Menu ENN Search

Appropriate Vitamin C Fortification Levels for CSB?

Report summary : The Institute of Medicine

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.


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:

  1. 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).
  2. 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)


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

More like this

FEX: The use and acceptability of micronutrient enriched foods

A study by Oxfam, UNHCR and Micronutrient Initiative. Emergency general rations supplied by the international aid community have frequently failed to supply adequate amounts...

FEX: Outbreak of micronutrient deficiency disease: did we respond appropriately?

By Dianne Stevens, Patricia Araru and Buwa Dragudi, Save the Children (UK) Dianne Stevens is a nutritionist with a Masters in Public Health and Tropical Medicine. She has been...

FEX: Towards the Overdue Elimination of Deficiency Disease Epidemics

By André Briend Andre Briend is a medical doctor, working for the Institut de Recherche pour le Développement (IRD), a French public research institution with a mandate to...

FEX: Further perspectives on scurvy outbreak

View this article as a pdf This is a poscript for the field article 'Scurvy outbreak among South Sudanese adolescents and young men - Kakuma refugee camp, Kenya,...

FEX: Scurvy outbreak among South Sudanese adolescents and young men – Kakuma refugee camp, Kenya, 2017-2018

View this article as a pdf Read the postscript to this article here. Summary of research1 Location: Kenya What we know: Refugee populations dependent on food assistance are...

FEX: Issue 10 Editorial

Dear Readers, Over the past ten years large-scale outbreaks of pellagra have only occurred amongst populations dependent on emergency food aid. The most recent outbreak in...

FEX: Iron and vitamin A deficiency in African refugees

Summary of published research1 Haemacue survey in Tanzania Five cross-sectional surveys were conducted in refugee camps in north and east Africa between 2000-2002 to assess...

FEX: Assessing micronutrient deficiencies in emergencies

Summary of review1 Field haemoglobin testing using a hemacue machine Micronutrient deficiencies have been reported for years in emergency settings, especially in refugee...

FEX: Scurvy outbreak and erosion of livelihoods masked by low wasting levels in drought affected Northern Afghanistan

By Fitsum Assefa Signs of scurvy: blackness of the legs indicative of haemorrhage Fitsum Assefa is a nutritionist who recently joined Save the Children, United States (SC/US)...

FEX: Acceptability and use of cereal-based foods in refugee camps: case studies from Nepal, Ethiopoa and Tanzania

By Catherine Mears with Helen Young Outbreaks of scurvy, pellagra and beri beri among refugees in the 1980s caused a public outcry, as many of these more unusual deficiency...

FEX: Micronutrients - The Basics

Taken from draft guideline material prepared by Fiona Watson, Institute of Child health, London. Micronutrients are essential for life and are distinct from macronutrients...

FEX: Persistent Micronutrient Problems among Refugees in Nepal

by Janack Upadhyay This article describes nutritional aspect of emergency food aid in Bhutanese refugee camps in Nepal; the author was regional Food & Nutrition...

FEX: The Nutrition Situation of Refugees and Displaced Persons

Summary of the ACC/SCN Refugee chapter by Jane Wallace The quarterly 'Reports on the Nutrition Situation of Refugees and Displaced Populations' (RNIS) are compiled and...

FEX: Potential of Using QBmix to Prevent Micronutrient Deficiencies in Emergencies

By Evelyn Depoortere, Epicentre Evelyn Depoortere is currently a medical epidemiologist for Epicentre. Previously she worked on several MSF missions, including Southern Sudan...

FEX: There is probably no single universal solution to the problem of scurvy

There is probably no single universal solution to the problem of scurvy ...stated a recent review of interventions to prevent scurvy occurring amongst refugees and other...

FEX: Micronutrient research in progress

Examination for scurvy in Tanzania An article in the last issue of Field Exchange presented a review of the approaches that agencies and others use for identifying...

en-net: Upto what extend iron flour fortification can increase the Hb level of anemic adolescent women if iron fortified wheat flour is feed to these anemic adolescent women for 3 months?

i am doing my Mphil research on iron wheat flour fortification for anemic adolescent women. can any one have any information or relevant site or paper that how much it will...

FEX: Scurvy outbreak in Afghanistan: an investigation by Action Contre la Faim (ACF) and WHO

By Philipe Leborgne, Caroline Wilkinson, Sylvie Montembaut, and Mija Tesse Ververs Dr Philippe Leborgne has been Head of the ACF Medical Department since 1994. Before this he...

FEX: Thiamine Deficiency and its Prevention and Control in Major Emergencies

Review in progress WHO are finalising a report on Thiamine Deficiency and its Prevention and Control in Major Emergencies This is a comprehensive review which is unique in...

FEX: Influence of USAID policies on food aid: time for reform?

Summary of published paper1 A paper has recently been published which describes the food commodities that are used in U.S emergency food aid programmes, and outlines issues in...


Reference this page

Appropriate Vitamin C Fortification Levels for CSB?. Field Exchange 5, October 1998. p5.



Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.