South Sudan NUTRITIONAL ANTHROPOMETRIC SURVEY CHILDREN UNDER FIVE YEARS OLD FINAL REPORT KUMBUR PAYAM, RASHAD COUNTY, NUBA MOUNTAINS

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1 South Sudan NUTRITIONAL ANTHROPOMETRIC SURVEY CHILDREN UNDER FIVE YEARS OLD FINAL REPORT KUMBUR PAYAM, RASHAD COUNTY, NUBA MOUNTAINS November 9 th to 27 th, 2004 Onesmus Muinde - Nutritionist Joy Kiruntimi - Nutritionist Deborah Morris - Nutrition Survey Program Officer Santino Gatkuoth - Nutrition Survey Program Officer (ACF-USA)

2 TABLE OF CONTENTS ACKNOWLEDGEMENTS... 3 SUMMARY... 4 INTRODUCTION... 8 METHODOLOGY Type of survey and sample size Sampling methodology Data Collection Indicators, guidelines and formulas used Acute Malnutrition Mortality Field work Data analysis RESULTS Distribution by age and sex Anthropometric analysis Acute malnutrition Risk of mortality: children s MUAC Measles vaccination coverage Household status Mortality rate Causes of mortality DISCUSSION RECOMMENDATIONS APPENDIXES Appendix 1. Villages where the survey was conducted, Kumbur Payam, November Appendix 2. Anthropometric survey questionnaire Appendix 3. Calendar of events Kumbur Payam November Appendix 4. Mortality survey questionnaire Appendix 5. Anthropometric Survey questionnaire for children less than six months

3 ACKNOWLEDGEMENTS ACF-USA acknowledges the invaluable support and assistance of the following: Sudan Relief and Rehabilitation Commission (SRRC) in Rashad County The local survey teams for working tirelessly. Local authorities, community leaders and mothers /caretakers for their co-operation. Save the Children USA (SC-USA) for their generous support during the survey through the provision of accommodation and transport. 3

4 SUMMARY Kumbur Payam is located in Rashad County, in Nuba Mountains region. The Nuba Mountains region is composed of four counties namely Rashad, Kadugli, Dilling and Lagawa. Rashad County itself is composed of four payams: Ildo, Kumbur, Iral and Kawalib. The inhabitants of Nuba Mountains are the Nuba people, gathering a total of 99 different tribes. In Kumbur Payam inhabitants are from a single tribe known as Tira. The payam is composed of 16 main villages. The population is mainly agro-pastoralist with major emphasis in crop cultivation. The area is generally hilly, made of red soil, and seasonal streams cut across most of the payam. The location is controlled by the Sudanese Peoples Liberation Army/Movement (SPLA/M). No insecurity incident has been reported since the ceasefire in January According to the Sudan Relief and Rehabilitation Commission (SRRC), the population in Kumbur Payam is estimated at 67,571 persons. Several organizations intervene in the location: Save the Children-US (SC-USA) in health activities CONCERN World Wide in food security and community development activities KOINONIA, NCA, Diocese of El Obeid (DOE) and UNICEF in education, water and health. 1. JUSTIFICATION OF THE SURVEY In October 2004, SC-USA reported cases of malnutrition in their health centers of Rashad: one third of children who visited their health facilities were diagnosed as malnourished. Medair North, present in the neighboring Dilling County, also reported cases of malnutrition in their health structures an average of one to two cases per week. Those children were coming mainly from Lagawa County. SC-USA, concerned with the reported situation but not having nutritional skills, appealed to ACF-USA to carry out a nutritional survey in order to get an accurate assessment of the nutritional status of the population. No baseline nutritional data for Nuba Mountains previously existed. Considering the available and worrying information, ACF-USA decided to carry out a nutritional survey in Rashad County. 2. OBJECTIVES To evaluate the nutritional status of the children aged 6 to 59 months To estimate the measles immunization coverage of the children aged 9 to 59 months To identify groups at higher risk of malnutrition: age group and sex. To estimate the crude mortality rate through a retrospective survey To assess the extent of household movements. 3. METHODOLOGY Based on SRRC population figures, a two-stage cluster sampling survey methodology was planned. However, because most of the villages were located at more than three hours walk and therefore not accessible, an exhaustive survey covering all the villages falling within a radius of three hours walk from Kumorassan (SC-USA compound) was carried out. Two villages situated beyond three hours walk were also included as SC-USA provided transport. A total of 870 children were measured during the nutritional survey. 4

5 A retrospective mortality survey (over the past 3 months) was also conducted at the same time as the anthropometric survey. 4. RESULTS Table 1. Anthropometric, mortality and measles coverage results AGE GROUP INDICATOR RESULTS months (n = 870) 6-29 months (n = 400) < 6 months (n = 55) Z-score % Median Z-score % Median Z-score % Median Global Acute Malnutrition: W/H < -2 Z-score and/or oedema 9.4% Severe Acute Malnutrition: W/H < -3 Z-score and/or oedema 1.5% Global Acute Malnutrition: W/H < 80% and /or oedema 5.5% Severe Acute Malnutrition: W/H < 70% and /or oedema 1.1% Global Acute Malnutrition: W/H < -2 Z-score and/or oedema 13.3% Severe Acute Malnutrition: W/H < -3 Z-score and/or oedema 1.5% Global Acute Malnutrition: W/H < 80% and/or oedema 8.8% Severe Acute Malnutrition: W/H < 70% and/or oedema 1.0% Severe Acute Malnutrition: W/H < -3 Z-score and/or oedema 0.0% Moderate Acute Malnutrition: W/H -3 Z-score and < -2 Z-score 0.0% Severe Acute Malnutrition: W/H < 70% and/or oedema 0.0% Moderate Acute Malnutrition: W/H 70% and < 80% 1.8% Crude retrospective mortality (last three months) Percentage of deaths among the under five years Measles immunization coverage By card According to caretaker 2 Not vaccinated 0.95/10,000/day 77.8% 24.5% 33.7% 41.8% 1 Results given without confidence intervals as an exhaustive survey methodology was used for data collection. 2 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker 5

6 4. DISCUSSION The analysis of the anthropometric data of children aged 6 to 59 months shows the following rates of acute malnutrition expressed in Z-scores: Rate of Global Acute Malnutrition (GAM): 9.4% Rate of Severe Acute Malnutrition (SAM): 1.5% 9.4% of the children measured had a low Weight for Height index and 1.5% were severely malnourished, 0.7% presenting oedema. The rates of GAM and SAM are below the emergency threshold of 15% and 4% respectively, as defined by WHO 3, therefore the nutritional situation in Kumbur Payam is considered as not worrying. The analysis of the MUAC measurements for children aged one to five years or having a height greater or equal to 75 cm revealed that 1.2 % of the measured children were moderately malnourished, 16.6% were at risk of malnutrition and 82.2% had a good nutritional status. The analysis of the rates of malnutrition for the age groups 6-29 months and months revealed a significant difference in the nutritional status (p <0.05). The 6-29 months children are 2.15 times (confidence interval = , at 95%) more at risk of malnutrition than the months old children. The crude mortality rate, 0.95/10,000/day, is below the alert level of 1/10,000/day 4. More than three quarters of the individuals who died during the three months preceding the survey were children under five years old (21 out of 27 cases). The main presumed causes of death 5 for this age group were malaria (eight cases) and watery diarrhea (four cases); for five cases, the cause of death was unknown 6. Among the above five years old, the main presumed causes of death were bloody diarrhea and yellow fever (two cases each). The nutritional situation in Kumbur Payam is not alarming and the reported cases of malnutrition might be explained by the following factors: - Poor sanitation situation: most of the population has access to boreholes and open wells, but water from the wells is usually not treated. Regarding sanitation, most of the people defecate in the open, which increases the risk of contamination of water sources. This poor environmental sanitation, as well as the poor personal hygiene, contributes to the high incidence of malaria and diarrhea, particularly among young children. It can be concluded that the poor sanitation situation in the location has probably contributed to the high prevalence of water borne-diseases, which indirectly impacted the nutritional status of the most vulnerable. - High disease prevalence: SC-USA offers health services in Kumbur Payam through one Primary Health Care Center (PHCC) and seven Primary Health Care Units (PHCUs). Although they provide routine vaccination and organize measles campaign in all the health facilities, explaining the fairly good measles vaccination coverage of 58.2%, diarrhea and malaria are highly prevalent in the area. - Feeding practices: the nutritional status of the children aged 6 to 29 months is of concern and could be linked to the weaning practices. Indeed, a focus group discussion held with the women revealed inadequate feeding practices: as in many parts of southern Sudan, the colostrums 7 is 3 WHO classification of wasting prevalence in populations, Health and nutrition information systems among refugees and displaced persons, Workshop report on refugee s nutrition, ACC / SCN, Nov As mentioned by the community. 6 Unknown: the family members could not explain what caused the death of the person and no medical examination was done to determine the cause of death. 7 The colostrums is the breast milk that mothers produce just after birth. It is particularly rich and considered as a key element of infantile disease prevention. 6

7 considered as bad milk and is therefore not given to infants; and most mothers introduce other food than breast milk few days after birth, while exclusive breastfeeding would be recommended; the early introduction of solid food compromises the digestive system of the children. These practices can contribute to the inadequate absorption of food and to the deterioration of the nutritional status of the infants. 5. RECOMMENDATIONS Taking into consideration the analysis of the situation, ACF-USA recommends the following: SC-USA to increase the drugs supplies in their health centers with the support of UNICEF or other donors. ACF-USA to discuss a possible collaboration with SC-USA in increasing the capacity of the existing health facility to treat acutely malnourished individuals. CONCERN World Wide to continue implementing food security program in the region. SC-USA to initiate health education and hygiene promotion, nutritional education, and mother and child care at the health centers and community levels 7

8 INTRODUCTION Kumbur Payam is located in Rashad County, in Nuba Mountains region. The Nuba Mountains region is composed of four counties namely Rashad, Kadugli, Dilling and Lagawa. Rashad County itself is composed of four payams: Ildo, Kumbur, Iral and Kawalib. The inhabitants of Nuba Mountains are the Nuba people, gathering a total of 99 different tribes. In Kumbur Payam inhabitants are from a single tribe known as Tira. The payam is composed of 16 main villages. The population is mainly agro-pastoralist with major emphasis in crop cultivation. The area is generally hilly, made of red soil, and seasonal streams cut across most of the payam. The location is controlled by the Sudanese Peoples Liberation Army/Movement (SPLA/M). No insecurity incident has been reported since the ceasefire in January According to the Sudan Relief and Rehabilitation Commission (SRRC), the population in Kumbur Payam is estimated at 67,571 persons. FOOD SECURITY The community mainly relies on crops cultivation, maize, sorghum, beans, cowpeas, simsim, groundnuts and pumpkins being grown to large extents. All households have a small farm in the surroundings of the house and another and larger one in the low lands, usually two hours walk away. The community said that the harvest this year was good, as a result of favorable rains, the availability of adequate farm inputs, the training of farmers and the introduction of new production technique like ox-ploughing. CONCERN Worldwide played a major role in the improvement of the food security situation. At the time of the survey, people had already harvested maize and beans, and were harvesting sorghum, simsim and groundnuts. The community keeps livestock, including cattle, sheep, goats, pigs and chicken. The Food and Agriculture Organization (FAO), in collaboration with the Nuba Relief Rehabilitation and Development Organization (NRRDO) offers veterinary services in the community, including vaccination, as well as provision of animal health kits to the herders through a cost sharing system. Because of the lack of rivers in Kumbur Payam, fish is hardly available and is usually imported from other counties of the Nuba Mountains region. Though the region is now experiencing a fairly goof food security situation, the World Food Program (WFP) used to distribute food to the most vulnerable people. The last distribution took place in September 2004 when cereals, CSB, and oil at 75% of the full ration were distributed, targeting 15,288 people 8, as displayed in the table below: 8 In total, the community received MT of cereals, MT of pulses, and 3.40MT of oil, CSB of MT and 0.1 MT of salt. 8

9 Table 2. WFP food ration distributed in Rashad, September Food Items Amount as received 100% ration 75% ration (g/day) 9 (g/day) Daily needs Cereals (sorghum) CSB Pulses (lentils) Salt Oil Calories (kcal)* ,200 % of protein in kcal % fat in kcal *: Calorific value calculated using NUT CALC (Epi surv) developed by ACF in collaboration with EPICENTRE. Considering the above mentioned information, the food security in the area is satisfying. HEALTH In 2001, just after the ceasefire agreement between the Government of Sudan and the SPLA, SC-USA began implementing health services in Kumbur Payam. As of today, SC-USA supports one PHCC and seven PHCUs. The geographical dispersion of the health centers ensures a good accessibility of the population to health services. Due to the high prevalence of diseases in the location, SC-USA decided to expand its services to curative care, in addition to preventive care. Therefore SC-USA offers the following: - Routine EPI vaccination and EPI campaigns, - Maternal health care, - Growth monitoring using Weight for Age index: it is implemented in all health centers. The analysis of the individual Weight for Age index of the children admitted in the centers showed nutritional problems, explaining the decision of SC-USA to appeal to ACF-USA to conduct a nutrition survey, - Preventive services, including health education that SC-USA intends to expand next year, - Curative treatment, including a inpatient ward at the PHCC where patients who require close examination are admitted - And an integrated HIV program: because of the anticipated influx of returnees and the already high prevalence of Sexual Transmitted Infections (STIs) in the region, associated with polygamy, SC- USA decided to offer Voluntary Counseling Treatment (VCT) in their PHCC and to do HIV/AIDS awareness within the community. The most common diseases reported in the health facilities include malaria, diarrhea, respiratory infections, malnutrition and STIs. SC-USA reported that because of donors constraints they could not get sufficient amounts of drugs, affecting the effectiveness of the medical services in the payam. SC-US refers patients with medical complications to the hospital of Ildo Payam, operated by Germany Emergency Doctor (GED) and located very far away. DOE is currently envisaging the construction of a hospital in Kumbur Payam, which would ease the referral and treatment of severe medical cases. 9 According to the quantities distributed by WFP 9

10 WATER AND SANITATION SC-USA, DOE and UNICEF Water Environment and Sanitation (WES) drilled boreholes in the area while CONCERN Worldwide rehabilitated hand dug wells and dams. Currently twelve boreholes are evenly distributed in the whole payam. According to local leaders, only one village, Kalkada, was reported to have insufficient supply of water. While water is available in quantity, the hygiene and sanitation situation in the area is poor. Most people defecate in the open, which increases the risk of contamination of water sources, particularly during the wet season. SC-USA has embarked on latrine education program within their health facilities and they hope that the community will replicate construction of latrines at home. EDUCATION Several organizations are running education programs in the region: KOINONIA, UNICEF, NRRDO, NCA and DOE. KOINONIA has a teachers training college and also supports a primary school. DOE also runs a primary school while NRRDO, UNICEF and NCA support community schools. AGENCIES INTERVENING IN THE AREA The agencies intervening in the area are mentioned in the table below: Table 3. Organizations intervening in Kumbur Payam and their activities Agency Activities SC-USA Health: PHCC and PHCUs Routine and EPI campaign Health education within the health units CONCERN Worldwide Food security monitoring. Distribution of seeds and tools Capacity building (Farmers and merchants). Integrated water management (rehabilitation of dams, hand dug wells and construction of terraces) KOINONIA Primary Education Teacher training. Diocese of El Obeid (DOE) Primary Education Drilling of boreholes Construction of a referral hospital. Nuba Relief Rehabilitation and Primary education Development Organization (NRRDO) Veterinary services Norwegian Church Aid (NCA) Support to community primary school UNICEF Drilling of boreholes Provision of medical kits Provision of education kits for primary school. WFP Targeted Food Aid distribution and monitoring FAO Support to CONCERN and NRRDO for agricultural activities INTERNALLY DISPLACED PERSONS (IDPS) AND RETURNEES 10

11 According to the SRRC, 4,011 returnees were recorded in Kumbur Payam between November 2003 and May 2004, and 1,024 from June to July Most of the returnees came from Khartoum, which is 12 hours drive from the location. No IDP movement was reported by the SRRC during that period. JUSTIFICATION OF THE NUTRITION SURVEY Because of the cases of malnutrition reported in their health centers as well as the similar situation observed by Medair North in the neighboring Dilling County, in October 2004 SC-USA appealed to ACF-USA to carry out a nutritional survey in order to get an accurate assessment of the nutritional status of the population. No baseline nutritional data for Nuba Mountains previously existed. Considering the available and worrying information, ACF-USA decided to carry out a nutritional survey in Rashad County. CONSTRAINTS ENCOUNTERED DURING THE IMPLEMENTATION Kumbur Payam is vast, and because the team could not use a vehicle and had to move by foot, the number of villages that they could access was limited. The sample size of the survey had to be reviewed accordingly and the team implemented an exhaustive survey in the area falling within a 3-hour walk radius from the main centre. 11

12 METHODOLOGY The survey was conducted from 9 th to 27 th November 2004 in Kumbur Payam, Rashad County, Nuba Mountains. 1. Type of survey and sample size According to the SRRC Secretary, the population figures were estimated at 67,571 persons. The number of children under five years was estimated accordingly at 13,514, i.e. 20% of the entire population. As mentioned above, an exhaustive survey was implemented, covering the villages within three hours walk from Kumorassan (SC-USA compound). In addition two villages beyond three hours walk were also covered as transport was provided by SC-USA. (See appendix 1 for the list of the villages and estimated population). A retrospective mortality survey (over the past three months) was also conducted, alongside the anthropometric exhaustive survey. 2. Sampling methodology An exhaustive survey was conducted, meaning that all the children aged 6-59 months encountered in the villages were included in the survey. A total of 870 children were measured. 3. Data Collection During the anthropometric survey, for each selected child aged 6 to 59 months, the following information was recorded (See appendix 2 for the anthropometric questionnaire): Age: recorded with the help of a local calendar of events (See appendix 3 for the calendar of events) Sex: male or female Weight: children were weighed without clothes, with a SALTER weighing scale of 25 Kg (precision of 100g). Height: children were measured on a measuring board (precision of 0.1 cm). Children less than 85 cm were measured lying down, while those greater than or equal to 85 cm were measured standing up. Mid-Upper Arm Circumference: MUAC was measured at mid-point of left upper arm for measured children (precision of 0.1 cm). Bilateral oedema: assessed by the application of normal thumb pressure for at least 3 seconds to both feet. Measles vaccination: assessed by checking for measles vaccination on EPI cards and asking caretakers. Household status: for the surveyed children, households were asked if they were permanent residents, temporarily in the area, or displaced. During the retrospective mortality survey, in all the visited households including where there were no children aged less than five years old the teams asked for the number of household members alive per age groups, the number of people present within the recall period, the number of deaths and births over the last three months and if any the presumed cause of death, and the number of persons who left or arrived in the last three months. (See appendix 4 for the mortality questionnaire). 12

13 4. Indicators, guidelines and formulas used 4.1. Acute Malnutrition Weight-for-Height Index For the children, acute malnutrition rates were estimated from the weight for height (WFH) index values combined with the presence of oedema. The WFH indices are compared with NCHS 10 references. WFH indices were expressed both in Z-scores and percentage of the median. The expression in Z-scores has true statistical meaning and allows inter-study comparison. The percentage of the median on the other hand is commonly used to identify eligible children for feeding programs. Guidelines for the results expressed in Z-scores: Severe malnutrition is defined by WFH < -3 SD and/or existing bilateral oedema on the lower limbs of the child Moderate malnutrition is defined by WFH < -2 SD and -3 SD and no oedema. Global acute malnutrition is defined by WFH < -2 SD and/or existing bilateral oedema Guidelines for the results expressed in percentage according to the median of reference: Severe malnutrition is defined by WFH < 70 % and/or existing bilateral oedema on the lower limbs Moderate malnutrition is defined by WFH < 80 % and 70 % and no oedema. Global acute malnutrition is defined by WFH <80% and/or existing bilateral oedema Children s Mid-Upper Arm Circumference (MUAC) The weight for height index is the most appropriate index to quantify wasting in a population in emergency situations where acute forms of malnutrition are the predominant pattern. However the mid-upper arm circumference (MUAC) is a useful tool for rapid screening of children at a higher risk of mortality. The MUAC is only taken for children with a height of 75 cm and more. The guidelines are as follows: MUAC < 110 mm MUAC 110 mm and <120 mm MUAC 120 mm and <125 mm MUAC 125 mm and <135 mm MUAC 135 mm severe malnutrition and high risk of mortality moderate malnutrition and moderate risk of mortality high risk of malnutrition moderate risk of malnutrition adequate nutritional status 4.2. Mortality The crude mortality rate (CMR) is determined for the entire population surveyed for a given period. The CMR is calculated from the death rate for the entire population (DR). The formulas are as follows: Death Rate (DR) = n / [((n+m 1 ) + M 2 ) / 2] Where n = number of deaths within a given period M 1 = number of persons alive over a given period M 2 = number of persons alive at the time of the survey 10 NCHS: National Center for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics. 165,

14 Crude Mortality Rate (CMR) = (DR x 10,000) / number of days in the period. The period corresponds to 3 months (90 days) preceding the survey. Therefore, CMR = (DR x 10,000) /90. It is expressed per 10,000-people / day. The thresholds are defined as follows 11 : Alert level: Emergency level: 1/10,000 people/day 2/10,000 people/day The proportion of deaths within the past three months among the under five years old is also calculated. 5. Field work All the surveyors participating in the survey underwent a four-day training, which included a pilot survey. Four teams of three surveyors each executed the fieldwork. ACF-USA staff supervised all the teams in the villages. The survey, including the training, lasted for a period of 19 days. 6. Data analysis Data processing and analysis were carried out using EPI-INFO 5.0 software and EPINUT 2.2 program. 11 Health and nutrition information systems among refugees and displaced persons, Workshop report on refugee s nutrition, ACC / SCN, Nov

15 RESULTS 1. Distribution by age and sex Table 4. Distribution of the sample by age and sex AGE BOYS GIRLS TOTAL Sex (In months) N % N % N % Ratio % % % % % % % % % % % % % % % 0.97 Total % % % 0.96 The distribution of the sample by sex shows a slight imbalance with more girls than boys. However, the sex ratio, equals to 0.96, indicates the random selection of the sample. Figure 1. Distribution of the sample by age and sex Age by sex distribution, Kumbor, Nov Age in months Boys Girls % -40% -20% 0% 20% 40% 60% Percenatge The results show a slight imbalance in age distribution, which results from the determination of the approximate age using the calendar of events. 15

16 2. Anthropometric analysis 2.1. Acute malnutrition Distribution of malnutrition in Z-scores for children aged 6 to 59 months The distribution of acute malnutrition in Z-scores showed that the global acute malnutrition is equal to 9.4% with 1.5% of the children being severely malnourished and 7.9% moderately malnourished. Table 5. Weight For Height Distribution by age in Z-scores AGE (in months) Total < -3 SD -3 SD & < - 2 SD -2 SD Oedema N N % N % N % N % % % % 1 0.5% % % % 1 0.5% % % % 2 1.1% % 3 2.0% % 1 0.7% % 7 5.3% % 1 0.8% TOTAL % % % 6 0.7% Table 6. Weight for Height vs. oedema in Z-score Presence of oedema < -2 SD -2 SD Marasmus/Kwashiorkor Kwashiorkor YES 1 0.1% 5 0.6% Marasmus Normal NO % % Six cases of oedema were found: five cases of Kwashiorkor and one case of Marasmus-Kwashiorkor in the sample. 16

17 Figure 2. Z-scores distribution Weight-for-Height, Nuba Mountains Weight for Height Z- score distribution, Kumbor, Nov Percentage Reference Sex Combined Z-score The displacement of the sample curve to the left of the reference curve is observed, indicating a poor nutritional situation among the target population. The mean Z-Scores of the sample, 0.85 (SD: 0.86), indicates an under-nourished population. Table 7. Global and Severe Acute Malnutrition by Age Group in Z-scores 6-59 months (N =870) 6-29 months (N =400) Global acute malnutrition 9.4% 13.3% Severe acute malnutrition 1.5% 1.5% Statistically, there is a significant difference between the malnutrition rates observed among the children aged 6-29 months and the children aged months old (p<0.05). Children aged 6-29 months present 2.15 times (1.39<RR<3.31) more risk of being malnourished than the children aged months old. Table 8. Nutritional Status in Z-scores by Sex Nutritional status Definition Boys Girls N % N % Severe malnutrition Weight for Height < -3 SD or oedema 1 0.2% 7 1.6% Moderate malnutrition -3 SD Weight for Height < -2 SD % % Normal Weight for Height -2 SD % % TOTAL % % The analysis shows that boys and girls present the same risk of being malnourished. The differences observed in the table above are not significant (p>0.05). 17

18 Distribution of malnutrition in percentage of the median The distribution of acute malnutrition in percentage of the median reveals a global acute malnutrition rate of 5.5%. 1.1% of the children were severely malnourished and 4.4% were moderately malnourished. Table 9. Weight/Height: Distribution by Age in percentage of median AGE (In months) < 70% 70% & < 80% 80% Oedema N N % N % N % N % % % % 1 0.5% % % % 1 0.5% % 6 3.2% % 2 0.1% % 0 0.0% % 1 0.7% % 1 0.8% % 1 0.8% TOTAL % % % 6 0.7% Table 10. Weight for Height vs. oedema in percentage of median Presence of oedema < -2 SD -2 SD Marasmus/Kwashiorkor Kwashiorkor YES 1 0.1% 5 0.6% Marasmus Normal NO % % Five cases of Kwashiorkor and one case of Marasmus-Kwashiorkor were detected in the sample. Table 11. Global and Severe Acute Malnutrition by Age Group in Percentage of Median 6-59 months (n =870) 6-29 months (n =400) Global Acute Malnutrition (GAM) 5.5% 8.8% Severe Acute Malnutrition (SAM) 1.1% 1.0% As observed is the Z-scores analysis, there is a significant difference in the nutritional status expressed in the percentage of the median between the age groups 6-29 months and months old (p<0.05). The children aged 6-29 months are 3.16 times (1.70<RR<5.9) more at risk of malnutrition than the months children. Table 12. Nutritional Status by sex in percentage of median Nutritional status Definition Boys Girls N % N % Severe malnutrition Weight for Height < 70% or oedema Moderate malnutrition 70% Weight for Height < 80% Normal Weight for Height 80% TOTAL The statistics analysis shows, as previously, that boys and girls have the same risk of malnutrition. There is no significant difference between girls and boys in regards to risk of malnutrition (p>0.05). 18

19 Nutritional status of the children below six months 55 children aged below six months, present in the households at the time of the survey, were measured in order to determine their nutritional status. See appendix 5 the anthropometric survey questionnaire for children below six months. 38.2% (21) of the measured below-six months children were boys and 61.8% (34) were girls. Table 13. Age distribution of the under six months Age in month N % Total No child below 49 cm height was found, so all the records were analyzed with the NCSH reference tables. According to the Weight for Height index in Z-scores, there were no malnourished infants, while according to the Weight for Height index in percentage of median, 1.8% (one) was malnourished. The nutritional situation of the under six months is considered as good. Feeding practices More than half of the mothers who had children less than six months breastfed exclusively (56.4%) while 43.6% had begun them weaning. The weaning food was usually composed of sorghum porridge and cow milk when available. Table 14. Feeding practices Feeding practices Frequency Percentage Exclusive breastfeeding % Mixed feeding (breast milk and weaning food) % Total % 2.2. Risk of mortality: children s MUAC As MUAC overestimates the level of under nutrition in children less than one year old, the analysis refers only to children having height equal to or greater than 75 cm. A total of 657 children have therefore been included in the analysis. 19

20 Table 15. MUAC distribution according to nutritional status Criteria Nutritional Total cm height 90 cm height status N % N % N % < 110 mm Severe malnutrition 0 0.0% 0 0.0% 0 0.0% 110 mm MUAC < 120 mm Moderate malnutrition 8 1.2% 8 2.5% 0 0.0% 120 mm MUAC < 135 mm At risk of malnutrition % % % MUAC 135 Normal % % % TOTAL % % % MUAC measurements revealed that none of the measured children was severely malnourished, i.e. at high risk of mortality, while 1.2% were moderately malnourished and 16.6% at risk of malnutrition. 82.2% had a good nutritional status. The results show that most of the malnourished children were found in the height group cm, which corresponds to the children aged one to three years. 3. Measles vaccination coverage Measles vaccination is done from the age of nine months; therefore only the children aged 9-59 months (813 children) were included in this analysis. Table 16. Measles vaccination coverage Measles Vaccination N % According to the EPI card % According to the caretaker % Not covered % Total % The coverage of measles vaccination evidenced by the vaccination card and according to the caretakers is fairly good compared to other areas of Sudan. 4. Household status The information on the residential status was collected from 548 caretakers during the anthropometric survey. 98.0% of the households declared to be resident, 0.4% were internally displaced and 1.6% temporarily residents. The average number of children under five years-old per household was 1.68 (SD 0.80), and 3.83 (SD 1.94) for the above five years old. 20

21 Table 17. Household status Residential status N % Residents % Internally Displaced 2 0.4% Temporarily residents 9 1.6% Total % 5. Mortality rate Crude mortality rate The crude mortality was calculated from the figures collected from all visited households, whether or not they had under-five children. There were 956 children under five years old alive at the time of the survey, as well as 2,178 above five years, meaning a total of 3,134 individuals alive. The under five group represented 30.5% of the population. A total of 27 deaths were reported within the preceding three months, among who 21 (78%) were below five years old. Death Rate (DR) = 27/[(( )+31134)/2] = Crude Mortality Rate (CMR) = [ x 10,000]/90 people/day = 0.95 According to the above formula, the crude mortality rate is 0.95/10,000/day. 6. Causes of mortality The main presumed causes of death 12 among the children under five years old were malaria (eight cases) and watery diarrhea (four cases). Table 18. Causes of death Under five Above five Cause of Death N % N % Watery diarrhea % % Bloody diarrhea % Malaria % % Pneumonia 1 4.8% - - Malnutrition 1 4.8% - - Unknown % - - Yellow fever 1 4.8% % Meningitis 1 4.8% - - Total As mentioned by the community. 21

22 DISCUSSION The results of the nutrition survey show that the nutritional situation in Kumbur Payam is not alarming. Indeed, the detected rated of malnutrition are below the emergency thresholds: 9.4% of Global Acute Malnutrition (GAM) and 1.5% of Severe Acute Malnutrition (SAM), expressed in Z-scores, and the analysis of the MUAC measurements confirm this statement. However, the nutritional status of the children aged 6 to 29 months is of great concern. The statistical analysis revealed that the children aged 6-29 months are 2.15 times (Confidence interval = , at 95%) more at risk of being malnourished than the months old children. This significant difference between the aged groups is most likely linked to the feeding practices which were observed to be inadequate, specifically in regards to weaning. The crude mortality rate, 0.95/10,000/day, is also below the alert level. More than three quarters of the individuals who died during the three months preceding the survey were children under five years old, the main presumed causes of death 13 being malaria and watery diarrhea. While the food security situation greatly improved over the months due to the good harvest of September / November, the combination of high prevalence of diseases, because of the poor sanitation and limited health prevention, and some of the observed childcare practices may explain the cases of malnutrition found in Kumbur Payam. Indeed, while most of the population seems to have access to water in sufficient quantity, sanitation practices remain at risk: water is not treated, and environmental and personal hygiene are poor, explaining the high incidence of diarrhea among the population. Malaria is also a common disease and contributed to a great number of deaths, especially among young children. Lack of disease prevention and of drugs according to SC-USA, in charge of the health services in the area, could have also participated in the deterioration of the nutritional status of the most vulnerable. In addition, the practices observed regarding breastfeeding and weaning may have had a significant impact on the condition of the youngest children and may also explain the results of the growth monitoring in SC-USA health centers. Inadequate feeding during the first age of the child is likely to compromise his/her growth. In conclusion, the nutritional situation in Kumbur Payam is not alarming. The main concerns and probable underlying causes of malnutrition are linked to poor sanitation, lack of drugs in the health centers, and the weaning practices common within the community. These issues could be addressed through long term impact interventions and monitoring would have to be ensured in order to anticipate any deterioration of the situation into an acute nutritional emergency. RECOMMENDATIONS Based on the above analysis, ACF-USA recommends the following: SC-USA to increase the drugs supplies in their health centers with the support of UNICEF or other donors. ACF-USA to discuss a possible collaboration with SC-USA in increasing the capacity of the existing health facility to treat acutely malnourished individuals. CONCERN World Wide to continue implementing food security program in the region. SC-USA to initiate health education and hygiene promotion, nutritional education, and mother and child care at the health centers and community levels 13 As mentioned by the community. 22

23 APPENDIXES Appendix 1. Villages where the survey was conducted, Kumbur Payam, November 2004 VILLAGES DISTANCE FROM SC-US COMPOUND TOTAL POPULATION ESTIMATED TARGET POPULATION Kalkada 5 hours Kumorassan 20 minutes Kumofok 30 minutes Kumokura 1 hour 1, Laro 3 hours Longan 3 hours Tura 4 hours Total 4,

24 Appendix 2. Anthropometric survey questionnaire ANTHROPOMETRIC SURVEY QUESTIONNAIRE DATE: VILLAGE: N Family N. Status (1) Age Mths Gender M/F Weight kg Height Cm CLUSTER No: TEAM No: Sitting Oedema Height Y/N cm(2) MUAC mm Measles C/M/N (3) (1) Status: 1=Resident, 2=Displaced (because of fighting, length < 6 months), 3=Family temporarily resident in village (cattle camp, water point, visiting family ) (2) Sitting Height is optional. To apply for ACF-USA survey. This data is for research (3) Measles*: C=according to EPI card, M=according to mother, N=not immunized against measles 24

25 Appendix 3. Calendar of events Kumbur Payam November 2004 MONTHS SEASONS JANUARY JANAIR FEBRUARY FABRAIR Returnees MARCH from MARIS Khartoum APRIL ABRIL MAY MAYO JUNE YUNIO JULY YULIUO AUGUST AGUSTOS SEPTEMBER OCTOBER NOVEMBER DECEMBER End of harvesting sorghum Relaxing and visiting friends Building of houses Clearing of farms Planting of maize and sorghum. Start of rain Continuation of planting Weeding and planting of Simsim Weeding and planting of groundnuts Weeding and harvesting of green maize Weeding and harvesting of green maize Harvesting of Simsim and groundnuts Start harvesting of sorghum and celebrate Christmas Attack by GOS in Kauda Ceasefire between GOS and SPLA USAID visited Nuba 9 Mountains 56 Crash of an airplane in 44 CDR Yusuf died and Kauda buried in Kauda and was replaced Displacement of people in Kaduguli by GOS Bombing by GOS in Kauda 12 children and I teacher died Serious fighting between GOS and SPLA over the body of CDR Yusuf Mine explosion in Lado which killed 6 soldiers and a major Catholic priest slaughtered a child and removed Kidneys Peace mediator Elijah 5 visited Nuba Bombing of people in 28 Vehicles could not people were 4 Kauda 7 people were move because of mud drowned in Kauda due killed. to flooding A USA senator John 15 3 visited Nuba mountains Mine explosion which 2 destroyed DCA vehicle and killed 8 people on its way to Kaduguli Commander Yusuf was taken to Britain for treatment Visit of SPLA chairman 11 in Nuba during Nuba conference 25

26 Appendix 4. Mortality survey questionnaire RETROSPECTIVE MORTALITY SURVEY QUESTIONNAIRE DATE: VILLAGE: CLUSTER No: TEAM No: Family N Nb of < 5 Years alive today 3 months ago Deaths Nb Nb Migrants Nb of >= Nb of < 5 Nb Cause Age Births arrived 5 years years (2) in the alive alive period Nb of >= 5 years alive left in the period (1) Status: 1=Resident, 2=Displaced (because of fighting, length < 6 months), 3=Family temporarily resident in village (cattle camp, water point, visiting family ) (2) Cause:1= Diarrhea (watery diarrhea), 2=Bloody diarrhea (Dysentery), 3=Measles, 4=Malaria, 5= TB, 6=Pneumonia, 7=Malnutrition, 8= Kala-azar, 9=Accident (gunshot, snakebite ), 10=Other (write presumed cause of death) Status (1) 26

27 Appendix 5. Anthropometric Survey questionnaire for children less than six months ANTHROPOMETRIC SURVEY QUESTIONNAIRE FOR CHILDREN LESS THAN 6 MONTHS DATE: VILLAGE: N. Family N. Age Mths Sex M/F Weight Kg CLUSTER No: TEAM No: Height Feeding practices* cm * Exclusive beast-feeding= 1; mixed feeding (breast-milk and weaning food) =2; exclusive weaning food =3. 27