AFGHANISTAN. Rapid Nutrition Assessment. Golan Refugee camp Khost Province. June Funded by:

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1 AFGHANISTAN Rapid Nutrition Assessment Golan Refugee camp Khost Province June 2015 Funded by: Prepared by Dr. Baidar Bakht Habib and Hassan Ali Ahmed Action Contre la Faim ACF is a non-governmental, non-political and non-religious organization

2 Abbreviations ACF ACTD BPHS CDR CHF CSO ENA Action contre la faim Action Against Hunger Afghanistan Centre for Training and Development Basic package of health services Crude Death Rate Common Humanitarian Fund Central Statistics Organization Essential Nutrition Action GAM Global Acute Malnutrition HAZ Height for Weight HH Household IYCF Infant and Young Child Feeding MOPH Ministry of Public Health MUAC Mid-upper arm circumference MW Measured Weight NCHS National Center for Health Statistics OW Observed Weight RC Reserve Cluster SAM Severe Acute Malnutrition SD Standard Deviation SMART Standardized Monitoring and Assessment of Relief and Transitions U5DR Under 5 Death Rate WASH Water, Sanitation and Hygiene WFP World Food Program WH Weight for Height WHO World Health Organization

3 ACKNOWLEDGEMENT Action Contre la Faim Afghanistan would like to thank to the following organizations and individuals for their help and support in this Gulan camp Rapid Nutrition Assessment: The community members for welcoming and supporting the Health Net TPO teams being on the field during the data collection. The multiple National and international Non-Governmental Organization for sharing information on the general situation in Khost Province. Khost PPHD and especially the PNO for their support and authorization of the survey. Common Humanitarian Fund (UNOCHA-CHF) for their financial support in the survey. ACF teams in Kabul and Paris. Health Net TPO Afghanistan teams in Kabul and Khost, especially Dr. Zahor, Dr. Abdul Baqi and Abdul Qayum. The entire data collection teams in Khost Province for making the whole process smooth.

4 1. INTRODUCTION In June 2014 thousands of families from Pakistan fled North Waziristan region in Pakistan to Khost and Paktya Afghanistan. Due to this huge influx of population displacement and movement of residents of Waziristan region in Pakistan the government of Afghanistan at provincial level established the refugee camp in Gurbuz district, Gulan area, near the border with Pakistan. It is estimated that there are currently 54,582 1 individuals living in Gulan camp. The camp is located approximately 20 km from Khost city. There is still an influx of population movement into the camp from Pakistan due to the on-going tensions and military operations by the Pakistan military in Waziristan region. This Rapid Nutrition Assessment (RNS) covers the total population of the camp. It is worthy to note that officially the camp was not divided into any zones but for the purposes of this assessment, data from Solidarities International has been acquired for stratification of the camp into zones to ease the sampling (as shown in Figure 1 below). The criterion for zoning the camp was based on Solidarities International s current WASH activities. Figure 1: Sketch map of subdivision of the camp used. The population of these zones was estimated to be 54,685 people (see Table 1). Details are indicated in Table 1 below. It is important to note that the original boundaries for the 1 Most recent UNHCR data on camp population (May 2015)

5 camp were no longer respected and there are refugees residing outside the boundaries of the camp including the originally set buffer zone. See ANNEX 1 for original map of the camp. Table 1: Zones and estimated population (UNHCR data on camp population, May 2015) Zone Brief localization of the zone Total HH A B NW part inside the camp boundary area including the buffer zone SW part inside the camp boundary area including the buffer zone Total population C Middle part of the camp boundary area D SE part Inside the camp boundary area E1 NW-part outside the camp boundary area E2 NE part outside the camp boundary area F1 SW part outside the camp boundary area F2 SE part outside the camp boundary area including the buffer zone TOTAL ,685 It is important to note that this RNA results are representative only of the population of these 8 zones. The assessment followed the RNA Guidelines for Afghanistan. 2. OBJECTIVES 2.1 Broad objective The main objective was to evaluate the need of emergency nutrition response in Gulan Refugee Camp, Khost Province. 2.2 Specific objective The specific objectives of this assessment were to: Broadly estimate the rate of of Global Acute Malnutrition (GAM) among children from 6 to 59 months living in Gulan Refugee camp. Estimate the morbidity among children from 6 to 59 months living in Gulan refugee camp Estimate the coverage of measles vaccination among children from 9 to 59 months living in Gulan refugee camp 3. JUSTIFICATION Due to the unavailability of necessary information, this assessment aimed to provide essential evidence on the nutritional status of children under 5 years old living in the

6 refugee camp in Gulan. It is also aimed that the findings from this assessment would allow the relevant actors to take decision where necessary. 4. METHODOLOGY 4.1. Geographic target area and population groups The target population of this assessment was families with children 0 to 59 months living in Gulan camp, in Khost province. However, the data was analyzed and the results presented only for children 6 to 59 months for the benefit of programming Survey organisation and team The assessment took place right after a larger SMART survey carried out in 3 districts in Khost. The assessment was conducted by the same team from the SMART survey who received a 7-day training on data collection and standardization test. Data collection took three days, from 21 st to 23 rd Survey design The assessment was a cross-sectional transversal study with two stages cluster sampling. The procedures of segmentation were used when necessary Sample Size As per the RNA methodology for Afghanistan, a minimum sample size of 200 children from 6-59 months was fixed to get meaningful results with acceptable precision.. The sample also needs to be reached through collecting information from a minimum of 25 clusters out of 8 zones targeted in the assessment. The number of households per cluster was adapted following the reference percentage of under-5 population for Afghanistan, which was 15.6% 2. Therefore option B from the explanatory box below was used for selecting the HH sample size for this RNA. A. When the percentage of children under 5 is below 15%, 25 clusters of 12 households have to be selected B. When the percentage of children under 5 is above 15%, 25 clusters of 10 households have to be selected (RNA for Afghanistan, 2014) 4.5. Cluster selection Two stage cluster sampling was used. In the first stage, clusters were randomly selected based on Probability Proportional to Size (PPS) using the ENA for SMART software 2011, updated 21 st April The selection of cluster is presented in ANNEX 4. The zone level population figures were collected from UNHCR data for camp population (May 2015). 2 Afghanistan Mortality Survey 2010

7 4.6. Selection of households The second stage of sampling was the selection of households within the selected clusters using a systematic random method as described below. On arrival at the zone: The survey team introduced themselves and the objective of the survey was explained to the zone leaders. In zone where more than one clusters were assigned, segmentation was done and selected segments were sampled The required numbers of households were selected using systematic random sampling. The sampling interval was determined by: Sampling interval = Total number of sampling units in the population Number of sampling units in the sample (12) Selection of the first household: A number between 1 and the sampling interval was randomly chosen. Selection of the following household: Number of the 1st household sampled + sampling interval and so on. Households where eligible children or entire families were absent at first attempt, were revisited. Households were not substituted. 4.7 Data collection and field work Anthropometric data The sex was recorded with codes: f = female and m=male. The age of children was written in months. The use of proper tools to determine age can be time consuming and require prior preparation (e.g. Event calendar in ANNEX 5). The teams were sensitized on the importance of the age record and one specific day was set to develop an appropriate event calendar for calculating age in the camp. Weight (in kg): Children were weighed to the nearest 0.1 kg using an Electronic Uniscale (or SECA). Children, who were able to stand, were asked to stand on the weighing scale and their weight was recorded. The double weighing method was applied 3 for those children who could not stand up. Height (in cm): Height boards were used to measure the height of children. The precision of the measurement was 0.1 cm. Children less than 87 cm were measured lying down and those equal or above 87 cm, were measured standing up. All children were checked for oedema. If a child was suspected to have nutritional oedema then both enumerators MUST confirm this. It was essential that all staff were well trained to check for edema. 3 The first measurement is the weight of the care taker and the second is the weight of the caretaker with the child. The scale can record the first measurement and automatically extract it from the second measurement, showing only the weight of the child on the screen.

8 MUAC was taken on the LEFT arm using MUAC tape. The MUAC measurement was recorded in nearest mm. Once measured, visible small mark on the left upper arm or on the fingernails of the child was made in order to avoid measuring the same child several times. All children detected as SAM whether by presence of bilateral pitting oedema and/or weight-for-height <-3 z-score and/or MUAC < 115 cm, referred to the nearest facility or agency responsible for therapeutic care for immediate treatment. Measles immunization status The mothers/caretakers (CT) of all sampled children were asked if the child was immunized against measles or not, and if there was a vaccination card. The answers to such question were then recorded as Y (Yes); VWC (Vaccination without Card); N (No); DK (Does not Know), according to the findings. Morbidity data The mothers/cts of all sampled children were asked: If the child had diarrhea within the last 15 days. Diarrhea was defined as every episode of more than 3 liquid stools per day. Recording of received answers were made as follows: Y (Yes); N (No); If the child had Acute Respiratory Infection (ARI) within the last 15 days. ARI was defined as any episode of severe, persistent cough or difficulty breathing. Recording of received answers were made as follows: Y (Yes); N (No); according to the findings. A simple tally sheet instead of a questionnaire was used (ANNEX 2) where surveyors could simply write down these information for each child. The number of the child in the household and the number of the household in the cluster were also recorded. 5. RESULTS 5.1. Data quality check The overall data quality was excellent (See ANNEX 3: Plausibility check report on anthropometric results). The sample can be considered representative as the sex ratio was classified as excellent; the overall age ratio was also excellent. The anthropometric results are qualified as reliable for emergency programming as the digit preferences were classified as good and the standard deviation (SD) for WHZ was 1.09 (below the limit of SD of 1.2). In addition, the design effect for WHZ <- 2 was 1.68, indicating the population is relatively homogeneous with regards to global acute malnutrition. The tests of kurtosis indicated a normal distribution of WHZ around the mean, and the test of skewness indicated slight excess of wasting children in the sample, most probably due to the existence of pockets of very high GAM.

9 5.2. Nutrition Status A total of 790 children, aged 0-59 months, from 292 households, were assessed for their nutrition status using anthropometric measurements. Distribution by age and sex Among the surveyed children, boys and girls were equally represented (boys/girls ratio was 1.09). The age ratio between 6-29 months and months was 0.90, above the limit of No significant differences were observed between the age groups (P value =0.443). Anthropometric Analysis Estimation of prevalence of malnutrition was done based on WHO 2006 standards. The prevalence of Global Acute Malnutrition (GAM) was 12.3% ( % CI). The precision of GAM results was within the limits of ± 5.3, as stipulated by RNA methodology for this prevalence. The prevalence of stunting was 37.1% ( % CI), and the prevalence of underweight was 26.5% ( % CI). The prevalence of GAM, based on MUAC <125 mm or presence of bilateral pitting oedema, was 22.0% ( % CI). The prevalence of SAM based on MUAC <115 mm or presence of bilateral pitting oedema was 5.6% ( % CI). The findings are summarized in Table 2. Table 2: Summary of Nutrition Indicator Results, Gulan camp, Gurbaz district, Khost, Province June 2015 (WHO Reference 2006) Indicators Results (95% CI) Results by gender (95% CI) Boys Girls WHZ-score n=737 Prevalence of Global Acute Malnutrition Weight for height< -2 z and/or oedema 12.3% ( ) 15.5 % ( ) 8.9 % ( ) Prevalence of Severe Acute Malnutrition Weight for height < -3 z and/or oedema 3.8% ( ) 4.6 % ( ) 2.9 % ( ) MUAC n=751 Prevalence of Global Acute Malnutrition MUAC <125 mm and/or oedema 22.0% ( ) 19.4 % ( ) 24.8 % ( ) Prevalence of Severe Acute Malnutrition MUAC <115 mm and/or oedema 5.6 % ( ) 4.1 % ( ) 7.2 % ( ) HAZ- scores n=693 Prevalence of Stunting Height for age <-2 z-score 37.1 % (( ) 39.9 % ( % (

10 Prevalence of Severe Stunting Height for age <-3 z-score 14.4% (( ) 17.2 % ( ) 11.4 % ( ) WAZ-scores n=744 Prevalence of Underweight Weight for age <-2 z-score 26.5% ( ) 31.2 % ( ) 21.3 % ( ) Prevalence of severe Underweight Weight for age <-3 z-score 8.3 % ( ) 10.3 % ( ) 6.2 % ( ) Prevalence of oedema was 0.0 % 5.3. Health Related Results Morbidity data was collected among children 0-59 months (two-week recall) to assess the occurrence of main diseases. Table 3: Morbidity results, Gulan Camp Khost Province June 2015 Parameters Numbers Results Watery diarrhea (n=791) % Acute Respiratory infection (n=791) % Both (n=791) ,17% The information on measles vaccination was collected only for children 9-59 months; the results are indicated in Table 4. Table 4: Health Indicators results, Gulan Camp Khost Province June 2015 Parameters Numbers Results Measles by card, children from 9 59 (n=715) % Measles both card and recall, children from 9-59 (n=715) %

11 6. CONCLUSION The GAM rates defined by WHZ<-2 Z-scores can be classified as serious according WHO 2000 threshold classification of severity of the situation 4. Moreover, the rate of MUAC <125 mm confirmed the possible existence of critical situation. These high rates of acute malnutrition are combined with the high stunting rate (above 35%) which is an additional factor suggesting decreased resilience and increased risk of mortality and morbidity. About 54.5% of the children were found to be both stunted and having low MUAC while 28.9% were found to be both stunted and wasted. A total of 18 children were presenting signs of all three indexes. The results also indicated a high occurrence of diarrhea and acute respiratory infection/cough. About 30.21% of the children had an episode of watery diarrhea and 25.92% had an episode ARI/cough, two weeks prior to the survey. Around 15.17% of the children reported of having symptoms of both ARI and diarrhea. The measles vaccination coverage was found to be extremely low in the camp. Only 28.67% of children above 9 months were immunized against measles. These rates fall far below the recommended Sphere 2011 minimum standards of 95%. This could increase a substantial risk of measles outbreak, especially in the camp where lack of access to the basic hygiene was observed. Poor WASH practices (including open defecation) were also observed in zones of the camp. The access to health services was also limited, especially with the increased influx of refugees and the limited number of facilities offering health services compared to the needs. Some of the respondents reported that they tried to seek health services in Khost city (21 km away from the camp) but a high number of respondents reported of having difficulties to access such services due to the distance and also due to lack of transportation between the camp and the city. To best of our knowledge, there was no prior nutrition survey or assessment done in the camp (at least in the past year), to which the present results could be compared to. Therefore, given the serious severity of the situation, it is very relevant to establish a regular surveillance in the camp to monitor the situation. A second round of RNA is, therefore, proposed to be carried out in February 2016 in order to closely monitor any changes in the nutritional situation of the population in the camp and also to analyze how the trends of acute malnutrition evolves in the coming months. 4 < 5% Acceptable; 5 9 % Poor ; % Serious; > 15 % Critical

12 7. RECOMMENDATIONS Immediate interventions to address both Severe and Moderate Acute malnutrition (SAM & MAM) cases in the Gulan camp are needed. An urgent measles vaccination campaign for children aged 6 months to 15 years, including the administration of Vitamin A to children aged 6 59 months. Advanced primary health services might be foreseen within the camp in order to improve access to child health care. Specific attention on diarrhea management might be foreseen too, with CHV network for example (ORS and Zinc). Improved access to primary and secondary health care have to be facilitated by UNHCR; WASH social mobilization activities might reinforce access to water and hygiene and better WASH practices of the different population groups at risk. A second round of RNA needs to be carried out in February 2016 for further monitoring of nutritional status and measles coverage to establish trend.

13 8. ANNEXES ANNEX 1: original map of Gulan Camp, Gurbaz district, Khost province, Afghanistan

14 ANNEX 2: RNA tally sheet, Gulan Refugee Camp, Khost Province June 2015 د وم م Team Number در Cluster Number ر ر (dd/mm/yyyy) Date of interview روی ر Village Name HH No دور وم Child No دوم ر ١ Sex س F/M Age month ر ت Weight وزن (kg) ورام XX.X Height (cm) د ر XXX.X Oedem a ړ وب Y/N MUAC (mm) وک ر XXX Has your child had diarrhea in the past two weeks? ا وم و رو دوه ھ#و اون ا 'ل دروده / )رY/N Has your child had ARI in the past two weeks? ا وم و رو دوه ھ#و # +*ت و) درووده / )رY/N Have your child been vaccinated measles? اوم ودریوا ن ا) Y رتری Y VWC وھژم DK ٢ ٣ ۴ ۵ ۶ Case definitions : +*ت دواداره 4 و) (( breathing Acute Respiratory Infection is any episode with severe, persistent cough or difficulty # دری د درو 6 و زت اون ط واد ( day Diarrhea is as every episode of more than 3 liquid stools per

15 ANNEX 3: Plausibility Check data on anthropometric data CRITERIA SCORE Interpretation Missing/ flagged data 0 Excellent Overall sex ratio 0 Excellent Overall age distribution 0 Excellent Digit pref. score Weight 0 Excellent Digit pref. score Height 2 Good Digit pref. score MUAC 2 Good Standard deviation WHZ 0 Excellent Skewness WHZ 0 Excellent Kurtosis WHZ 0 Excellent Poisson distribution WHZ 1 Good Overall score WHZ 5 Excellent ANNEX 4: Cluster selection table for Gulan Camp. Zone Geographical unit Population size Cluster A NW part inside the camp boundary area including the buffer zone ,2 B SW part inside the camp boundary area including the buffer zone ,4 C Middle part of the camp boundary area ,6,7 D SE part Inside the camp boundary area ,RC,9,10

16 E1 NW-part outside the camp boundary area ,12,13,14,15,RC E2 NE part outside the camp boundary area ,RC,17 F1 SW part outside the camp boundary area ,19,20,21,22,23 F2 SE part outside the camp boundary area including the buffer zone ,25 *Segmentation will be applied for each zone to define the different clusters. ANNEX 5: Local Event Calendar د ی ھی 1393 ھی 1392 ھی 1391 ھی د روز ورځ د روز ورځ د روز ورځ د روز ورځ د روز ورځ د د و د د و د د و د د و د د و ددرعوو 51 ددرعوو 39 ددرعوو 27 ددرعوو 15 د درعوو!"!"!"!"!" 3 دو د '& د %ړ#وو دود '& د %ړ#وو دود '& د %ړ#وو دود '& د %ړ#وو دود '& د %ړ#وو د (ھ# د ) ورځ د (ھ# د ) ورځ د (ھ# د ) ورځ د (ھ# د ) ورځ د (ھ# د ) ورځ زا ر د+ دراو 14 د+ دراو 26 د+ دراو 38 د+ دراو 50 د+ دراو د, و # د, و # د, و # د, و # د, و # 2 ډ ای ډ ای ډ ای ډ ای ډ ای د %. د د د %. د د د %. د د د %. د د د %. د د ډ#ی 49 ډ#ی 37 ډ#ی 25 ډ#ی 13 ډ#ی 0./ ورځ 0./ ورځ 0./ ورځ 0./ ورځ 0./ ورځ 1 طن دروژي 48 دروژي 36 دروژي 24 دروژي 12 دروژي د 3' /" د 3' /" د 3' /" د 3' /" د 3' /"

17 ان ا ا 3 + ا 3 + ا 3 + ا 3 + ا و د (&" "&) و د 45 ورځ "&) و د 45 ورځ "&) و د 45 ورځ "&) و د 45 ورځ ورځ ددروو ددروو ددروو ددروو ددروو دود 7!وو دود 7!وو دود 7!وو دود 7!وو دود 7!وو د %. د 3 و د %. د 3 و د %. د 3 و د %. د 3 و د %. د 3 و 45 د: د 9 ګو 33 د: د 9 ګو 21 د: د 9 ګو 9 د: د 9 ګو د: د 9 ګو د 5 ارو و د>ان د 5 ارو و د>ان د 5 ارو و د>ان د 5 ارو و د>ان د 5 ارو و د>ان "ری "ری "ری "ری "ری ب 56 4= 4=د او 44 د=4 او= = 4=د او 20 4= 4=د او 8 4= 4=د او د ژ?ره د 9 ری و د C7 د 9 #و و (A) د D ي و د او) د #E وھ و ز#ت )دو وی دواوری د 3 وعو او #E 3 وع Gی در '3 و HI ورځ د د ر Jو د ژ?ره د 9 ری و د C7 د 9 #و و (A) د D ي و د او) د #E وھ و دژ?رهد 9 ریو د C7 د 9 #وو (A) د D يو د او) د #E وھ و د ژ?ره د 9 ری و د C7 د 9 #و و (A) د D ي و د او) د #E وھ و د ژ?ره د 9 ری و د C7 د 9 #و و (A) د D ي و د او) د #E وھ و س ز#ت )دو وی دواوری د 3 وعو او #E 3 وع Gی در 3' و HI ورځ د در J و ز#ت )دو وی دواوری د 3 وعو او #E 3 وع Gی در 3' و HI ورځ د در J و ز#ت )دو وی دواوری د 3 وعو او #E 3 وع Gی در 3' و HI ورځ د در J و ز#ت )دو وی دواوری د 3 وعو او #E 3 وع Gی در 3' و HI ورځ د در J و د %. د ژره و د %. د ژره و د %. د ژره و د %. د ژره و د %. د ژره و د رو" د را 9 ګ ورځ و+ # "? 3 ه K K د رو" د را 9 ګ ورځ و+ # "? 3 ه K K د رو" د را 9 ګ ورځ و+ # "? 3 ه K K درو"درا 9 ګورځ و+ # "? 3 ه K K د رو" د را 9 ګ ورځ و+ # "? 3 ه K K ده ی ت 54 &دو # د Lو? د 42 &دو # د Lو? د 30 &دو # د Lو? د 18 &دو # د Lو? د 6 &دو # د Lو? د واورو واورو واورو واورو واورو درو"دو 9 درو"دو 9 درو"دو 9 )دوری درو"دو 9 )دوری درو"دو 9 )دوری )دوری )دوری ( او!" E# K ( او!" E# K ( او!" E# 3 وع K ( او!" E# K ( او!" E# K 3 وع Gی 3 وع Gی Gی 3 وع Gی 3 وع Gی د #! د.وو 28 د #! د.وو 16 د #! د.وو 4 د #! د.وو د #! د.وو

18 دL5 ۍ و دL5 ۍ و دL5 ۍ و دL5 ۍ و دL5 ۍ و د %3 د را 9 ګ و د %3 د را 9 ګ و د %3 د را 9 ګ و د %3 د را 9 ګ و د %3 د را 9 ګ و