MEDECINS SANS FRONTIERES - Belgium

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1 ETHIOPIA COORDINATION MEDECINS SANS FRONTIERES - Belgium Tel / , , Fax :+251.1/ P.O.Box Addis Ababa -ETHIOPIA e - mail: msfbaa@telecom.net.et NUTRITIONAL SURVEY DENAN, OGADEN, ETHIOPIA OCTOBER 17-20, 2000 MSF- BELGIUM October 2000 MSF-Belgium Pascale Delchevalerie Jo Robaye Michel Van Herp

2 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 1.6 Livestock 1.7 Water situation 2) OBJECTIVES 3) METHODOLOGY 4) RESULTS 3.1 Sampling method 3.2 Sample size 3.3 Target population 3.4 Indicators collected 3.5 Teams 3.6 Implementation 4.1 Demographic distribution 4.2 Distribution of the sample by sex and age 4.3 Prevalence of malnutrition In and in percentage of the median Malnutrition in function of age and sex distribution Malnutrition function of status and location Evolution of the nutritional indices from May to October Mortality 4.5 Measles coverage 4.6 TFC/SFC coverage 5) CONCLUSIONS AND RECOMMENDATIONS ANNEXES 2

3 SUMMARY A nutritional survey was conducted in the camp and the town of Denan from October 17 to October 20, 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 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* s < -2 z-scores or oed. = GAM* < -3 z-scores or oed. = SAM* [ ] [ ] Percent. Of the Median < 80% or oedema =GAM < 70% or oedema =SAM * 95% confidence intervals with calculated cluster effect * GAM= global acute malnutrition - SAM =severe acute malnutrition [ ] [ ] 1 Resident (=resident of Denan town or displaced people who arrived before end of Ramadan (=08/01/2000). Displaced (=Internal displaced person (IDP) leaving in Denan since 08/01/2000, end of Ramadan.)

4 Comparaison of anthropometrical indices on the period from May to October 2000, Denan, Ethiopia Table 1. Total population Anthropometrical Indices < -2 z-score or oed. = GAM 18/05 (n=765) 52,4 % [47,3-57,6] 08/08 (n=897) 43,7 % [38,1-49,3] 17/10 (n=914) 40,8 % [35,7-45,9] < -3 z-score or oed. = SAM 11,2 % [8,9-13,6] 4,1 % [3,0-5,2] 5,7 % [4,0-7,4] Bilateral Oedema 1,4 % [0,5-2,2] 0,1 % [0,0-0,3] 1,1 % [0,45-1,7] < 80 % or oed. = GAM 40,1 % [35,2-45,0] 33,8 % [28,8-38,8] 31,3 % [26,8-35,8] < 70 % or oed. = SAM 5,2 % [3,5-6,9] 2,6 % [1,7-3,4] 3,2 % [2,0-4,3] < ,0 % [31,4-42,6] 23,1 % [18,4-27,8] 15,5 % [12,0-19,0] <110 6,9 % [5,1-8,8] 2,0 % [0,9-3,2] 1,1 % [0,4-1,8] * 95% confidence intervals with calculated cluster effect. 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 4

5 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% [ ]) than children > 29 months (0.5 % [ ]). 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 % ( ) against 47.1 % ( ) but there is an increase in the coverage of severely malnourished children: 63.6 % ( ) compared to 24.4 % ( ).. 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? 5

6 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 Initially the focus of their programme were emergencies, including a presence in the Gode region from , 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 15 th of Feb. This campaign covered Gode zone and ended on the This campaign achieved 39% coverage of the expected target population (quoted at 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% ( muac=5415 children) suffering from moderate malnutrition and 21% at risk ( muac=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. 6

7 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 people in the town (end of April) have increased to in August, with an under five population of children (23.5% ) and 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 persons, increasing up to 15,501 persons 2 with an under five population of 3023 children (19.5%) in August and 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. Evolution of population in Denan, Ethiopia, April May June July Aug. sept Oct Nov Dec IDP's arrivals IDP's departures Total population 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: 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 5 th of September (7,5 kg of Maize, 3,75 kg of CSB and 1,5 l of oil / person). 2 These population figures and the mapping were given by MSF CHW s (=community health worker, 1 CHW/1000 persons) working in the town and in the camp. See annexe 1 & 2a-2b 3 DPPC is the Disaster Prevention and Preparedness Committee. 7

8 DPPC distributed 12,5 kg of wheat / person on 26 th of August and 9 th 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 10 th 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. New admissions, cured and deaths in TFC, Denan, Ethiopa, May June July Aug. sept Oct Nov Dec Cured New admissions Deaths Admissions, cured, deaths, transferts, in SFC, Denan, Ethiopia, New admissions Cured Deaths Transferts TFC TFC: May June July August Sept, Oct. Nov. Dec. 8

9 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: measles cases 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. 4 MUAC= Middle Upper Arm Circumstance 5 W/H = Weight for Height 9

10 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. 10

11 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). 3.2 Sample size 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 was chosen. In the camp and the town, 30 clusters of at least 30 children were completed. 3.3 Target population Children of height between 65 and 110 cm were included in the sample for the survey. 3.4 Indicators collected The following information was collected (see annex 4): A household questionnaire enquired about the following factors: Status Resident (=resident of Denan town or displaced people who arrived before end of Ramadan (=08/01/2000). Displaced (=Internal Displaced Person (IDP) leaving in Denan since 08/01/2000, end of Ramadan. Family size Total number of people in the family Number of children under 5 years of age in the family 1. Food security Access to food distribution Date of last distribution received Per child - the following information was collected: birth date or age expressed in months sex MUAC weight with a precision of 100g height with a precision to the nearest 0.1 cm presence of pitting bilateral oedema on both feet after 3 seconds of pressure measles vaccine given by card, given by history or not at all received presence in SFC 3.5 Teams 5 teams conducted the survey in the camp and the town of Denan. Each team was compose of 4 members: 1 Expatriate MSF doctor, nurse or logistician as team leader and registrar 1 translator 2 measurers (from SFC team) The teams received a half-day training (see annex 5.) 11

12 Information on the intention to carry out the survey and the importance of the survey was disseminated to the population of Denan camp by the CHW s. 3.6 Implementation The survey was carried out from 17 th to the 20 th of October 2000 in both Denan camp and town. The population was informed by the CHW s to stay in their houses during the survey. The SFC was closed for 4 days in the morning. 4. RESULTS The analysis was done by computer using EPIINFO 6, EPINUT2.2 and EXCEL. Results for weight and height index values are based on the Reference Population Table of the NCHS/CDC/WHO Demography distribution 609 families were visited during the survey. The total population for these families was 3513 persons, with 960 children under five years of age. Description of the sample Town Camp Residents IDP's Number of families Total number of persons Number of < 5y children 453 (29 %) 507 (26 %) 289 (27,1 %) 662 (27,1 %) Mean nb of persons per family 6,2 5,4 6,6 5,5 Households without < 5y children 46 (18,4 %) 109 (30,3 %) 29 (17,9 %) 126 (28,1 %) Proportion of displaced families 88 (35,2 %) 359 (100 %) 4.2 Distribution of the sample by sex and age Out of 914 children measured 435 (47,6 %) were boys, 479 (52,4 %) were girls. Sex Ratio Boys: Girls: 0.9 : 1 Age group Nb of child. percentage months 66 7,2 % months ,2 % months ,9 % months ,2 % months ,5 % 12

13 4.3 Prevalence of malnutrition In Z- scores and in percentage of the median Table1. Anthropometrical indices in cm children (N=914), Denan, Ethiopia, October Anthropometrical Indices Number of Percentage 95% CI* children < -2 z-score or oed. = GAM ,8 % [35,7-45,9] < -2 and >= -3 z-score = MAM ,1 % [30,4-39,8] < -3 z-score or oed. = SAM 52 5,7 % [4,0-7,4] Bilateral Oedema 10 1,1 % [0,45-1,7] < 80 % or oed. = GAM ,3 % [26,8-35,8] < 80% and >= 70 % = MAM ,1 % [23,9-32,3] < 70 % or oed. = SAM 29 3,2 % [2,0-4,3] <135 and >= ,0 % [27,6-34,3] < 125 and >= ,4 % [11,1-17,8] < ,1 % [0,4-1,8] GAM = Global Acute Malnutrition MAM = Moderate acute Malnutrition SAM = Severe acute Malnutrition 13

14 4.3.2 Malnutrition in function of age and sex distribution Age Table 2. Anthropometrical indices in 6-29 months (n=251) and months (n=663) children Denan, Ethiopia, October Anthropometrical Indices 6-29 months months < -2 z-score or oed. = GAM 40,6 % 40,8 % (95 % CI) [34,4-46,8] [35,7-45,9] < -3 z-score or oed. = SAM 7,97 % 4,83 % (95 % CI) [4,75-11,2] [2,56-7,1] Bilateral Oedema 2,8 % 0,5 % (95 % CI) [0,96-4,6] [0,0-0,9] < 80 % or oed. = GAM 35,4 % 29,7 % (95 % CI) [30,3-40,6] [24,2-35,2] < 70 % or oed. = SAM 5,98 % 2,11 % (95 % CI) [3,3-8,6] [0,65-3,6] <135 and >= % 28,7 (95 % CI) [30-44,1] [24,9-32,4] < 125 and >= ,1 % 10,5 % (95 % CI) [18,3-31,9] [7,5-13,3] <110 2,8 % 0,5 % (95 % CI) [0,6-5,0] [0,0-0,9] * 95% confidence intervals with calculated cluster effect. For the bilateral oedema, the severe acute malnutrition in percentage of the median and the moderate malnutrition measured by muac, there is a statistically significant difference between the 2 age groups. For the global malnutrition there is no statistically significant difference between the 2 age groups Sex For the distribution in function of the gender we don t notice a significant difference between boys and girls as during the previous survey. 14

15 4.3.3 Malnutrition in function of status and location Table 3. Anthropometrical indices in cm children (N=914), Denan, Ethiopia, October 2000, in function of status. Anthropometrical Indices Resident IDP < -2 z-score or oed. = GAM 32,6 % 44,5 % (95 % CI) [24,3-41] [39,5-49,4] < -2 and >= -3 z-score = MAM 27,3 % 38,6 % (95 % CI) [20,5-34,1] [33,6-43,7] < -3 z-score or oed. = SAM 5,3 % 5,9 % (95 % CI) [2,4-8,2] [3,9-7,9] Bilateral Oedema 1,06 % 1,1 % (95 % CI) [0,06-2,07] [0,3-1,9] < 80 % or oed. = GAM 24,5 % 34,3 % (95 % CI) [16,6-32,3] [ 29,7-39] < 80% and >= 70 % = MAM 22,7 % 30,5 % (95 % CI) [15,2-30,2] [26,1-35,0] < 70 % or oed. = SAM 1,8 % 3,8 % (95 % CI) [0,3-3,3] [2,3-5,3] <135 and >= ,9 % 33,2 % (95 % CI) [19,5-32,2] [29,7-36,7] < 125 and >= 110 6,7 % 17,9 % (95 % CI) [3,7-9,8] [14,3-21,4] <110 0% 1,6 % (95 % CI) [0,6-2,6] * 95% confidence intervals with calculated cluster effect. In contrary to what was found during the survey in August, now there is no statistically significant difference in global and severe malnutrition according to the status, except for the muac that shows higher rates in IDP s. 15

16 Table 4. Anthropometrical indices in cm children (N=914), Denan, Ethiopia, October 2000, in function of location. Anthropometrical Indices Town Camp < -2 z-score or oed. = GAM 35,5 % 45,5 % (95 % CI) [27,8-43,3] [39,4-51,5] < -2 and >= -3 z-score = MAM 29,9 % 39,7 % (95 % CI) [23,9-35,8] [33,3-46,1] < -3 z-score or oed. = SAM 5,6 % 5,8 % (95 % CI) [2,8-8,4] [3,6-7,9] Bilateral Oedema 0,94 % 1,2 % (95 % CI) [0,13-1,7] [0,2-2,2] < 80 % or oed. = GAM 28,5 % 33,7 % (95 % CI) [21,1-35,9] [ 28,4-39,1] < 80% and >= 70 % = MAM 25,7 % 30,2 % (95 % CI) [19,3-32,1] [24,8-35,7] < 70 % or oed. = SAM 2,8 % 3,5 % (95 % CI) [0,9-4,7] [2,0-5,0] <135 and >= ,0 % 33,5 % (95 % CI) [22,8-33,2] [29,4-37,7] < 125 and >= 110 7,5 % 20,6 % (95 % CI) [4,7 10,3] [16,9-24,3] <110 0,5 % 1,6 % (95 % CI) [0,0 1,1] [0,5-2,8] * 95% confidence intervals with calculated cluster effect. In contrary to what was found during the survey in August, now there is no statistically significant difference in global and severe malnutrition according to the location, except for moderate malnutrition measured with the muac that shows higher rates in IDP s Evolution of the nutritional indices from May to October Table 5. Total population Anthropometrical Indices 18/05 (n=765) 08/08 (n=897) 17/10 (n=914) < -2 z-score or oed. = GAM 52,4 % [47,3-57,6] 43,7 % [38,1-49,3] 40,8 % [35,7-45,9] < -3 z-score or oed. = SAM 11,2 % [8,9-13,6] 4,1 % [3,0-5,2] 5,7 % [4,0-7,4] Bilateral Oedema 1,4 % [0,5-2,2] 0,1 % [0,0-0,3] 1,1 % [0,45-1,7] < 80 % or oed. = GAM 40,1 % [35,2-45,0] 33,8 % [28,8-38,8] 31,3 % [26,8-35,8] < 70 % or oed. = SAM 5,2 % [3,5-6,9] 2,6 % [1,7-3,4] 3,2 % [2,0-4,3] < ,0 % [31,4-42,6] 23,1 % [18,4-27,8] 15,5 % [12,0-19,0] <110 6,9 % [5,1-8,8] 2,0 % [0,9-3,2] 1,1 % [0,4-1,8] * 95% confidence intervals with calculated cluster effect. 16

17 Table 6. Residents Anthropometrical Indices 18/05 (n=) 08/08 (n=) 17/10 (n=282) < -2 z-score or oed. = GAM 49,1 % [41,2-57,0] 28,9 % [21,1-36,6] 32,6 % [24,3-41] < -3 z-score or oed. = SAM 11,0 % [7,4 14,6] 3,1 % [1,2-5,0] 5,3 % [2,4-8,2] Bilateral Oedema 1,06 % [0,06-2,07] < 80 % or oed. = GAM 37,4 % [30,1-44,7] 21,6 % [15,2-28,1] 24,5 % [16,6-32,3] < 70 % or oed. = SAM 7,3 % [4,3-10,3] 2,1 % [0,8-3,3] 1,8 % [0,3-3,3] < 125 6,7 % [3,7 9,8] <110 0% * 95% confidence intervals with calculated cluster effect. Table 7. IDP's Anthropometrical Indices 18/05 (n=) 08/08 (n=) 17/10 (n=632) < -2 z-score or oed. = GAM 55,1 % [48,8-61,4] 50,8 % [45,3-56,4] 44,5 % [39,5-49,4] < -3 z-score or oed. = SAM 12,4 % [9,0-15,8] 4,6 % [2,9-6,3] 5,9 % [3,9-7,9] Bilateral Oedema 1,1 % [0,3-1,9] < 80 % or oed. = GAM 42,5 % [36,2-48,8] 39,6 % [34,3-44,9] 34,3 % [ 29,7-39] < 70 % or oed. = SAM 5,3 % [2,9-7,7] 2,8 % [1,6-4,0] 3,8 % [2,3-5,3] < ,5 % [15,8-23,1] <110 1,6 % [0,6-2,6] * 95% confidence intervals with calculated cluster effect. Table 8. Town Anthropometrical Indices 18/05 (n=) 08/08 (n=) 17/10 (n=428) < -2 z-score or oed. = GAM 46,5 % [39,9-53,2] 33,0 % [27,0-39,0] 35,5 % [27,8 43,3] < -3 z-score or oed. = SAM 11,1 % [7,8-14,4] 3,1 % [1,5-4,7] 5,6 % [2,8-8,4] Bilateral Oedema 0,94 % [0,13-1,7] < 80 % or oed. = GAM 35,4 %[29,7-41,1] 25,1 % [19,7-30,5] 28,5 % [21,1 35,9] < 70 % or oed. = SAM 6,0 % [3,5-8,5] 2,0 % [0,9-3,2] 2,8 % [0,9-4,7] < 125 7,9 % [5,0 10,8] <110 0,5 % [0,0 1,1] * 95% confidence intervals with calculated cluster effect. 17

18 Table 9. Camp Anthropometrical Indices 18/05 (n=765) 08/08 (n=897) 17/10 (n=486) < -2 z-score or oed. = GAM 57,9 % [51,5-64,7] 52,0 % [45,7-58,3] 45,5 % [39,4-51,5] < -3 z-score or oed. = SAM 12,5 % [8,8-16,2] 4,9 % [3,0-6,9] 5,8 % [3,6-7,9] Bilateral Oedema 1,2 % [0,2 2,2] < 80 % or oed. = GAM 44,7 %[37,6-51,7] 40,5 % [34,5-46,5] 33,7 % [28,4-39,1] < 70 % or oed. = SAM 6,0 % [3,2-8,8] 3,0 % [1,6-4,3] 3,5 % [2,0-5,0] < ,2 % [18,6 25,9] <110 1,6 % [0,5-2,8] * 95% confidence intervals with calculated cluster effect. Table months Anthropometrical Indices 18/05 (n=227) 08/08 (n=229) 17/10 (n=251) < -2 z-score or oed. = GAM 52,4 % [45,7-59,1] 42,4 % [36,2-48,5] 40,6 % [34,4-46,8] < -3 z-score or oed. = SAM 17,2 % [12,4-22,0] 3,1 % [0,7-5,4] 7,97 % [4,75-11,2] Bilateral Oedema 2,8 % [0,96-4,6] < 80 % or oed. = GAM 45,8 % [39,0-52,7] 41,5 % [34,3-48,6] 35,4 % [30,3-40,6] < 70 % or oed. = SAM 12,3 % [7,8-16,9] 3,9 % [1,5-6,4] 5,98 % [3,3-8,6] < ,5 % [12,0-19,0] <110 2,8 % [0,6-5,0] * 95% confidence intervals with calculated cluster effect. Table months Anthropometrical Indices < -2 z-score or oed. = GAM 18/05 (n=538) 53,2 % [47,4-58,9] 08/08 (n=668) 44,2 % [37,8-50,5] 17/10 (n=663) 40,8 % [35,7-45,9] < -3 z-score or oed. = SAM 9,7 % [7,3-12,1] 4,5 % [3,1-5,9] 4,83 % [2,56-7,1] Bilateral Oedema 0,5 % [0,04-0,9] < 80 % or oed. = GAM 38,5 % [33,2-43,7] 31,1 % [25,9-36,4] 29,7 % [24,2-35,2] < 70 % or oed. = SAM 3,3 % [1,9-4,8] 2,1 % [1,1-3,1] 2,11 % [0,65-3,6] < ,5 % [12,0-19,0] <110 0,5 % [0,0-0,9] Discussion 1. Global malnutrition rate remains very high. 1 out of 3 children is malnourished. The global malnutrition rate did not decrease significantly in neither in percentage of the median, but it decreased significantly in MUAC. 2. 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. 18

19 This doesn t influence our screening because we control the W/H for all children with muac < 135mm and this represent 39.7 % of the children. 3. The severe malnutrition decreased significantly in, percentage of the median, and MUAC from May to August but not in October. 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% [ ]) than children > 29 months (0.5 % [ ]). 4. In May and October, we don t notice a significant difference for the distribution in function of the status and the location contrary to August, where the relative risk to be malnourished was 1.8 [ ] (in z-score or in % of M) times higher for the displaced than for the residents and 1.6 [ ] (in z-score or in % of M) times higher for the camp than for the town. 5. For the global malnutrition, there was a statistically significant decrease in August for the residents (in z-score or in % of M) and the town (in % of M) but not for the displaced and the camp. In October, there is no decrease for any categories. 6. For the severe malnutrition a statistically significant decrease was found in August for residents, IDP s and the town in s as in percentage of the median, for the camp the decrease was only statistically significant in s. There is no statistically significant difference from August to October for any categories. 7. For the distribution of the malnutrition in function of the age group, in May, the relative risk to be severely malnourished was 1.8 ( ) (in z-score) to 3.7 ( ) (%M) time higher for 6-29 months than for months; in August, there was no statistically significant difference between the 2 age groups and in October, we found again a higher rate of oedema and SAM (in %M) for the 6-29 months. 8. From may to August, there was a statistically significant decrease for the severe malnutrition for all age groups, both in terms of s but in percentage of the median, the decrease for the SAM was only significant for the 6-29 months age group. 9. For the global malnutrition there is no statistically significant decrease either in August and October for all age groups, both in terms of s as well as in percentage of the median. 4.4 Mortality A weekly mortality surveillance was put in place with the use of community health workers, each one of them is responsible for a specific area in either camp or town, they make house to house visits, collect mortality information, screen with MUAC the children and refer all at risk to the screening point in the SFC and refer all suspected measles and bloody diarrhoea cases. Mortality data collected since 7 August 2000 until 15 October 2000, a period of 10 weeks so 70 days. The total number of death counted: 25 The average population over these 10 weeks: 27,909 So 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 19

20 The number of death for the < 5: 12 The average < 5 population over these 10 weeks: 6,279 So the < 5 mortality rate over the period 6 August 15 October: (12:6279) x (10000:70) = 0.27/10000/day So both CMR and <5 MR have decreased enormously since the retrospective mortality survey done in May and still decreased from the period June - August. Both mortality rates are in the limits of normal rates: CMR 0.5/10.000/day is considered as normal in developing countries and <5MR 1/10.000/day is normal. 4.5 Measles coverage All ages >9 months confirmed by vaccine card: 15.8 % ( ) 15.7% ( ) confirmed by history: 79.5 % ( ) 79.8% ( ) Not vaccinated: 4.7 % ( ) 4.4% ( ) Total vaccinated with or without card: 95.3% ( ) 95.5% ( ) The measles coverage surveyed by both card and history is 95.5 % ( ) for children >= 9 months old. We don t notice statistically significant difference at the measles coverage in function of status, location, age group or gender as during the other survey but a lot of mothers lost their card since August. 4.6 TFC/SFC Coverage We compared the number of children who were attending the TFC /SFC with the number of children achieving the admission criteria. Table 12 Coverage of MSF feeding programs (comparing attendance with children with admission criteria during the survey), Denan, Ethiopia, October Coverage Therapeutic feeding centre (=TFC) 63.6 % [ ] Supplementary feeding centre. (= SFC) 53.1 % [ ] TFC+SFC 54.3 % [ ] We also compared the number of expected admissions extrapolate from the number of children reaching the admission criteria. For TFC we can expect between children and for the SFC between children. For the coverage of the TFC there is a statistically significant increase since August but the coverage of the SFC and the total coverage are same than in August. 5. CONCLUSIONS AND RECOMMENDATIONS 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. 20

21 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% [ ]) than children > 29 months (0.5 % [ ]). 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 % ( ) against 47.1 % ( ) but there is an increase in the coverage of severely malnourished children: 63.6 % ( ) compared to 24.4 % ( ). 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? Pascale Delchevalerie MSF- Belgium November