Guidelines For Viral Hepatitis Surveillance And Case Management

Nutrition Landscape Information System (NLiS)

Disease surveillance
Constant coordination and consultation at all stages of the collection and analysis chain will greatly facilitate the overall efficiency of operations. During the neonatal period, childhood and adolescence, iodine deficiency disorders can lead to hypo- and hyperthyroidism. WHO does not recommend a particular setting for giving birth. The relationship between two variables, making them interchangeable for defining an indicator, may vary over time as a result of implementation of a programme, and this must be taken into account. This indicator is defined as the number of trained nutrition professionals per , population in the country in a specified year.

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WHO surveillance case definitions for ILI and SARI

When the definitions and categories for reporting cases of acute viral hepatitis are expanded to include those identified by laboratory test results alone, it will be important to distinguish symptomatic from asymptomatic individuals.

This is because the numbers of asymptomatic persons identified can be highly variable depending on testing practices, and result in artificial differences in incidence both temporally and geographically. In addition, the ability to identify such individuals is primarily limited to HAV and HBV infections, for which IgM antibody assays specific for acute infection are available. The full implications of expanding surveillance case definitions to include asymptomatic individuals will not be known until these strategies are implemented.

Although previously not included among nationally notifiable conditions, the public health importance of chronic viral hepatitis infections dictates that they be added. Several states and counties have established viral hepatitis infection databases for persons testing positive for HBsAg or anti-HCV, but their experience indicates that managing large numbers of HBsAg positive and anti-HCV positive laboratory reports has the potential to overwhelm a surveillance system and divert scarce resources into data management rather than disease prevention.

The expected integration of functions and standards in NEDSS that facilitate the implementation of such databases will enhance capacity to manage and monitor these reports. Further assessment at the state and local level is needed to determine the most feasible and useful approaches for establishing these types of systems and linking them to prevention activities. Periodic epidemics of Hepatitis A have occurred in the United States approximately every decade; the last nationwide epidemic occurred in 1.

Since then, rates of Hepatitis A have declined precipitously and are now the lowest ever recorded. Nevertheless, Hepatitis A remains one of the most frequently reported vaccine preventable diseases in the United States. In , a total of 13, cases of Hepatitis A were reported to CDC Annual summary of notifiable diseases, , which, when corrected for underreporting and asymptomatic infections, represents an estimated 57, cases and , infections. Rates among Hispanics remain higher than among non-Hispanics.

Asymptomatic or unrecognized infections occurring in young children are often a source of infection to others. Most cases of Hepatitis A result from person-to-person transmission during community-wide epidemics in which children play a critical role in sustaining Hepatitis A virus HAV transmission.

Prevention strategies Hepatitis A vaccine has been licensed in the United States since , and in routine childhood Hepatitis A vaccination was recommended in communities with the highest Hepatitis A rates, which included American Indian, Alaskan Native and selected Hispanic, migrant and religious communities.

Coincident with the implementation of Hepatitis A vaccination of children in those communities, there have been dramatic reductions in Hepatitis A rates in those areas.

In , the recommendations for routine vaccination of children were extended to include children living in states or counties with rates at least twice the national average i. It was suggested that vaccination also be considered for children living in states or counties with average rates that exceeded the national average i.

Reductions in Hepatitis A rates in these areas since suggest that routine vaccination is having an impact but further monitoring is needed to determine whether these decreased rates are sustained and attributable to vaccination.

Pre-exposure vaccination is also recommended for persons at high risk for Hepatitis A including illegal drug users, men who have sex with men, persons traveling to countries where HAV is endemic, and persons with occupational risk of infection i.

Surveillance Because no chronic infection develops after Hepatitis A, reported cases of acute disease provide a valid measure of ongoing transmission and the overall burden of disease due to HAV. Investigation of reported cases to determine their characteristics and source for infection provides the best information for monitoring trends in transmission patterns. Monitoring changes in overall and age-specific disease rates is the only means available to assess the effectiveness of Hepatitis A vaccination programs.

Demographic and risk factor information collected through surveillance can be used to direct ongoing prevention efforts by identifying new target groups or areas in which vaccination programs should be initiated.

Missed opportunities for vaccination can be assessed by investigating cases occurring in persons belonging to a group for which vaccination is recommended to determine where they have received health care and other recommended vaccinations. Intensive investigation of cases occurring in persons who received Hepatitis A vaccine may be used to evaluate the frequency and causes of vaccine failure.

Timely identification of persons with acute Hepatitis A allows exposed contacts to receive effective prophylaxis to prevent secondary spread of HAV. This is important in preventing outbreaks associated with day care centers or infected food handlers and to prevent person-to-person transmission in households and extended family settings and among sexual contacts.

Hepatitis A often occurs in the context of community wide epidemics, but outbreaks also occur among persons reporting certain behaviors e. By investigating reported cases for risk factors and recent exposures, groups at increased risk for infection can be identified for targeted prevention activities or a potential common source can be identified that might have placed additional persons at risk.

Acute Hepatitis B is one of the most commonly reported vaccine preventable diseases; in , cases were reported Annual summary of notifiable diseases, However, because most newly infected persons are asymptomatic 3 , and because even symptomatic persons are underreported 4 , reported Hepatitis B cases markedly underestimate the incidence of HBV infection.

In addition to acute disease, approximately 1. These persons are at increased risk for chronic liver disease, including cirrhosis and hepatocellular carcinoma, and they are the major reservoir of ongoing HBV transmission.

The incidence of HBV infection differs significantly by race and ethnicity with the highest rates among blacks; rates are higher among Hispanics than non-Hispanics. Incidence also varies by age with the highest rates reported among persons years of age. Post-exposure prophylaxis is highly effective in preventing transmission of HBV from mother to infant. However, an estimated of these infants become chronically infected with HBV each year because not all infected mothers are identified and not all infants receive appropriate post-exposure prophylaxis.

Although perinatal HBV infections have been nationally notifiable since , reported cases have not been reliable for monitoring the number of perinatal infections that are occurring in the United States because of a lack of follow-up serologic testing of infants born to infected mothers.

The timely identification of persons recently infected with HBV provides the opportunity not only to counsel the infected individual but also to identify susceptible contacts requiring post-exposure prophylaxis early enough to prevent further transmission. By monitoring the exposures of recently infected persons, surveillance for acute disease also provides the information critical for identifying outbreaks of Hepatitis B that, while uncommon, do occur.

Nosocomial outbreaks involving patient-to-patient transmission have occurred in association with a variety of transmission vehicles including multidose medication vials, reusable fingerstick devices, and other contaminated medical equipment 8 , 9 , 10 , 11 , Although cases of provider-to-patient transmission of HBV are rare in the United States continued vigilance is needed to detect these cases should they occur.

Surveillance for perinatal HBV infection is needed to evaluate the effectiveness of the perinatal HBV prevention program by monitoring the incidence of these infections and to identify HBV-infected infants for referral for medical management and treatment if appropriate. Post-vaccination testing also identifies uninfected infants who did not respond to vaccination and require re-vaccination because of ongoing exposure to infected household contacts including their mothers.

Intensive investigation of infected infants is needed to assess and reduce missed opportunities for providing post-exposure immunoprophylaxis and to assess the frequency and risk factors for failure of immunoprophylaxis. Although rare, possible reasons for failure of immunoprophylaxis include incomplete vaccination, in utero infections, delayed vaccination doses, and infection with an HBV variant 13 , 14 , 15 , 16 , Many states currently have regulations requiring laboratories to report all HBsAg positive results to local health departments.

These results can be used to identify persons with chronic HBV infection who need counseling and referral for medical follow-up and whose contacts require immunization. Determining the frequency and characteristics of persons reported as HBsAg-positive also describes who and where infected persons are being identified. Although dependent upon testing practices, this information can help in developing minimum estimates of infection burden and is useful for identifying gaps in current testing practices.

Further investigation of chronically infected persons or a sample of them to determine why they were identified and what actions e. These persons serve as a source of transmission to others and are at risk for chronic liver disease or other HCV-related chronic diseases. HCV infection occurs among persons of all ages, but the highest incidence of acute Hepatitis C is found among persons years. African Americans and whites have similar incidence rates of acute disease with higher rates in persons of Hispanic ethnicity.

Prevention strategies With no effective vaccine or post-exposure prophylaxis, reducing the burden of HCV infection and HCV-related disease in the United States requires implementation of primary prevention activities to reduce the risk of contracting the infection and secondary prevention activities to reduce the risk of liver disease and other HCV-related chronic diseases among HCV-infected persons Surveillance Hepatitis C surveillance is a critical component of a comprehensive strategy to prevent and control HCV infection and HCV-related chronic liver disease.

To accomplish the goals of Hepatitis C surveillance, activities are needed to identify persons with acute Hepatitis C, as well as persons with chronic HCV infection. Surveillance for acute Hepatitis C -newly acquired symptomatic infection- is needed to monitor ongoing transmission of HCV, and investigation of these cases to determine their characteristics and risk factors provides the best information for monitoring trends in transmission patterns.

The collection of this information for reported cases is useful for characterizing groups at risk of infection and targeting prevention activities. Monitoring changes in acute disease incidence and in the risk factors for infection can be used to assess the effectiveness of prevention programs. By monitoring the exposures of recently infected persons, surveillance for acute Hepatitis C also provides the information needed to detect outbreaks that, while uncommon, do occur. Although rarely reported in the United States except in the chronic hemodialysis setting, nosocomial outbreaks of HCV involving patient-to-patient transmission can occur if infection control techniques or disinfection procedures are inadequate and contaminated equipment is shared among patients.

The risk of HCV transmission from an infected health care worker to patients appears to be very low but vigilance is needed to detect these cases should they occur.

Conducting surveillance for acute Hepatitis C on a nationwide basis has been difficult because a no serologic marker for acute infection is available; b cases are usually reported on the basis of a positive laboratory report and most health departments do not have the resources to conduct investigations to determine if these reports represent acute infection, chronic infection, repeated testing of a person who was previously reported, or a false-positive result; and c it can be difficult to differentiate acute infection from exacerbation of chronic infection based on clinical features of disease.

Instead acute disease incidence and transmission patterns have been monitored using reported cases from CDC's Sentinel Counties Study of Acute Viral Hepatitis, in which all patients with signs and symptoms of viral hepatitis are investigated to ascertain cases of acute Hepatitis C. However, reliable state-specific data are needed to direct and evaluate Hepatitis C prevention and control programs.

In addition to expanding the use of strategies such as sentinel surveillance or serial serologic surveys to address local needs for Hepatitis C surveillance data, the implementation of methods that facilitate the management and evaluation of case reports of suspected Hepatitis C can enhance the capacity of state or local health departments to conduct surveillance for acute Hepatitis C. For example, the revision of the case definition for acute Hepatitis C to include a higher ALT threshold provided a more efficient and specific criterion to determine which reports require further investigation to distinguish anti-HCV positive individuals with acute disease from those with remote or chronic infection.

Many states currently have regulations requiring laboratories to report all anti-HCV positive results to local health departments.

Although limitations exist to the use of anti-HCV positive laboratory reports to conduct surveillance for HCV infection, these reports can be an important source from which state and local health departments can identify HCV-infected persons who need counseling and medical follow-up. Determining the frequency and characteristics of persons reported as anti-HCV-positive also describes who and where infected persons are being identified.

However, a small percentage of persons with signs and symptoms typical of acute viral hepatitis do not have serologic markers of infection with these viruses, and may be infected with other viruses.

The incidence of delta hepatitis cannot be directly calculated from national surveillance data because this disease is not reportable in the United States; however, in prevalence studies among patients with acute Hepatitis B, 1.

Hepatitis E is rare in the United States and most reported cases have been associated with travel to HEV-endemic countries 21 , However, several cases of acute Hepatitis E have been reported in persons with no recent history of travel outside the United States , and HEV infection should be considered in patients with non-ABC hepatitis.

Additional candidate hepatitis viruses that have been isolated from patients with posttransfusion hepatitis include Hepatitis G virus also called GB virus C , TTV, and SENV 25 , 26 , 27 , 28 ; however, none of these viruses has been demonstrated to be a cause of acute or chronic hepatitis 27 , Methods to improve the timeliness and completeness of reporting include a implementing laboratory reporting laws, b ensuring that all patients who have signs and symptoms of acute viral hepatitis are appropriately tested and reported; and c ensuring that all patients with chronic hepatitis, or who have risk factors for HBV or HCV infection are appropriately tested and reported if positive.

All states should implement rules or regulations requiring laboratories to promptly report test results positive for any of the following serologic markers of acute or chronic hepatitis: Computerized data systems are maintained by many clinical laboratories.

The establishment of information management systems for receiving data electronically from laboratories can facilitate surveillance for viral hepatitis by increasing timeliness and completeness of case identification.

State regulations for laboratory reporting of serologic markers of viral hepatitis should include requirements to report available information which could facilitate case identification and investigation, including contact information for the patient and for the patient's physician. Reports of positive test results should also include the results for other serologic markers of viral hepatitis that were evaluated on the same individual, and serum aminotransferase e.

ALT levels, if available. In addition, pregnancy status should be reported if testing was done as part of a prenatal test panel.

The clinical features of acute disease caused by hepatitis viruses are similar. Appropriate diagnostic testing of such patients is crucial to ensure complete case ascertainment. To facilitate accurate testing, laboratories, managed care organizations and payors should encourage implementation and use of standardized diagnostic panels for testing patients with signs and symptoms of acute hepatitis which should include all of the serologic markers that are included in state laboratory reporting requirements e.

In addition, educational efforts should be developed and promoted in conjunction with professional organizations to increase awareness of appropriate testing algorithms and reporting laws among clinicians.

Routine screening of pregnant women for HBsAg is done to identify infants of infected women who require post-exposure prophylaxis. High risk populations for chronic HBV infection e. The specificity of HBsAg or anti-HCV testing is high when used to evaluate persons with signs or symptoms of hepatitis. However, as with any test, the positive predictive value of these tests when used to screen asymptomatic persons depends on the prevalence of the condition among the persons being tested, and the likelihood of a false-positive test result increases when the tests are used in low-risk populations.

Confirmation of a positive test result for HBsAg or anti-HCV by an additional more specific assay is needed to rule out a false-positive result, especially in persons with no identified risk factor for infection. The presence of other serologic markers of HBV infection i. The collection of a minimum set of standardized data elements Table I on all reported cases of viral hepatitis ensures that information collected can be effectively used at the local, state and national level.

These minimum data elements should conform wherever possible to the definitions and formats specified for NEDSS. In addition to locators e. Patient name and other identifying information e. A unique identifier is essential for appropriate patient follow-up, distinguishes newly identified cases from previously reported individuals and allows linkage to related health-care data. Efforts are underway by CDC and its' public health partners to develop a unique identifier composed of standardized data elements that are used throughout the health-care and public health sectors.

Policies for ensuring patient privacy and security of data should be in place for any system maintaining unique patient identifiers. In addition to these core elements, information including recent exposures should be collected and reported as part of the recommended case investigation of cases of acute viral hepatitis or perinatal HBV infection.

The information to be collected and reported for investigations of different types of viral hepatitis are described in the virus specific guidelines below. Recommendations regarding the types of information that might be collected in a chronic infection database also are included in the disease specific sections below; however, further evaluation is needed to determine the types of information that will be most useful.

These databases can be used to:. The specific information elements to be maintained in a database of chronically infected persons will depend upon the objectives of establishing the database and the feasibility of collecting that information. At a minimum, sufficient information should be collected to distinguish newly identified persons from previously reported individuals including information to establish a unique identifier e.

Information about the clinical characteristics of the individual e. The collection of the minimum demographic information that is required for reporting of acute cases is also recommended for cases of chronic infection as these data can be used to describe the population of infected persons that has been identified, information useful for allocating public health resources and directing and evaluating prevention programs. The collection of additional information for a sample of persons in these databases can be useful to further characterize the infected population e.

The recommended information to be collected in databases of persons with chronic HBV or HCV infection is included in the disease specific sections below. When any type of database is established, the confidentiality of individual identifying information should be ensured according to applicable laws and regulations.

Guidelines that clarify how and when line-listed data with or without personal identifiers are transmitted and used can facilitate the protection of confidential data. Mechanisms such as automated systems for the mailing of follow-up educational materials might be useful. Such systems require relatively few health department resources and involve little or no interaction with patients or their health care practitioner; however, the effectiveness of such systems should be evaluated.

Effective mechanisms for delivering follow-up to mobile and hard-to-reach individuals such as injection drug users need to be identified. Periodic, regular evaluations of surveillance data for quality, completeness, and timeliness are essential to identify specific aspects of surveillance and case investigation that need improvement.

The completeness of surveillance data is assessed by determining the frequency with which individual data elements are reported with non-missing data. The quality or validity of the data is measured by the proportion of each data element that is reported with a correct or valid answer.

Timeliness of surveillance data can be measured by determining the average length of time in days required for each of the steps in the surveillance process.

The use of standardized indicators to assess the completeness e. The development of data quality indicators to measure the completeness of case-investigation and follow-up activities e. Periodic summaries of analyzed surveillance data that are accompanied by a concise interpretation can be useful to a variety of audiences including public health decision makers, clinical case reporters, and other health professionals.

Health department should consider developing specialized communications for dissemination of annual reports of case rates analyzed by person, place and time to different audiences. These communications might also include: In addition to dissemination via printed media, other dissemination mechanisms such as the internet should be explored. In addition to summarized data, line listed data should be provided to local health departments to ensure complete and accurate description of identified cases and to highlight those cases that require further follow-up.

The regular at least quarterly provision of summarized state specific surveillance data by CDC can be useful to state and local health departments in monitoring the reporting of cases to CDC and in providing feedback to local health departments and other public health partners.

To date, asymptomatic individuals who are IgM anti-HAV positive have not been included as reportable cases. However, these cases do represent incident infections and it is expected that as rates of acute disease continue to decline, the case definition will be expanded to include newly infected individuals identified on the basis of laboratory results alone.

When the case definition is expanded to include asymptomatic HAV infections, these cases will need to be distinguished from symptomatic cases to ensure accurate interpretation of surveillance data.

Confirmed or suspected cases of acute Hepatitis A should be reported and investigated as soon as possible after the case is identified to ensure adequate time to implement preventive measures, including the provision of post-exposure prophylaxis to contacts.

To report a case as confirmed, it should be verified that the case meets both the serologic and clinical criteria of the case definition. The components of a case investigation should include:. Symptomatic cases need to be distinguished from asymptomatic cases to accurately assess changes in incidence.

To date, asymptomatic individuals who are IgM anti-HBc positive have not been included as reportable cases. However, it is expected that as rates of acute disease continue to decline, the case definition will be expanded to include newly infected individuals identified on the basis of laboratory results alone.

In expanding surveillance to include asymptomatic HBV infections, these cases will need to be distinguished from symptomatic cases to ensure accurate interpretation of surveillance data. Case Investigation Confirmed and suspected cases of acute Hepatitis B should be reported and investigated as soon as possible after the case is identified to ensure adequate time to implement preventive measures including post-exposure prophylaxis of contacts.

In reporting, symptomatic cases need to be distinguished from asymptomatic cases to accurately assess changes in incidence. Identification of any of the following risk factors among persons with acute Hepatitis B should prompt an investigation to determine if additional cases are associated with a common source of transmission: Missed opportunities for pre-exposure vaccination should be assessed among cases of acute Hepatitis B occurring in persons for whom Hepatitis B vaccination is recommended e.

Missed opportunities for vaccination should also be assessed among cases occurring in children less than 18 years of age to determine the frequency and characteristics of these cases so that the effectiveness of routine childhood vaccination programs can be monitored and any barriers to vaccinating children can be identified and resolved.

Assessing the frequency and causes of immunization failure. The frequency of cases occurring in vaccinated persons should be determined to monitor the efficacy of vaccination and to detect possible cases of vaccine failure. Additional investigation is needed to identify causes for these potential breakthrough infections e. Health care professionals who need information regarding investigation of these cases can contact CDC's Division of Viral Hepatitis, National Center for Infectious Diseases at Infants born to HBsAg-positive mothers should receive Hepatitis B immune globulin HBIG and the first dose of Hepatitis B vaccine within 12 hours of birth, followed by the second and third doses of vaccine at 1 and 6 months of age, respectively.

Virtually all infants who are infected with HBV are asymptomatic. The primary method for identifying such infants is to test pregnant women for HBsAg and test the infants born to infected women for HBsAg at months of age.

Case investigations of suspected cases of perinatal HBV infection should be conducted promptly. Information to be collected includes Table IV:. Reporting to CDC Confirmed cases of perinatal HBV infection should be reported to health departments as specified by local regulations. Monitoring the operation and effectiveness of perinatal HBV prevention programs: The following indicators can be used to monitor the operation and effectiveness of perinatal HBV prevention programs and should be determined for all infants born to HBV-infected women:.

The frequency of cases occurring in infants who received post exposure prophylaxis should be determined to monitor its efficacy. Investigation of cases of perinatal HBV infection should be done to evaluate causes of possible breakthrough infections and should include obtaining sera from the infant and mother to test for the presence of HBV variants.

The objectives and activities of existing state-based databases of persons who test positive for HBsAg vary considerably and have not been standardized. The following case definition, case ascertainment methods, and case investigation and follow-up methods are provided as a guide for management of persons who test HBsAg positive.

Further assessment is needed to determine the most feasible and useful approaches to establish these types of systems. They may have no evidence of liver disease or may have a spectrum of disease ranging from chronic hepatitis to cirrhosis or liver cancer. Case investigation and follow-up should be conducted for persons with HBsAg-positive laboratory results and should include Table V.

Uses of Surveillance Data Databases of HBsAg-positive persons should be established to distinguish newly reported cases of chronic HBV infection from previously identified cases.

Periodic analyses of the cumulative number of persons with HBV infection included in these databases could be used to provide local, state and national estimates of the proportion of persons with HBV infection who have been identified. A case that meets the clinical case definition and is laboratory confirmed. The primary method to ascertain suspected cases of acute Hepatitis C is by follow-up of reported clinical cases of Hepatitis C and non-A, non-B hepatitis.

However, most HCV-infected persons who are identified on the basis of anti-HCV positive laboratory reports have chronic, rather than acute, infections. Thus, the investigation of these reports is not likely to be an efficient mechanism to identify acute Hepatitis C cases unless additional clinical information is obtained with the serologic result. Routine reporting of ALT levels with anti-HCV positive laboratory results might be useful to identify persons who are most likely to have acute disease, and would enhance the usefulness of laboratory reporting in conducting surveillance for acute Hepatitis C.

Case investigations should be conducted of suspected cases of acute Hepatitis C and should include Table VI:. Identifying outbreaks Identification of any of the following risk factors in persons with acute Hepatitis C should prompt an investigation to determine if additional cases are associated with a common source of transmission:. Monitoring trends in disease incidence and determining risk factors for infection Acute Hepatitis C surveillance data should be analyzed at regular intervals by time, place and person to monitor disease incidence.

The proportion of cases with specific risk factors should be determined to monitor disease transmission patterns. The objectives and activities of existing state-based databases of persons reported as anti-HCV positive vary considerably and have not been standardized. The following case definition, case ascertainment methods, and case investigation and follow-up methods are provided as a guide for management of persons who test anti-HCV positive.

However, further evaluation is needed to determine the most feasible and useful approaches to establish these types of systems. Most HCV-infected persons are asymptomatic.

However, many have chronic liver disease, which can range from mild to severe including cirrhosis, and liver cancer. However, collection of risk factor information for such persons may provide useful information for the development and evaluation of programs to identify and counsel HCV-infected persons.

Uses of Surveillance Data Periodic analyses of the cumulative number of persons enrolled in HCV infection databases could be used to provide local, state and national estimates of the proportion of persons with HCV infection who have been identified. Recommended information elements to be maintained in such databases are described in Appendix.

Individuals with signs and symptoms of acute viral hepatitis who are negative for serologic markers of acute Hepatitis A IgM anti-HAV , acute Hepatitis B IgM anti-HBc and Hepatitis C anti-HCV should be reported via the state health department to CDC and further investigation to describe the characteristics of the case and to identify a causal agent may be considered.

Chronic Liver Disease Surveillance Surveillance for HBV and HCV-related chronic liver disease can provide information to measure the burden of disease, determine natural history and risk factors, and develop and evaluate the effect of therapeutic and prevention measures on incidence and severity of disease.

Measles is a significant infectious disease because it is so contagious that the number of people who would suffer complications after an outbreak among nonimmune people would quickly overwhelm available hospital resources. When vaccination rates fall, the number of nonimmune persons in the community rises, and the risk for an outbreak of measles consequently rises.

Millennium Development Goals indicators database. This indicator reflects the percentage of women who consumed any iron-containing supplements during the current or past pregnancy within the last 2 years. It provides information about the quality and coverage of perinatal medical services.

Daily iron and folic acid supplementation is currently recommended by WHO as part of antenatal care to reduce the risk of low birth weight, maternal anaemia and iron deficiency.

However, despite its proven efficacy and wide inclusion in antenatal care programmes, its use has been limited in programme settings, possibly due to a lack of compliance, concerns about the safety of the intervention among women with an adequate iron intake, and variable availability of the supplements at community level.

This indicator is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework. The indicator is defined as the proportion of women who consumed any iron-containing supplements during the current or past pregnancy within the last 2 years.

Data can be reported on any iron-containing supplement including iron and folic acid tablets IFA , multiple micronutrient tablets or powders, or iron-only tablets which will vary by country policy. Improving the intake of iron and folic acid by women of reproductive age could improve pregnancy outcomes and enhance maternal and infant health.

Iron and folic acid supplementation improve iron and folate status of women before and during pregnancy, in communities where food-based strategies are not yet fully implemented or effective.

Folic acid supplementation with or without iron provided before pregnancy and during the first trimester of pregnancy is also recommended for decreasing the risk of neural tube defects. Anaemia during pregnancy places women at risk for poor pregnancy outcomes, including maternal mortality and also increases the risks for perinatal mortality, premature birth and low birth weight.

Infants born to anaemic mothers have less than one half the normal iron reserves. Morbidity from infectious diseases is increased in iron-deficient populations, because of the adverse effect of iron deficiency on the immune system. Iron deficiency is also associated with reduced work capacity and with reduced neurocognitive development.

Demographic and Health Surveys. Global Nutrition Monitoring Framework: Operational guidance for tracking progress in meeting targets for Children with diarrhoea receiving oral rehydration therapy. This indicator is the prevalence of children with diarrhoea who received oral rehydration therapy.

It is the proportion of children aged 0—59 months who had diarrhoea and were treated with oral rehydration salts or an appropriate household solution. The terms used for diarrhoea should cover the expressions used for all forms of diarrhoea, including bloody stools consistent with dysentery and watery stools, and should encompasses mothers' definitions as well as local terms. Diarrhoeal diseases remain one of the major causes of mortality among children under 5, accounting for 1.

As oral rehydration therapy is a critical component of effective management of diarrhoea, monitoring coverage with this highly cost—effective intervention indicates progress on an intermediate outcome indicator of the Global Nutrition Targets, prevalence of diarrhoea in children under 5 years of age. Children with diarrhoea receiving zinc. This indicator reflects the prevalence of children who were given zinc as part of treatment for acute diarrhoea. Unfortunately, there are no readily available data on this indicator, which is maintained in the NLIS to encourage countries to collect and compile data on these aspects in order to assess their national capacity.

Measures to prevent childhood diarrhoeal episodes include promoting zinc intake. Diarrhoeal diseases account for nearly 2 million deaths a year among children under 5, making them the second most-common cause of child death worldwide. The greater the prevalence of zinc supplementation during diarrhoea treatment, the better the outcome of treatment for diarrhoea. WHO and the United Nations Children's Fund UNICEF recommend exclusive breastfeeding, vitamin A supplementation, improved hygiene, better access to cleaner sources of drinking-water and sanitation facilities and vaccination against rotavirus in the clinical management of acute diarrhoea and also the use of zinc, which is safe and effective.

Specifically, zinc supplements given during an episode of acute diarrhoea reduce the duration and severity of the episode, and giving zinc supplements for days lowers the incidence of diarrhoea in the following months. Currently no data are available. The impact of zinc supplementation on childhood mortality and severe morbidity. Report of a workshop to review the results of three large studies.

Geneva , World Health Organization, Children aged months receiving v itamin A supplements. These indicators are the proportion of children aged months who received one and two doses of vitamin A supplements, respectively. The indicators are defined as the proportion of children aged months who received one or two high doses of vitamin A supplements within 1 year. Current international recommendations call for high-dose vitamin A supplementation every months for all children between the ages of 6 and 59 months living in affected areas.

The recommended doses are IU for month-old children and IU for those aged months. Programmes to control vitamin A deficiency enhance children's chances of survival, reduce the severity of childhood illnesses, ease the strain on health systems and hospitals and contribute to the well-being of children, their families and communities.

The World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year The critical role of vitamin A for child health and immune function also makes control of deficiency a primary component of efforts to improve child survival and therefore of the achievement of the fourth Millennium Development Goal, a two-thirds reduction in mortality of children under 5 by the year As there is strong evidence that supplementation with vitamin A reduces child mortality, measuring the proportion of children who have received vitamin A within the past 6 months can be used to monitor coverage with interventions for achieving the child survival-related Millennium Development Goals.

Supplementation with vitamin A is a safe, cost-effective, efficient means for eliminating its deficiency and improving child survival. Immunization, Vaccines and Biologicals. These indicators are the proportion of children aged months who received one or two doses of vitamin A supplements.

The indicator reflects the proportion of babies born in facilities that have been designated as Baby-friendly. Proportion of births in Baby-friendly facilities is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework.

This indicator is defined as the proportion of babies born in facilities designated as Baby-friendly in a calendar year. To be counted as currently Baby-friendly, the facility must have been designated within the last five years or been reassessed within that timeframe.

Facilities may be designed as Baby-friendly if they meet the minimum Global Criteria, which includes adherence to the Ten Steps for Successful Breastfeeding and the International Code of Marketing of Breast-milk Substitutes. The Ten steps include having a breastfeeding policy that is routinely communicated to staff, having staff trained on policy implementation, informing pregnant women on the benefits and management of breastfeeding, promoting early initiation of breastfeeding, among others.

The International Code of Marketing of Breast-milk Substitutes restricts the distribution of free infant formula and promotional materials from infant formula companies. The more of the Steps that the mother experiences, the better her success with breastfeeding.

Improved breastfeeding practices worldwide could save the lives of over children every year. National implementation of the Baby-friendly Hospital Initiative. Implementation of the Baby-friendly Hospital Initiative. Mothers of children months receiving counselling, support or messages on optimal breastfeeding.

Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process with important implications for the health of mothers. Optimal practices include early initiation of breastfeeding within 1 hour, exclusive breastfeeding for 6 months followed by appropriate complementary with continued breastfeeding for 2 years or beyond.

Even though it is a natural act, breastfeeding is also a learned behaviour. Virtually all mothers can breastfeed provided they have accurate information, and support within their families and communities and from the health care system. This indicator has been established to measure the proportion of mothers receiving breastfeeding counselling, support or messages. The proportion of mothers of children months who have received counselling, support or messages on optimal breastfeeding at least once in the previous 12 months is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework.

The indicator gives the percentage of mothers of children aged months who have received counselling, support or messages on optimal breastfeeding at least once in the last year. Counseling and informational support on optimal breastfeeding practices for mothers has been demonstrated to improve initiation and duration of breastfeeding, which in has many health benefits for both the mother and infant. Breast milk contains all the nutrients an infant needs in the first six months of life. Breastfeeding protects against diarrhoea and common childhood illnesses such as pneumonia, and may also have longer-term health benefits for the mother and child, such as reducing the risk of overweight and obesity in childhood and adolescence.

Breastfeeding has also been associated with higher intelligence quotient IQ in children. Salt iodization has been adopted as the main strategy for eliminating iodine-deficiency disorders as a public health problem, and the aim is to achieve universal salt iodization. While other foodstuffs can be iodized, salt has the advantage of being widely consumed and inexpensive. Salt has been iodized routinely in some industrialized countries since the s.

This indicator is a measure of whether a fortification programme is reaching the target population adequately. The indicator is a measure of the percentage of households consuming iodized salt, defined as salt containing parts per million of iodine.

Iodine deficiency is most commonly and visibly associated with thyroid problems e. Consumption of iodized salt increased in the developing world during the past decade: This means that about 84 million newborns are now being protected from learning disabilities due to iodine-deficiency disorders. Monitoring the situation of women and children. Sustainable elimination of iodine deficiency disorders by Micronutrient deficiencies, iodine deficiency disorders.

Population with less than the minimum dietary energy consumption. This indicator is the percentage of the population whose food intake falls below the minimum level of dietary energy requirements, and who therefore are undernourished or food-deprived. The estimates of the Food and Agriculture Organization of the United Nations FAO of the prevalence of undernourishment are essentially measures of food deprivation based on calculations of three parameters for each country: The average amount of food available for human consumption is derived from national 'food balance sheets' compiled by FAO each year, which show how much of each food commodity a country produces, imports and withdraws from stocks for other, non-food purposes.

FAO then divides the energy equivalent of all the food available for human consumption by the total population, to derive average daily energy consumption. Data from household surveys are used to derive a coefficient of variation to account for the degree of inequality in access to food. Similarly, because a large adult needs almost twice as much dietary energy as a 3-year-old child, the minimum energy requirement per person in each country is based on age, gender and body sizes in that country.

The average energy requirement is the amount of food energy needed to balance energy expenditure in order to maintain body weight, body composition and levels of necessary and desirable physical activity consistent with long-term good health. It includes the energy needed for the optimal growth and development of children, for the deposition of tissues during pregnancy and for the secretion of milk during lactation consistent with the good health of the mother and child.

The recommended level of dietary energy intake for a population group is the mean energy requirement of the healthy, well-nourished individuals who constitute that group.

FAO reports the proportion of the population whose daily food intake falls below that minimum energy requirement as 'undernourished'. Trends in undernourishment are due mainly to: The indicator is a measure of an important aspect of food insecurity in a population. Sustainable development requires a concerted effort to reduce poverty, including solutions to hunger and malnutrition.

Alleviating hunger is a prerequisite for sustainable poverty reduction, as undernourishment seriously affects labour productivity and earning capacity. Malnutrition can be the outcome of a range of circumstances. In order for poverty reduction strategies to be effective, they must address food access, availability and safety. Rome, October The State of Food Insecurity in the World Economic growth is necessary but not sufficient to accelerate reduction of hunger and malnutrition.

FAO methodology to estimate the prevalence of undernourishment. FAO, Rome, 9 October Infant and young child feeding. The recommendations for feeding infants and young children 6—23 months include: The caring practice indicators for infant and young child feeding available on the NLIS country profiles include: Early initiation of breastfeeding. This indicator is the percentage of infants who are put to the breast within 1 hour of birth.

Breastfeeding contributes to saving children's lives, and there is evidence that delayed initiation of breastfeeding increases their risk for mortality. Infants under 6 months who are exclusively breastfed. This indicator is the percentage of infants aged 0—5 months who are exclusively breastfed. It is the proportion of infants aged 0—5 months who are fed exclusively on breast milk and no other food or drink, including water.

The infant is however, allowed to receive ORS and drops and syrups containing vitamins, minerals and medicine. Exclusive breastfeeding is an unequalled way of providing the ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process, with important implications for the health of mothers. An expert review of evidence showed that, on a population basis, exclusive breastfeeding for 6 months is the optimal way of feeding infants.

Breast milk is the natural first food for infants. It provides all the energy and nutrients that the infant needs for the first months of life. Breast milk promotes sensory and cognitive development and protects the infant against infectious and chronic diseases. Exclusive breastfeeding reduces infant mortality due to common childhood illnesses, such as diarrhoea and pneumonia, and leads to quicker recovery from illness.

Breastfeeding contributes to the health and well-being of mothers, by helping to space children, reducing their risks for ovarian and breast cancers and saving family and national resources. It is a secure way of feeding and is safe for the environment.

Infants aged 6—8 months who receive solid, semisolid or soft foods. WHO recommends starting complementary feeding at 6 months of age. It is defined as the proportion of infants aged 6—8 months who receive solid, semisolid or soft foods.

When breast milk alone no longer meets the nutritional needs of the infant, complementary foods should be added. This is a very vulnerable period, and it is the time when malnutrition often starts, contributing significantly to the high prevalence of malnutrition among children under 5 worldwide.

Children aged 6—23 months who receive a minimum dietary diversity. This indicator is the percentage of children aged 6—23 months who receive a minimum dietary diversity. As per revised recommendation by TEAM in June , dietary diversity is present when the diet contained five or more of the following food groups: Children aged 6—23 months who receive a minimum acceptable diet. This indicator is the percentage of children aged 6—23 months who receive a minimum acceptable diet.

Proportion of children aged months who receive a minimum acceptable diet is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework.

The composite indicator of a minimum acceptable diet is calculated from: Dietary diversity is present when the diet contained four or more of the following food groups: The minimum daily meal frequency is defined as: A minimum acceptable diet is essential to ensure appropriate growth and development for feeding infants and children aged 6—23 months. Without adequate diversity and meal frequency, infants and young children are vulnerable to malnutrition, especially stunting and micronutrient deficiencies, and to increased morbidity and mortality.

Source of all infant and young child feeding indicators. Infant and Young Child Feeding database. Infant and young child feeding list of publications. Global Nutrition Monitoring Framework.

Children with diarrhoea receiving oral rehydration therapy and continued feeding. This indicator is the prevalence of children with diarrhoea who received oral rehydration therapy and continued feeding. It is the proportion of children aged months who had diarrhoea and were treated with oral rehydration salts or an appropriate household solution and continued feeding. As oral rehydration therapy is a critical component of effective management of diarrhoea, monitoring coverage with this highly cost-effective intervention indicates progress towards the child survival-related Millennium Development Goals.

Health expenditure includes that for the provision of health services, family planning activities, nutrition activities and emergency aid designated for health, but excludes the provision of water and sanitation.

Health financing is a critical component of health systems. National health accounts provide a large set of indicators based on information on expenditure collected within an internationally recognized framework.

National health accounts consist of a synthesis of the financing and spending flows recorded in the operation of a health system, from funding sources and agents to the distribution of funds between providers and functions of health systems and benefits geographically, demographically, socioeconomically and epidemiologically.

General government expenditure on health as a percentage of total government expenditure is the proportion of total government expenditure on health.

General government expenditure includes consolidated direct and indirect outlays, such as subsidies and transfers, including capital, of all levels of government social security institutions, autonomous bodies and other extrabudgetary funds.

It consists of recurrent and capital spending from government central and local budgets, external borrowings and grants including donations from international agencies and nongovernmental organizations and social or compulsory health insurance funds.

GDP is the value of all final goods and services produced within a nation in a given year. Public health expenditure consists of recurrent and capital spending from government central and local budgets, external borrowings and grants including donations from international agencies and nongovernmental organizations and social or compulsory health insurance funds. Private health expenditure is the sum of outlays for health by private entities, such as commercial or mutual health insurance providers, non-profit institutions serving households, resident corporations and quasi-corporations not controlled by government involved in health services delivery or financing, and direct household out-of-pocket payments.

These indicators reflect total and public expenditure on health resources, access and services, including nutrition. Although increasing health expenditures are associated with better health outcomes, especially in low-income countries, there is no 'recommended' level of spending on health. The larger the per capita income, the greater the expenditure on health. Some countries, however, spend appreciably more than would be expected from their income levels, and some appreciably less.

When a government spends little of its GDP or attributes less of its total expenditure on health, this may indicate that health, including nutrition , are not regarded as priorities. National health accounts - World Health Statistics, http: Human development report http: Core health indicators http: Human development report indicator glossary for indicator 3.

Wealth, health and health expenditure. General government expenditure on health as a percentage of total government expenditure is defined as the level of general government expenditure on health GGHE expressed as a percentage of total government expenditure. The indicator contributes to understanding the weight of public spending on health within the total value of public sector operations. It includes not just the resources channelled through government budgets but also the expenditure on health by parastatals, extrabudgetary entities and notably the compulsory health insurance.

The indicator refers to resources collected and pooled by public agencies including all the revenue modalities. The indicator provides information on the level of resources channelled to health relative to a country's wealth. These indicators reflect government and total expenditure on health resources, access and services, including nutrition, in relation to government expenditure, the wealth of the country, and per capita.

When a government attributes less of its total expenditure on health, this may indicate that health, including nutrition , are not regarded as priorities. UNDAFs usually focus on three to five areas in which the country team can make the greatest difference, in addition to activities supported by other agencies in response to national demands but which fall outside the common UNDAF results matrix.

For each national priority selected for United Nations country team support, the UNDAF results matrix gives the outcome s , the outcomes and outputs of other agencies working alone or together, the role of partners, resource mobilization targets for each agency outcome and coordination mechanisms and programme modalities.

The nutrition component of the UNDAF reflects the priority attributed to nutrition by the United Nations agencies in a country and is an indication of how much the United Nations system is committed to helping governments improve their food and nutrition situation. The indicator is "strong", "medium" or "weak", depending on the degree to which nutrition is being addressed in the expected outcomes and outputs in the UNDAF.

UNDAF documents follow a predefined format, with a core narrative and a results matrix. The matrix lists the high-level expected results 'the UNDAF outcomes' , the outcomes to be reached by agencies working alone or together and agency outputs. The results matrix the UNDAF document was used to assess commitment to nutrition , because it represents a synthesis of the strategy proposed in the document and is available in the same format in most country documents. The outcomes and outputs specifically related to nutrition were identified and counted.

The outputs were compared with the evidence-based interventions to reduce maternal and child under nutrition recommended in the Lancet Nutrition Series Bhutta et al. The method and scoring are described in detail by Engesveen et al. What are the implications? A weak nutrition component in the UNDAF document does not necessarily imply that no United Nations agency in the country is working to improve nutrition ; however, unless such efforts are mentioned in strategy documents like the UNDAF, they may receive inadequate attention from development partners to ensure the necessary sustainability or scale-up to adequately address nutrition problems in the country.

The multisectoral nature of nutrition means that it must be addressed by a wide range of actors. Basing such action in frameworks for overall development contributes to ensuring the accountability of United Nations partners. Interventions for maternal and child under nutrition and survival. The Lancet Engesveen K et al. SCN News , Nutrition component of poverty reduction strategy papers.

The poverty reduction strategy approach was introduced in to empower governments to set their own priorities and to encourage donors to provide predictable, harmonized assistance aligned with country priorities. The PRSP should state the development priorities and specify the policies, programmes and resources needed to meet the goals. It is prepared by governments in a participatory process involving civil society and development partners, including the World Bank and the International Monetary Fund, and should result in a comprehensive, country-based strategy for poverty reduction.

The indicator is "strong", "medium" or "weak", depending on the degree to which nutrition is addressed in the PRSP, in terms of recognition of under nutrition as a development problem, use of information on nutrition to analyse poverty and support for appropriate nutrition policies, strategies and programmes.

The papers were systematically searched for key words to identify the parts that concerned nutrition , food security , health outcomes and interventions that would be relevant for the World Bank method. In order to classify the commitments to nutrition in the PRSPs, a scoring system was developed, which is described in more detail by Engesveen et al. The emphasis given to nutrition in PRSPs reflects the extent to which the government considers it essential to improve nutrition for poverty reduction and national development.

In other words, it can be an indication of the government's priority for improving nutrition. A strong nutrition component in a PRSP means that the government considers nutrition a priority for poverty reduction and national development.

A weak nutrition component in the document does not necessarily imply that no government department is working to improve nutrition ; however, unless such efforts are mentioned in strategy documents like PRSPs, they may not be sufficiently sustainable or be scaled-up to adequately address nutrition problems in the country. Basing such action in frameworks for overall development contributes to ensuring the accountability of relevant government departments.

Sources and further reading. Poverty reduction strategy papers. Assessing countries' commitment to accelerate nutrition action demonstrated in poverty reduction strategy paper, UNDAF and through nutrition governance.

SCN News , , Shekar M, Lee Y-K. Mainstreaming nutrition in poverty reduction strategy papers: What does it take? A review of the early experience. Health, Nutrition and Population Discussion Paper, Landscape analysis on countries' readiness to accelerate action in nutrition , This indicator is a description of the strengths and weaknesses of various aspects of nutrition governance in countries. The following 10 elements or characteristics are used to assess and describe the strength of nutrition governance: These elements were identified by countries as key elements for successful development and implementation of national nutrition policies and strategies during a review of the progress of countries in implementing the World Declaration and Plan of Action for Nutrition adopted by the International Conference on Nutrition, the first intergovernmental conference on nutrition Nishida et al.

The components of the composite indicator have been identified by countries as important for determining the completeness of national nutrition plans and policies Nishida, Mutru, Imperial Laue , For instance, a national nutrition plan and policy was considered to provide the political basis for initiating action.

In many countries, official government endorsement or adoption of a national nutrition plan or policy facilitated its implementation. The role of an intersectoral coordinating committee in implementing national nutrition plans and policies was also considered crucial, although the nature i. Another important element was considered to be regular surveys and other means of collecting data on nutrition.

A periodically updated national nutrition information system and routinely collected data on food and nutrition were considered important for evaluating the effectiveness of national nutrition plans and policies and identifying subsequent actions. Strategies for effective and sustainable national nutrition plans and policies. Modern aspects of nutrition , present knowledge and future perspective. Basel , Karger Forum for Nutrition 56 , This indicates whether a government has adopted legislation to monitor and enforce the International Code of Marketing of Breast-milk Substitutes, which helps create an environment that enables mothers to make the best possible feeding choice, based on impartial information and free of commercial influences, and to be fully supported in doing so.

This indicator is defined on the basis of whether a government has adopted legislation for effective national implementation and monitoring of the International Code of Marketing of Breast-milk Substitutes. The Code is a set of recommendations to regulate the marketing of breast-milk substitutes, feeding bottles and teats.

The Code aims to contribute "to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution" Article 1.

Improper marketing and promotion of food products that compete with breastfeeding often negatively affect the choice and ability of a mother to breastfeed her infant optimally. The Code was formulated in response to the realization that such marketing resulted in poor infant feeding practices, which negatively affect the growth, health and development of children and are a major cause of mortality in infants and young children.

Breastfeeding practices worldwide are not yet optimal, in both developing and developed countries, especially for exclusive breastfeeding under 6 months of age. In addition to the risks posed by the lack of the protective qualities of breast milk, breast-milk substitutes and feeding bottles are associated with a high risk for contamination that can lead to life-threatening infections in young infants.

Infant formula is not a sterile product, and it may carry germs that can cause fatal illnesses. Artificial feeding is expensive, requires clean water, the ability of the mother or caregiver to read and comply with mixing instructions and a minimum standard of overall household hygiene. These factors are not present in many households in the world. Frequently asked questions , These indicators provide information on national policies for legal entitlement to maternity protection, including leave from work during pregnancy and after birth, as well breastfeeding entitlements after return to work.

Since the International Labour Organization ILO was founded in , international labour standards have been established to provide maternity protection for women workers. Key elements of maternity protection include: The right to cash benefits during absence for maternity leave is intended to ensure that the woman can maintain herself and her child in proper conditions of health and with a suitable standard of living.

The source of benefits is important due to potential discrimination in the labour market if employers have to bear the full costs. The right to continue breastfeeding a child after returning to work is important since duration of leave entitlements generally is shorter than the WHO recommended duration of exclusive and continued breastfeeding.

A composite indicator on maternity protection is included as a policy environment and capacity indicator in the core set of indicators for the Global Nutrition Monitoring Framework. It currently uses the ILO classification of compliance with Convention on three key provisions leave duration, remuneration and source of cash benefits , but an alternative method taking into account higher standards as stated in Recommendation as well as breastfeeding entitlements is under development.

The ILO periodically publishes information on the above key indicators, including the assessment of compliance with Convention No. However, an alternative method is under development which may use a scale to indicate the degree of compliance is under development.

This method will also take into account higher standards for leave duration and remuneration in Recommendation , as well as breastfeeding entitlements within both the Convention and Recommendation. Pregnancy and maternity are potentially vulnerable time for working women and their families.

Expectant and nursing mothers require special protection to prevent any potential adverse effects for them and their infants. They need adequate time to give birth, to recover from delivery process, and to nurse their children. At the same time, they also require income security and protection to ensure that they will not suffer from income loss or lose their job because of pregnancy or maternity leave.

Such protection not only ensures a woman's equal access and right to employment, it also ensures economic sustainability for the well-being of the family. Returning to work after maternity leave has been identified as a significant cause for never starting breastfeeding, early cessation of breastfeeding and lack of exclusive breastfeeding. In most low- and middle-income countries, paid maternity leave is limited to formal sector employment or is not always provided in practice.

The ILO estimates that more than million women lack economic security around childbirth with adverse effects on the health, nutrition and well-being of mothers and their children. Maternity cash benefits for workers in the informal economy. Rollins et al Why invest, and what it will take to improve breastfeeding practices? Database of national labour, social security and related human rights legislation.

The legislative data are collected by ILO through periodical reviews of national labour and social security legislation and secondary sources, such as the International Social Security Association and International Network on Leave Policies and Research; as well as consultations with ILO experts in regional and national ILO offices around the world.

The composite indicator on maternity protection included in the Global Nutrition Monitoring Framework is currently defined as whether the country has maternity protection laws or regulations in place compliant with the provisions for leave duration, remuneration and source of cash benefits in Convention Documentation for the maternity protection database http: Degree training in nutrition exists.

What does the indicator tell us? This indicator reflects the capacity of a country to train professionals in nutrition in terms of having national higher education institutions offering training in nutrition. This indicator is defined as the existence of higher education institutions offering training in nutrition in the country. Higher education training institutions include universities and other schools offering graduate and post-graduate degrees in nutrition or dietetics, including public health nutrition, community nutrition, food and nutrition policy, clinical nutrition, nutrition science and epidemiology.

Trained nutrition professionals work at facilities including health facilities as well as at population and community levels and may influence nutrition policies, and designing and implementation of nutrition intervention programmes at various levels. They also play an important role in training of other health and non-health cadres to plan and deliver nutrition interventions in various settings. It is recognized that availability, within a country, of sufficient workforce with appropriate training in nutrition will lead to better outcomes for country-specific nutrition and health concerns.

A competency framework for global public health nutrition workforce development: World Public Health Nutrition Association. Registering as Registered Nutritionist.

Building systemic capacity for nutrition: Nutrition is part of medical curricula. This indicator reflects the inclusion of maternal, infant and young child nutrition in pre-service training of health personnel.

This indicator is defined as the existence of pre-service training in maternal, infant and young child nutrition for health personnel. The survey investigates training in three key areas of maternal, infant and young child nutrition, namely growth monitoring and promotion, breastfeeding and complementary feeding, and management of severe or moderate acute malnutrition.

The first two of these three training topics are relevant for all forms of malnutrition, whereas the third topic only pertains to undernutrition. Training on other topics e. Adequate training of health professionals is essential to ensure that nutrition activities are included in their regular health care activities. Nutrition counseling training changes physician behavior and improves caregiver knowledge acquisition.

Nutrition Journal ; Trained nutrition professionals density. The focus of the nutrition professional indicator is on individuals trained to pursue a nutrition professional career, described in most countries as dieticians or nutritionists including nutrition scientists, nutritional epidemiologists and public health nutritionists.

These individuals are trained sufficiently in nutrition practice to demonstrate defined competencies and to meet certification or registration requirements of national or global nutrition or dietetics professional organizations. Dieticians and nutritionists may complete the same training and perform the same functions in some countries but not others.

This indicator is defined as the number of trained nutrition professionals per , population in the country in a specified year. Validation of the indicator has shown that it can predict several maternal, infant and young child nutrition outcomes.

Global nutrition monitoring framework: Density of nurses and midwi ves. Nurse and midwife density indicates whether nurses and midwifery personnel are available to address the health care needs of a given population. It is the number of nursing and midwifery personnel and density per 10 population.

These personnel include professional nurses, professional midwives, auxiliary nurses, auxiliary midwives, enrolled nurses, enrolled midwives and other personnel, such as dental nurses and primary care nurses. Traditional attendants are not counted here but as community or traditional health workers. There is no gold standard for a sufficient health workforce to address the health care needs of a given population.

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