HKI's Tsunami Response – Supplementation with vitamins and

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					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
** Partners:
  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
  A supplements.
• 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
Bags                                                                                                  2,800
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
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  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,
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  Findings should be provided                   Supplementation with Micronutrients            agement of acute diarrhoea. WHO/
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  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
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Acknowledgements                                Bulletin. Year 1, Issue 1 January 2005         tion & Health Surveillance System An-
We are very grateful to the heads and           (          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                                                
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

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