Appropriate Vitamin C Fortification Levels for CSB? 

In 1995 the Senate Appropriations Committee Report directed USAID to initiate a pilot programme to increase the vitamin C content of CSB and WSB to 90 mg/100gm from the traditional 40mg/100gms, and to report on the findings. The results of the study were published last year. The main conclusions and recommendations were as follows. 

Where Scurvy occurs 
Scurvy outbreaks have occurred amongst refugee populations entirely dependent on emergency relief rations. The greatest number of outbreaks occurred in the 1980s in Somalia. Except for recurring mild scurvy outbreaks among Bhutanese refugees in Nepal, all other outbreaks in the past two decades have been in refugee camps in the greater Horn of Africa. The reason for this localised occurrence is not clear, but may be due to location of these camps in isolated areas away from local populations and markets and on land unsuitable for cultivation. Thus, the need for higher vitamin C fortification of CSB and WSB would be sporadic and localised. 

Costs of increasing fortification level 
Only a small proportion (7%) of US supplied CSB and WSB is designated for emergency feeding programmes in East Africa, where scurvy has been reported. Thus, 93% of the cost of adding more vitamin C to blended fortified foods, would be wasted. 

Specified fortification level not being met 
The study also identified unacceptable variability in fortification levels of vitamin C in CSB which raises serious questions about the ability of manufacturers to meet specified nutrient levels in the final product. The committee believed it would be inappropriate to increase any micronutrient fortification of these commodities without better manufacturing controls. 

Vitamin C losses 
Information from the pilot study indicates that vitamin C losses during shipping and storage are not a concern but losses of vitamin C during cooking may be a major limiting factor ranging from a low of 52% up to as much as 82%. In addition, although iron deficiency appears to be a much more widespread problem than scurvy in emergency feeding situations, the use of higher levels of vitamin C fortification to enhance iron absorption is not a cost-effective method of improving iron status. 

Recommendations 
The level of vitamin C fortification of blended food aid commodities should not be increased but maintained at current levels of 40 mg/100 gms. Other strategies to prevent or mitigate outbreaks of scurvy should however be implemented. These include: 
a) Strengthening health surveillance systems in refugee camps to monitor populations at risk of vitamin C deficiency.  Risk factors for vitamin C deficiency and scurvy should be monitored (see table below). 
b) Targeting identified populations at risk of scurvy with appropriate vitamin C interventions. These include: 
1. increased access to local foods and markets, 
2. local fortification of commodities, 
3. use of vitamin C tablets if  scurvy is already present, 
4. managing two supplies of CSB and/or WSB, the conventionally fortified blends and a small proportion of highly fortified blends that would be targeted as part of the general ration to situations where risks of vitamin C deficiency are high. 
 

Risk factors to be monitored
Camp / community level Individual level	Individual level
poor acceptance of donated foods, (especially blended fortified foods) resulting from cultural preference and difficulties of access for relief organisations because of war or remoteness.  populations totally dependent on food aid  duration of stay in camp  seasonality (dry season)  inability to cultivate  market failure  limited local supplies of fresh produce or lack of resources to trade for other food sources	age and physiological status (young children, pregnant and lactating women and the elderly have been found more susceptible)

Reference 
Institute of Medicine (1997) Vitamin C Fortification of Food Aid Commodities: Final Report. National Academy Press, 
Washington, D.C. 1997. National Academy Press, 2101 Constitution Avenue, N.W, Box 285, Washington DC 20055. Tel No 202 334 3313. or visit the NAP's on-line book-store at www.nap.edu

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