NUTRITIONAL SURVEY

DENAN,

OGADEN, ETHIOPIA

OCTOBER 17-20, 2000

MSF- BELGIUM

October 2000

MSF-Belgium

Pascale Delchevalerie

Jo Robaye

Michel Van Herp

TABLE OF CONTENTS

SUMMARY

1) INTRODUCTION

1.1 Context

1.2 Demographic data

1.3 Food distribution

1.4 Nutritional services

1.5 Medical information

1.1 Livestock

1.2 Water situation

2) OBJECTIVES

3) METHODOLOGY

3.1 Sampling method

3.2 Sample size

3.3 Target population

3.4 Indicators collected

3.5 Teams

3.6 Implementation

4) RESULTS

4.1 Demographic distribution

4.2 Distribution of the sample by sex and age

4.3 Prevalence of malnutrition

4.3.1 In Z-score and in percentage of the median

4.3.1 Malnutrition in function of age and sex distribution

4.3.2 Malnutrition function of status and location

4.3.3 Evolution of the nutritional indices from May to October 2000.

4.4 Mortality

4.1 Measles coverage

4.2 TFC/SFC coverage

5) CONCLUSIONS AND RECOMMENDATIONS

ANNEXES

SUMMARY

A nutritional survey was conducted in the camp and the town of Denan from October 17 to October 20, 2000.

Objectives

  • To quantify the global and severe malnutrition among children from 65 to 110 cm in the camp and the town of Denan.
  • To identify high risks groups.
  • To compare the results with the previous surveys (Mai and August 2000) and follow the evolution of the nutritional status of this group of children.
  • To evaluate the coverage of the feeding programme.
  • To evaluate the measles coverage of children under 5 years.

Methodology

The standard methodology of UNHCR/WFP/MSF was followed; a two-stage cluster sampling was used. The sample size was defined according to an expected prevalence of malnutrition of 30%. A degree of 4,5% as precision and 5% risk of error. In the camp and the town, 30 clusters of at least 30 children were completed. Inclusion criteria: children with a length between 65 cm and 110 cm. Data collection were age, sex, weight, height, Muac, oedema, measles vaccine given by card and measles given by history, attendance in SFC. Results for weight and height index values are based on the Reference Population Table of the NCHS/CDC/WHO 1982.

A family survey was also done in all the houses visited (even the ones without children under five). Data collected were status, resident or displaced[1], total number of persons in the family, number of children less than five years, if they received food from the GFD and date of last distribution.

Results

1) Nutritional survey

Sample size: 914 children

% Boys: 47,6 %

% Girls: 52,4 %

Sex ratio B: G 0,91:1

Anthropometrical Indices / Percentage / 95% CI*
Z-scores
< -2 z-scores or oed. = GAM* < -3 z-scores or oed. = SAM* / 40.8
5.7 / [35.7 – 45.9]
[4.0 – 7.4]

Percent. Of the Median

< 80% or oedema =GAM
< 70% or oedema =SAM / 31.3
3.2 / [26.8 - 35.8]
[2.0 - 4.3]

* 95% confidence intervals with calculated cluster effect

* GAM= global acute malnutrition - SAM =severe acute malnutrition

2) Family survey

Sample size: 3513

Families interviewed: 609

Under 5 population: 960

% under 5’s: 27,3%

Average people per family: 5,7

Access to last food distribution (09/10/00): 99% (97,7 – 99,6)

The Crude Mortality Rate over the period from 6 August – 15 October:

(25:27,909) x (10,000:70 days) = 0.13/10.000/day

The < 5-mortality rate over the period 6 August – 15 October:

(12:6279) x (10000:70) = 0.27/10000/day

3) Measles coverage

Measles coverage confirmed by vaccine card: 15,8% (11,6-20,1)

Measles coverage confirmed by history: 79,5% (75,1- 83,8)

Not vaccinated: 4,7% (2,4 - 7,0)

4) SFC coverage

Global coverage: 54,3% (44,8 – 63,9)

MAM coverage : 53,1% (43,5 – 62,8)

SAM coverage : 63,6% (47,1 – 80,1)

Conclusions

  • The prevalence of the global malnutrition observed is still very high.
  • Compared with the results of the survey done in August there is no significant reduction of the global malnutrition rate, neither of the severe malnutrition rate in Z-score and percent of the median.
  • We can see a decreasing in the malnutrition rate measured in MUAC. The malnutrition measured in MUAC is underestimated compare to the percentage of median what is quite unusual. We found already this in August and thought it could be due to a bias in the way the measurement was taken, but this time we controlled carefully the measurements and the technique was well respected.
  • The percentage of bilateral oedema has increased since August (is same rate than in May). The percentage is higher in children of 6 - 29 months (2.8% [0.96 – 4.6]) than children > 29 months (0.5 % [0.0 – 0.9]).
  • The difference in malnutrition rates between residents and IDP’s or between town and camp is not significant as in August.
  • After 6 months of activities, the nutritional programs succeeded to decrease the mortality and the severe malnutrition but didn’t influence the global malnutrition rate.
  • Almost all persons included in the survey report to have received general food distributions but the ration distributed has decreased since ICRC stopped the distributions beginning of September and the actual ration is insufficient.
  • Some livestock reappeared but there are still families who depend only on GFD. IDP’s have no intention to leave Denan in a near future and there are still new arrivals. Often, the new arrivals have malnourished children.
  • The mortality rates are back to normal rates.
  • The measles coverage surveyed by both card and history 95.3 % , which is almost 100 %. A lot of mothers lost their cards since August. The measles outbreak is over.
  • The global SFC coverage didn’t change since August: 54.3 % (44.8 – 63.9) against 47.1 % (41.2 – 57.0) but there is an increase in the coverage of severely malnourished children: 63.6 % (47.1 – 80.1) compared to 24.4 % (6.4 – 42.4)..

Recommendations

  • To improve the ration, qualitatively and quantitatively, through the general food distribution programme already in place by DPPC/WFP in the affected areas.
  • To maintain the supplementary programme for moderately malnourished individuals and to reopen the therapeutic feeding for severely malnourished children.
  • To reinforce the CHW network to improve the coverage of the Nutritional program. Eventually, to use mobile W/H teams in the camp?
  • To investigate through a focus group survey, the reasons why the GAM is not decreasing and why the coverage of the feeding centres is so low.
  • To repeat a nutritional survey in 3 to 6 months to assess the trends in the nutritional status.
  • To continue a nutritional and epidemiological surveillance system.
  • To continue the vaccination of the non vaccinated children at the screening point in the SFC.
  • To investigate with partners on “long term” solutions to improve the general situation of the region?

1) INTRODUCTION AND BACKGROUND INFORMATION

1.1 Context

The Ogaden in the Somali National Regional State V lies to the South East of Ethiopia, bordering Somali, Kenya and Djibouti. This area is known for its instability since the Somali-Ethiopian war in the 1970’s with continuing conflict influenced by secessionist groups and regional wars. At the present time the area is insecure, restricting activities for all international actors in the area.

MSF-B has been present in Ethiopia since 1985. Initially the focus of their programme were emergencies, including a presence in the Gode region from 1991-1996, but in recent years projects have become more development orientated. At the present time MSF B is present in Region V, Somali State, in the regional capital, Jijiga and Gode where they run a tuberculosis programme. Up until February this year MSF B was also present in the Degah Bur zone, working in rural health and water, but due to a critical incident against MSF in February this programme was suspended.

In January 2000 the Ethiopian government with regard to the threat of a nation-wide famine due to the failure of rains in recent years launched an urgent international appeal. Thus MSF decided to study the nutritional situation in Gode area where it was already present. The first team was evacuated following the security incident in Degah Bur zone. However MSF clearly recommended an intervention for both the malnourished and an ongoing measles epidemic that the team had clearly identified during their short visit during the first week of February. Due to the security risk, MSF decided it could not be permanently present but that they could assist in the Zonal Health Bureau in a mass measles vaccination campaign. At the same time other local actors assured the DPPC task force in Addis Ababa that they would take in charge the malnutrition and water supply problem.

A two-person team was sent immediately to Ethiopia and Gode and they started the training of medical personnel and launched the measles vaccination campaign on 15th of Feb. This campaign covered Gode zone and ended on the 21.03.00. This campaign achieved 39% coverage of the expected target population (quoted at 120.000 persons at the beginning of the campaign) and 45.9% of children under-five years of age, for measles vaccination and Vitamin A distribution. At the same time all children between 6 months and five years also had a MUAC taken - this showed a severe malnutrition problem of 13% in this population (<110muac/oed = 3618 children measured), with 19.4% (110-125muac=5415 children) suffering from moderate malnutrition and 21% at risk (126-135muac=5809 children) - thus over 50% of the under five population with a serious risk. It was also clear that the other actors in the area were having difficulty to cope with the population requirements. Again the recommendation of the team was an immediate nutritional intervention in the Gode zone, where priority should be given to Denan, Gode and Imey areas.

Following a third and final assessment mission in early April it was decided that there was a reasonable security situation in the Gode which can allow MSF to have a team permanently presence in the Gode zone.

Taking this into consideration MSF launched a programme with two main actions:

1.A nutritional intervention to treat the severe and moderately malnourished.

2. Set up a nutritional and epidemiological surveillance system.

1.2 Demographic data

Denan has changed considerably over the past months with a large population movement towards the town. The initial population estimated at 9.000 people in the town (end of April) have increased to 12.151 in August, with an under five population of 2.795 children (23.5%°) and 12.979 just before the survey in October.

There is also a displaced camp at the outskirts of the town (this camp started in January 2000) which was initially (26/04) estimated at 7.000 persons, increasing up to 15,501 persons[2] with an under five population of 3023 children (19.5%) in August and 16.542 just before the survey of October.

During July and August, there were some population movements from camp to town to find some protection from the sandstorms and few people went back to their village of origin. The number of new arrivals decreased from last week of July to mid-September and a new flow started again from mid-September with a mean of 300 new people per week. Apparently some of this second flow is IDP’s who were installed in Burkaya (24 km from Denan) and decided to move to Denan because no NGO’s were going to their location.

1.3 Food distribution

Since November the DPPC[3] started with general food distributions in Denan town and for some of the surrounding villages. This food distribution was 1200 Kcal per person, and consisted of a dry ration of wheat flour only. End of May, the ICRC started a complementary distribution to the population of 4 districts in Gode zone: Denan, Gode, Imi and Adadle (target population of the programme: 188.000 people) consisting of 10 kg Unimix and 2 litre of oil per person, so a 12 kg monthly ration of 1900 Kcal per person.

Since the end of May, the distributions were regular. from 20/05 to 31/08, between the rations of DPPC and ICRC, people received a daily ration of 1761 Kcal/pers with 46,8g of proteins (=10,6%) and 44,3g of fat (=22,6%). ICRC decided to stop their distributions on the end of August. The last one was done on the 5th of September (7,5 kg of Maize, 3,75 kg of CSB and 1,5 l of oil / person).

DPPC distributed 12,5 kg of wheat / person on 26th of August and 9th of October (In August, some people received only 10kg). It means that for September and October, the people received a daily ration of 2086 to 2221 Kcal / person with 68,7 to 73,8 gr of Proteins (= 13,2 to 13,3%) and 35,6 to 36,3 gr of Fat (=15,4 to 14,7%).

In the future, the population will only receive the DPPC ration = 1375 Kcal / day / pers with 51,2 gr of Proteins (= 14,9 %) and 6,2 gr of Fat (= 4,1%).

1.4 Nutritional services

MSF Belgium started its activities in Denan end of April 2000 with a therapeutic feeding centre (TFC) and a supplementary feeding centre (SFC). In the beginning of May a second therapeutic feeding centre was opened.

The attendance in theTFCs increased regularly up to a maximum of 642 children mid June, then decreased to 179 before the survey of August and 46 on 10th of September. The remaining children were transferred to SFC (only 6 of them were still under 70%) and the TFC was closed on 15/09. (from the beginning,1569 children had been admitted in the program). In the SFC the attendance went up to 3019 end of June to 2155 children per week before the survey.

TFC:

All severely malnourished children below 70% weight for height, children with oedema or a MUAC[4] < 110mm are admitted in the therapeutic feeding centre.

In the TFC the children are fed intensively until they reach W/H[5] > 80%. Basic medical care and individual follow up is given to all children in care.

SFC:

All children with W/H between 70% and 80% (including children discharged from the TFC) are admitted to the supplementary feeding centre and receive a dry ration of BP5 on a weekly basis. From the end of June, the BP5 were replaced by a premixed ration of Famix 2 Kg, Sugar 150 gr and Oil 250 gr.

These children are discharged when they reach 85 % W/H for two consecutive weeks, from August, the children who were in the program for more then 10 weeks and didn’t gain weight but were in good health were discharged with W/H > 80% for 3 consecutive weeks.

1.5 Medical information

There is a primary health care post in Denan town, which is run by an Auxiliary Nurse from the Zonal Health Bureau of Gode Zone. With the increase in the population, the health post needed additional support. UNICEF gave a first donation of drugs to the health centre at the beginning of May.

Lethality rate observed in both TFC’s from 26/04/2000 till 15/09/2000:

  • 92 deaths / 1569 children admitted = 5,8% (66 = 71.8% of them died during the 5 first weeks of the program).

Morbidity data observed in both TFC’s from 26/04/2000 till 15/09/2000:

- 261 measles cases

- 356 cases of bloody diarrhoea (including adults for 3 weeks in July-August)

- 53 cases of strong suspicion of tuberculosis

- since September, an augmentation of the malaria cases with severe cases (with neck stiffness) who were hospitalised in our centre. Lumbar punction samples taken on few cases were negatives for meningitis. Total number of severe cases 25 (attack rate = 0,085%). Lethality rate = 32 % (most of the deaths occurred before people got treatment or in the 24 first hours of treatment.)

- since the rainy season started, the cases of pneumonia increase, especially in infants, with already some deaths.

1.6 Livestock and market

Due to the four years old drought in this area the predominantly nomadic population and their families have been moving towards general food distribution points as fail to find water and their animals die. At the beginning of May it started to rain although this rain came too late for the Ogaden. The livestock was already dead and many families were destitute depending on general food distributions. The period required for this population to recuperate, livestock recovery, conception, gestation and sufficient milk production will take at least several months.

Since June-July, some livestock reappeared, mostly camels and goats. The market is now crowded, milk and meat are available. The money circulating through the salaries of NGO’s staff has attracted business people and Denan became again a business centre. The harvest started end of August (Sorghum, Maize) but because of presence of food from GFD, the price of cereals dropped to 20 Ebirr / bag instead than 80 Ebirr in this season.

1.7 Water situation

Feeding centres

Water supply to the feeding centre is organised from a riverbed well 12 km North West from Denan village.

Due to heavy rains this well flooded leaving Denan without water supply as of 3 May. Water trucking from Gode became impossible the next day so a combination of different strategies assured water supply to the feeding centre:

1.Installation of water transport facilities and a water treatment unit at 2 km from the feeding centre using assisted sedimentation to treat very turbid run-off rainwater. At the same time, rehabilitation of 2 existing flood free wells was initiated. The water treatment unit moved 3 times according to the available surface water and was closed end of July due to lack of surface water. Since then, all the water is provided by the well at 12 km.

2.Installation in the feeding centre of a water storage stock of 65 m3 and a rainwater collection system.

The usual hygiene and sanitation infrastructures were installed in the feeding centre and a team of hygiene promoters assured the correct use of these infrastructures.

IDP Camp

A very basic emergency sanitation program for the IDP camp adjoining

Denan village was started up including:

1. Lobby for distribution of non-food items by ICRC and others: the plastic sheeting promised by SCF in July is ready in their stock in Gode but still not distributed, one month after the beginning of the rainy season!

2. Installation of trench latrines and a hygiene education program run via the CHW network.

3. Supply safe water from the MSF water treatment unit to assist SCF with the general water supply.

4.Donate MSF bladders and tap stands to assist SCF with the general water transport and distribution.

2) OBJECTIVES

The objectives of the survey were:

  • To quantify the global and severe malnutrition among children from 65 to 110 cm height in the camp and the town of Denan.
  • To identify high risk groups.
  • To compare the results with the previous surveys (Mai and August 2000) and follow the evolution of the nutritional status of this group of children.
  • To evaluate the coverage of the feeding programmes.
  • To evaluate the measles coverage of children under 5 years.

3) METHODOLOGY

3.1 Sampling method

The two-stage random clusters sampling method was carried out according to the method recommend of UNHCR/WFP/MSF. A total of 30 clusters were selected from the new mapping of the town and the camp of Denan. Each cluster was composed of 30 children selected at random in proportion to the population density of the selected areas (see annex 3).