Pfanner R, Martini bulletins_indonesia.htm).
other needs of the displaced popula- E, Halati S, Graciano F, Webb P, van