SMART During COVID-19
Note: The SMART Team at Action Against Hunger Canada is carefully monitoring the global COVID-19 situation and will be continually updating this page as necessary.
Date Published: 31 March 2020
Question: How do we gather nutrition data during COVID-19?
Background: The novel coronavirus disease 2019 (COVID-19) was first identified in late 2019 in Wuhan, the capital of the Hubei Province in central China, and has since been classified as a pandemic by the WHO. On 11 March 2020, with 118,000 cases confirmed in 114 countries, the WHO Director-General declared the COVID-19 outbreak as a pandemic[1]. As of 31st March 2020, more than 820,000 cases have been confirmed globally with upwards of 40,000 deaths across at more than 179 countries[2]. The countries with the highest number of confirmed cases were the United States, Italy, Spain, China, Germany, and France as of 31st March 2020[3]. The situation is rapidly evolving and poses a serious global public health risk.
The WHO has defined four transmission categories for COVID-19[4]:
- No cases – countries with no cases
- Sporadic Cases – countries with 1 or more cases, imported or locally detected
- Clusters of Cases – countries experiencing cases clustered in time, geographic location, and/or common exposure
- Community Transmission – countries experiencing larger outbreaks of local transmission.
Countries are increasingly being upgraded to the category of community transmission.
COVID-19 causes respiratory illness, the symptoms of which include a cough, fever, and, in more severe cases, difficulty breathing. It spreads primarily through contact with an infected person through respiratory droplets when they cough or sneeze, or when a person touches a surface or object contaminated by the virus, then enters the body through mucus membranes when touching one’s eyes, nose, or mouth. The most effective means of prevention and reducing transmission is to frequently wash your hands with soap and water (or an alcohol-based hand sanitizer), avoid touching your face, maintaining recommended social distance (at least 1 meter or 3 feet) with people, staying home if sick, and covering your own mouth and nose with a bent elbow or tissue when coughing or sneezing.[5] While the majority of cases result in mild symptoms, severe cases can progress to pneumonia, and in even more critical cases, death. Recent research has placed case fatality risk estimates between 0.25% and 3.0%[6]. However, there is a significant variation in case fatality rate by age group, with older age groups and persons with underlying health conditions being the most vulnerable[7].
Looking through a nutrition lens, undernutrition is considered a risk factor for complications in people with COVID-19, due to a compromised immune system[8]. With older age groups being more vulnerable to COVID-19 fatality, children may be indirectly affected by the loss of providers and caregivers, especially the elderly.
Risks to SMART Surveys
Although the primary outbreak in China was most readily imported by travellers to neighbouring Asian countries, Europe, and North America, cases are now increasingly being reported in low-income country contexts where SMART surveys are most commonly implemented. These outbreaks are of high concern for countries with underdeveloped healthcare systems which could easily become overwhelmed if faced with a large outbreak.
As the SMART methodology relies on survey teams travelling to remote areas and coming in direct contact with household members, particularly when taking anthropometric measurements, this could potentially contribute to the spread of COVID-19 in these settings. Teams should be cognizant of the perception that survey teams could be contribute to the spread of COVID-19 in the areas they are surveying. Fear and unease by government officials who typically approve the survey process could hinder survey implementation. Fear and unease at the community level can also increase the number of clusters that cannot be accessed and households who may decline to participate in surveys.
Taking these considerations into account, the implications for SMART survey implementation has been cautiously grouped into potential short, medium, and long-term implications with the health and safety of all being the primary consideration and top priority:
Short-term Implications (next 3 months):
- Unable to deploy international SMART staff for technical support
- Likely postponement or cancellation of SMART surveys upcoming in the next 1-3 months as the situation is evolving rapidly and increased fear of transmission can pose significant challenges to the implementation of surveys
- May need to resort to other sources of nutrition data to fulfill the gap left by postponed or cancelled SMART surveys
Medium-term Implications (next 3-12 months):
- Deployment of international SMART staff when necessary and appropriate considering risk, ensuring that the health and safety of all is the top priority and primary consideration
- SMART surveys planned to capture seasonality (often lean season) may be postponed until after the season of interest or postponed by one year
- If SMART surveys are implemented, they must do so with consideration of all appropriate health and safety protocols in alignment with global recommendations to reduce COVID-19 transmission
- May need to resort to other sources of nutrition data to fulfill the gap left by postponed or cancelled SMART surveys
Long-term Implications (12 months and beyond):
- International deployments resume when appropriate considering risk, ensuring that the health and safety of all is the top priority and primary consideration
- If SMART surveys are implemented, they must do so considering all appropriate health and safety protocols in alignment with global recommendations to reduce COVID-19 transmission
- If SMART surveys are implemented, their results can be compared/contrasted with other sources of data relied on during the COVID-19 crisis
- May need to develop strong guidance for the implementation of SMART surveys in the context of contagious disease outbreaks
Imagined SMART survey scenarios:
Decision making to implement assessments needs to carefully consider the following:
- Transmission category of the country, region, and areas where teams would be working
- Travel trajectories of survey manager, supervisors, enumerators, and any supportive actors, if any of these movements risk increasing transmission or contracting the virus
- What additional steps will be necessary to obtain assessment approval at national, regional, and local levels
- Robust procedural steps by survey team to reduce the risk of transmission in alignment with global and national health guidance
The scenarios for implementing assessments can be grouped into three possibilities:
| Scenario 1: no mobility restrictions and functional nutrition service function | Scenario 2: partial mobility restrictions and partial nutrition service function | Scenario 3: full mobility restrictions and no nutrition service function |
| Suspend all household-level/population-based surveys in line with government directives put in place. For the critical assessments, discuss and agree what mitigation measures can be implemented to minimize transmission. Coordinate with the Health and other Clusters to minimize amount of assessments conducted. Increase in-country capacity to analyze and utilize secondary data analysis | Suspend all household-level/population-based surveys in line with government directives put in place. It is advisable to cancel all assessments and replace them with secondary data analysis. Increase in-country capacity to analyze and utilize secondary data analysis. | Cancel all assessments and replace them with secondary data analysis. For example, use GAM prevalence data from previous survey to estimate current prevalence, taking into account contributing factors. Monitor situation with data collected at health facility level (incidence not prevalence), and support is given to health facilities to strengthen their reporting and COVID-19 safety and hygiene procedures. |
Next steps:
- Ongoing monitoring of SMART and COVID-19 as the situation develops
- Host a webinar among multi-national SMART practitioners to compare and discuss best practices moving forward
- Case-by-case consideration and risk-benefit analysis for SMART survey implementation with the health and safety of all being the primary consideration
References
[1] 11 March 2020 WHO Director-General’s opening remarks at the media briefing on COVID-19 https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020 accessed 31 March 2020
[2] Coronavirus COVID-19 Global Cases by the Centers for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU) https://www.arcgis.com/apps/opsdashboard/index.html?_branch_match_id=769562559869459159#/bda7594740fd40299423467b48e9ecf6 accessed 31 March 2020
[3] Coronavirus COVID-19 Global Cases by the Centers for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU) https://www.arcgis.com/apps/opsdashboard/index.html?_branch_match_id=769562559869459159#/bda7594740fd40299423467b48e9ecf6 accessed 31 March 2020
[4] WHO Critical preparedness, readiness and response actions for COVID-19 https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/critical-preparedness-readiness-and-response-actions-for-covid-19 accessed 31 March 2020
[5] WHO coronavirus disease (COVID-19) advice for the public https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public accessed 31 March 2020
[6] CDC Research Letter Wilson, N., Kvalsvig, A., Barnard L., Baker M., Case-Fatality Risk Estimates for COVID-19 Calculated by Using a Lag Time for Fatality https://wwwnc.cdc.gov/eid/article/26/6/20-0320_article accessed 31 March 2020
[7] CDC The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) – China 2020 https://github.com/cmrivers/ncov/blob/master/COVID-19.pdf accessed 31 March 2020
[8] Action Against Hunger COVID-19: The Impact of the Outbreak https://www.actionagainsthunger.org.uk/blog/coronavirus-impact-outbreak accessed 31 March 2020