Scurvy and its Prevention and Control in Major Emergencies (WHO

Scurvy and its Prevention and Control in Major Emergencies (WHO - OMS, 1999, 70 p.)

		(introduction...)
		Acknowledgements
		Scurvy: definition
		Introduction
		Scurvy
		Vitamin C
		Recommended Daily Allowance (RDA)
		Sources of vitamin C
		Strategies to prevent scurvy in large refugee populations
		Costs
		Conclusions and recommendations
		References
		Annex 1
		Annex 2
		Annex 3
		Back Cover

Annex 1

Table A. Phases of refugee feeding operations and possible sources of vitamin C

Phase	Characteristics	Food source	Vitamin C source
Initiation/3-6 months	initial request for help filed	may be local or borrowing from other programmes	fortified food aid; vitamin C tablets; vitamin C-rich commodities; where feasible, locally procured fruits and vegetables; increased general ration
Establishment/6 months - 2 years	refugees dependent on food aid/minimal personal buying power	imported food aid	fortified food aid; where feasible locally procured fruits and vegetables; increased general ration; where feasible, germinated cereals/pulses; home gardens; local trading for vitamin C-rich foods
Protracted Refugee Operation/>2 years	efforts to develop inde-pendence and personal economic resource Employment pro-grammes maintained.	depending on local conditions, may involve tar-geting of food aid on basis of need	home gardens; local trading for vitamin C-rich foods

Note:
1. The first two phases are critical for the development of scurvy
2. Table is adapted from Hansch (1995)

Table B. Costs of various commoditites

Commodity	1m person days (USD)	Person/day (USD)
Total ration¹	200 000	0.200
Ration with 30 g blended food¹	215 000	0.215
Ration with 60 g blended food	230 000	0.230
Total ration +10%	220 000	0.220
Cereal (maize) not milled²	100 825	0.101
Cereal milled²	135 625	0.136
Cereal fortified* + milled²	150 025	0.150
Cereal (3/4 of cereal ration) + CSB (1/4 of cereal ration)²	147 125	0.147
Tablets (vitamin C @ 250 mg)³	1 170	0.001
Tomato paste @100 g/day⁴	96 000	0.096
Orange juice powder³ (reconstituted drink)	11 770	0.012
Fresh vegetables⁴**	100 000	0.100

¹ Source: Machakos Workshop Report (1995)
²Source: Beaton (1995)
³ Source: Toole (1995)
⁴ Source: UNHCR
* Fortified with micro nutrients (including vitamin C)
** Example Nepal (1993)

Table C. Cost comparisons

Commodity	I m person days (US$)	person/day (US$)
Blended foods increase 30 g to 60 g per day	15 000	0.015
Ration 10% increase (without blended foods)	20 000	0.020
Cereal milled and fortified compared to unmilled and unfortified	50 800	0.051
Cereal milled and fortified compared to milled and unfortified	14 400	0.014
Cereal milled and CSB (1/4 of cereal ration)* compared to unmilled, unfortified cereal ration	47 700	0.048
Cereal milled and CSB (1/4 of cereal ration)* compared to milled, unfortified cereal ration	11 500	0.012

*100 g CSB daily would be necessary in the general ration to provide missing micro nutrients e.g. vitamin C in blended foods 30-40 mg/100 g, RDA 30 mg

Table D. Some nutrition education messages that could prevent scurvy

Food storage and preparation

· Grow tomatoes, potatoes, onions, etc.
· on any available land and use waste water.
· *Do not store germinated pulses/grains.
· Store fresh vegetables and fruit for as short a time as possible.

Food production and consumption

· Vegetables should not be cut into small pieces before washing and cooking.
· Cook vegetables in minimum amount of water and also consume water.
· Cook food for as short a time as possible.
· Cover pot with lid while cooking to reduce cooking time.
· Eat food soon after cooking. Do not store cooked food.
· Cook blended food for not longer than 10 minutes.
· Blended food is good for the whole family, not only for infants.
· Eat as much fruit and vegetables as available.
· *Eat the sprouts and the shoots after germination

Medication

· *Take the vitamin C tablets regularly to prevent scurvy and death.

*Some examples of messages related to specific interventions.

Table E. Analytical values for some of the sailors' traditional antiscorbutics in the 18th century

	Ascorbic acid (mg/100g or/100 ml for liquids)
Cloud berries	80
Cranberries	5-10
Gooseberries, fresh	60-65
Gooseberries, preserved (as recommended by Lind)	0
Apple cider (fresh, unpasteurized)	4-5
Scurvy grass (leaves and buds)	200
Spruce pine needles	65-200
Spruce (leaves and young shoots)	30-270
Spruce (fresh aqueous infusion)	14-100
Spruce (fermented aqueous infusion)	<0.5
Freshly sprouted barley seed	30-100
Malt, dried & powdered	10
Cloud berries	80
Cranberries	5-10
Gooseberries, fresh	60-65
Gooseberries, preserved (as recommended by Lind)	0
Apple cider (fresh, unpasteurized)	4-5
Scurvy grass (leaves and buds)	200
Spruce pine needles	65-200
Spruce (leaves and young shoots)	30-270
Spruce (fresh aqueous infusion)	14-100
Spruce (fermented aqueous infusion)	<0.5

Source: Carpenter, 1986

Table F. Analytical values for the vitamin c content in mg/100 g of items in traditional inuit diets

	Raw	Lightly boiled
Seal flesh	0.5-3	0.5-2.5
Seal liver	18-35	14-30
Whale skin (narwhal)	18	N.D.
Whale skin (Beluga)	35	N.D.
Blubber (Beluga)	5	N.D.
Animal flesh, raw (caribou, musk ox, polar bear)	0.8-1.8	0.5
Fish flesh (cod, char)	0.5-2	N.D.
Cod roe	44	N.D.
Bird flesh, raw	1-2	0.3-1
Licorice root	21	4
Mountain sorrel	36	5
Angelica	14	-

Source: Hoppner et al. 1978

Table G. Vitamin C contents of some uncooked foods

	Vitamin C mg/100 g		Vitamin C mg/100 g
Fruits:		Vegetables:
peach	8	amaranth leaves	88
banana	13	beans, peas	10-30
cherry	8	broccoli	90-150
grapefruit	43	cabbage	30-60
guava	160	carrot	5-10
hawthorne berries	160-800	cauliflower	60-80
lime	27	garlic	12
mango		dark-green-leafy vegetables	100-150
ripe	4875	kale	120-180
unripe		leek	15-30
melons	13-33	onion	10-30
orange, lemon	50	parsley	170
papaya	64	pepper	125-200
pineapple	40	spinach	50-90
tangerine	30	tomato	24
raspberry	18-25
rose hips	1000	Cereals:
strawberry	40-90	millet, rice, wheat, maize	0
Animal products:		Tubers:
meats	0-2	cassava	36
liver, kidney	10-40	sweet potato	23
milk, cow	1-2	potato	36462
milk, human + camel	3-6

Source: FAO. Food composition tables. Minerals and vitamins for international use. Rome, 1954.

Table H. Intake levels of ascorbic acid in various parts of the world, in mg per person per day

Region	Extreme range^a)	Majority range^b)	Comments
Africa	5-375	-	Low values for cereal and millet diets. High values for diets based on cassava, yams, etc.
Asia, including the Far East	10-150	25-70	Higher values are for China (Taiwan), where diets include a greater proportion of vegetables and fruits. Low values are for millet and rice diets in India and East Pakistan respectively.
Latin America	10-110	10-50
Near East	5-90	10-50
Europe	50-130	50-130
USA	-	100

a) Average lowest and highest per capita intakes reported in surveys
b) Lowest and highest per capita intakes of more than 80% of the population reported in surveys

Table I. Vitamin C losses in the processing and preparation of food

		Ascorbic acid (% remaining)
*Potatoes*
	fresh dug main crop	30 mg/100 g
	boiled, peeled	50-70% raw value
	in jacket, baked	80% raw value
*Milk*
	whole raw	2.0 mg/100 g
	pasteurized	75% raw value
*Cabbage*
	raw	60 mg/100 g
	cooked	33% raw value
*Frozen vegetables*		75% raw value
*Canned vegetables*		85-40% raw value

Source: Marks, 1975