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S o u t h S u d a n

NUTRITIONAL ANTHROPOMETRIC SURVEY

CHILDREN UNDER 5 YEARS OLD Padak (Athoac Region)

South Bor County UPPER NILE (JONGLEI STATE)

19th - 29th May 2002

Henry Sebuliba -Nutritionist Bertha Ocholla -Nutritionist

Action Against Hunger – USA (ACF-USA)

South Sudan

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SUMMARY ………………………………………………………………………………3

ACKNOWLEDGEMENTS ……………………………………………………………...9

INTRODUCTION ………………………………………………………………………11

OBJECTIVES …………………………………………………………………………...13

METHODOLOGY …………………………………………………………………...…14

1. TYPE OF SURVEY AND SAMPLE SIZE………………………………….…14 2. SAMPLING METHODOLOGY………………………………………………..14 3. COLLECTED DATA ...…………………………………………………………14 4. INDICATORS, GUIDELINES AND FORMULAS USED .……………….…15

4.1. Acute Malnutrition …………………..…….……………………………….15 4.2. Mortality……………………………………………………………………..16

5. FIELDWORK……………………………………………………………....……17 6. DATA ANALYSIS ………………………………………………………………17

RESULTS ……………………………………………………………………………..…..18

1. DISTRIBUTION BY AGE AND SEX ……………………………………….……...18

2. ANTHROPOMETRIC ANALYSIS ………………………………………..…..…...20 2.1. Acute Malnutrition .……………………………………………………..………...20

Distribution of malnutrition Z- Score……….…………… ………….……..…...20 Distribution of malnutrition in percentage of the median ………….……..…….23

2.2. Risk of mortality: Children’s MUAC ……………………………….………. …. 24 2.3. Adult malnutrition: Caretakers’ MUAC ……………………….….………..…….25

3. MEASLES VACCINATION COVERAGE …………………………………….….25 4. HOUSEHOLD STATUS AND CARETAKER INFORMATION ..………..……..25 5. RETROSPECTIVE MORTALITY SURVEY……………………………………...25

5.1. MORTALITY RATE ……………………………………………………..…….25

5.2. CAUSES OF MORTALITY …………………………………………………....26

DISCUSSION-RECOMMENDATIONS ……………………………………………….27

APPENDIX ……………………………………………………………………………….30

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SUMMARY 1. OBJECTIVES General objectives of the survey were: To evaluate the nutritional status of children aged 6 to 59 months To evaluate the measles immunisation coverage of children aged 9 to 59 months To evaluate the nutritional status of caretakers using the MUAC To estimate the crude and under-five mortality rates To assess the extent of household movement Specific objectives are: To identify groups at higher risk to malnutrition: age group and sex 2. METHODOLOGY The survey was conducted from 19th to 29th May 2002 in Padak Athoac region South Bor County, Jonglei State, Central Upper Nile region. A two-stage cluster sampling methodology was employed (30 clusters of 30 children each). Resultantly, the final sample size was composed of 900 children aged 6-59months. (With a height of 65 cm – 115cm). The first sampling frame consisted of all villages that are found in Baidit and Jalle Payams. However in this survey, three villages namely; Jalle, Anakdiar and Pathunol were not included because they were not easily accessible. Constraints encountered in the field • Physical accessibility to villages located on the other side (west) of the Nile was difficult,

requiring a 2 hours boat ride. This could not be undertaken. • Training had to be done through a local person acting as an interpreter, and it was realised, on

occasion, that he conveyed a different message.

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3. RESULTS Age

Group Indicator RESULT*

6-59 N=

900

Z-score Global Acute Malnutrition 37.7% [33.1 – 42.4%]

Severe Acute Malnutrition 6.6% [4.5 – 9.4%]

Acute

% median Global Acute Malnutrition 25.8% [21.8 – 30.2%]

Malnutrition Severe Acute Malnutrition 2.8% [1.8 – 4.2%]

6-29 N= 393

Z-score Global Acute Malnutrition 36.9% [30.1 – 44.2%]

Severe Acute Malnutrition 7.4% [4.2 – 12.3%]

% median Global Acute Malnutrition 25.8% [21.8 – 30.2%]

Severe Acute Malnutrition 2.8% [1.5 – 4.9%]

Oedema 0.6% [5 Children] Mother’s MUAC

<185mm 185 – 219mm

>=220mm

Malnourished ‘At risk’

‘Well nourished’

0.4% 27%

72.5% Under Five retrospective mortality♠

1.7 /10 000 /day

Crude retrospective mortality♠ 0.6 /10 000 /day Measles immunization coverage 81.2% *: Expressed over a 95% confidence interval ♠: Over three months preceding the survey (Temporary evacuation of Medair in February from Baidit was used as a reference point).

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4. DISCUSSION The prevalence of acute malnutrition for children aged 6 to 59 months as manifested in this survey is alarmingly high1 and it exists at a global rate of 37.7% according to the z-score index. The results also reveal very high prevalence of severe acute malnutrition at a rate of 6.6%. This implies, for every 100 children, seven children are vulnerable to mortality resulting malnutrition. Further analysis of survey results, reveals that statistical comparative analysis of malnutrition rates between children aged 6 to 29 and 30 to 59 months, indicate no significant difference (P>0.05). This implies that malnourished children in our sample are evenly distributed in both age groups. This scenario, points to a worrying nutrition state of this population considering that nutritional insecurity is not only limited to younger children but also the older children are equally at risk. Z-score index distribution analysis, reveals that a considerable proportion of children (31%) in the surveyed sample are moderately under- nourished (-2SD =<WFH>-3SD), while 28% of those who appear to be “adequately nourished” are at the borderline (distributed between –2SD and –1SD). In the event of a lengthy period of a hunger gap, the borderline children are likely to slip into a moderate state while the moderate slip into a severe state, adding to an already difficult situation. Thus the need to address the problem before it deteriorates further. MUAC results, further reveals that 6.2% of the under-five population are identified to be “at high risk of mortality due to malnutrition” while 42.4% are at moderate risk. As regards the caretakers, 27% are chronically energy deficient. In consideration of mothers’ roles at household level in this community, this poor nutritional state is likely to affect quality of childcare provided by the mothers as well as their ability to effectively ensure household food security. This is a matter of concern in view of the prevailing hunger gap. According to this survey, crude and under five retrospective mortality rates are low and below emergency levels. The main presumed causes of death were respiratory tract infections (45%) followed by diarrhoea diseases (27.3%) amongst the under five’s while in the above five population, respiratory tract infections again featured as the highest causes of mortality. Bor County was reported food secure by the ANA 2001/2 because of improved crop production, restocking process and improved access to trade and markets. However a 5% food deficit in poor households was predicted this year for the period of May –July. Consequently, food aid interventions for this region were planned and channelled through food for work micro projects starting in January this year4. With the exception of the registered returnees, who are still receiving food aid (3000 beneficiaries in May 2002), the last food distribution in this place occurred in July last year. 3980 beneficiaries were targeted with a 50% food ration meant to cover two months. However at the time of the survey, the food security situation of this population appeared threatened. From observations and discussions, non-pastoral communities settled far from the Nile and its tributaries appeared to be most hit since they possess no livestock and have little access to

1 WHO classification of wasting prevalence 4 WFP-TSU Southern Sudan

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fish. Although the consumption of wild foods had increased at the time of the survey, it seemed not to be sufficient. In addition, although the population had access to markets, it was noticed that little or no grain was available to potential buyers. During the survey, it was reported that individuals with the grain were withdrawing it from the market for own consumption. In addition, there was an unexpected influx of population (returnees) into the area last year. Though some of them were registered and accounted for, discussions with the people on the ground revealed that, a considerable number came in unregistered. These unregistered self-returnees, as well as the Murle population that came after the peace agreement appear to have had an immense impact on the overall availability of food in the population. (A lot of grain was exchanged for cattle from the Murles who are traditionally nomadic and exchange / sell animals for grain). In addition, discussions with individuals in this community revealed that Athoac region received the second rains late (normally they are received in October), this appears to have led to reduced grass availability for cattle and thus decreased milk production. The late and finally excessive second rains, at a critical moment led to flooding of low lands and caused reduced grain harvest also. (As result, Amul is said to have been extremely affected). In addition to the hunger gap there are aggravating factors that have a strong likelihood of contributing to the deterioration of the nutritional status. These include poor child weaning practises (Children are only breast fed till they are 2-3 years), raw milk consumption (this is potentially dangerous because of raw milk borne infections associated with animal ill health). Differential intra-household food distribution, inadequate personnel and environmental hygiene, poor health care seeking practises, absence of affective preventive health services, are problems, among others, that are likely to impact negatively on the nutritional status of the population2. Medair provides primary health care services through 1 PHCC and 9 PHCUs. At the time of the survey, 23 TB patients were reportedly admitted and receiving treatment in the Primary health care center manned by Medair5. Important to note is that, mortality resulting from respiratory tract infections could be associated with Tuberculosis disease infections that are predominant in this community. The spreading of T.B in this community is believed to be exacerbated by over crowding, inadequately ventilated houses and sharing of smoking pipes. In addition, the high incidences of diarrhoea related mortality could be linked to poor hygiene and sanitary conditions. According to the EPI card, measles immunization coverage for children aged 9 to 59 months is low at 42.1%. However measles vaccination according to the card and mothers declaration is 81.2%. However, due to recall bias, this result should be interpreted with caution. Given the polio vaccination campaigns that were done in this population, mothers could have got confused when the measles vaccination question was posed since vaccination cards were lost or not issued. 2 Observation and discussions with health personnel. 5 Discussion with Medair personnel

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Considering the interaction between malnutrition and infections, the presence or potentiality of such preventable and communicable diseases is likely to have a severe impact on the under- five population. It is worth mentioning, that a well -nourished population is more likely to resist to such life threatening diseases in contrast to a malnourished one. It is thus a matter of great importance to correct the nutritional status of this population.

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5. RECOMMENDATIONS First line intervention • To continue and improve treatment of severe acute malnutrition cases in Padak PHCC as

already started. • To open supplementary feeding programme during the hunger gap until the first harvests are

realized to prevent severe malnutrition and treat moderate malnutrition. • To establish a nutritional surveillance and reference system using the existing health structures

and the community to obtain a better coverage of the feeding programs, detect and monitor the evolution of malnutrition in children under five.

• General family ration has to be supplied to the most vulnerable in order to avoid relapses,

prevent moderate malnutrition and meet the household food needs. This should be done through out the hunger gap until the first harvests are realized.

Second line intervention • There is need to monitor closely the food security situation of this population to try to avoid

food gaps. • There is need for the implementation of food security programs that are adapted to the

population way of life and to enhance their coping mechanisms in situations of food stress. • Preventive health care services available in the community be strengthened and improved

through provision health education focusing on child/maternal nutrition and nutritional follow up plus personnel/ environmental hygiene and sanitation.

• Maintain the EPI coverage by carrying out regular EPI campaigns with specific emphasis on

measles. • A more in depth study should be conducted in the area to allow better understanding of this

community way of food utilization, preparation, conservation, intra-household distribution…

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ACKNOWLEDGEMENTS ACF - USA acknowledges the invaluable support and assistance of the following: ECHO (European Community Humanitarian Office) for funding the survey, Sudan Relief and Rehabilitation Agency (SRRA), both at Lokichoggio and field level: for facilitating the work in the field, Medair for hosting and extending logistic support to our team during the whole exercise, Last but not least, the local community, particularly the mothers/caretakers, are highly appreciated for their co-operation.

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INTRODUCTION Athoac region is situated in south Bor County, central upper Nile and covers an area of 9450 square kilometres. It is located on the eastern side of the river Nile. It comprises of two Payams namely Baidit and Jalle. Athoac region borders Juba County to the south, Yirol County to the west and Pibor County to the east. The total population of Athoac region at the time of the survey was estimated to be 50,960 (Estimated population figures from SRRA). South Bor is characteristically flat and swampy, and flooding is a normal occurrence in the district especially during the rainy season. At the time of the survey, administration of Athoac region was under SPLA/SPLM. The region has continued to experience relative political stability. This has encouraged a significant number of returnees from Equatorial region and Yirol County and also some of the people who had sought refugee in Uganda and Kenya have been trickling back and are resettled back in their homes. The Dinka people who are traditionally pastrolists inhabit Athoac region. They mainly rear cattle as traditional way of livelihood. In addition, cattle are kept as a form of assets, used in trade and for milk production. However due to attacks by the Neurs in 1991 in which thousands of cattle were killed and looted, the Bor Dinka community has transformed into Agro-pastor lists. The main food crops cultivated are sorghum and maize. Another food source available in this community is fish mainly for the Moynthany tribe is harvested from river Nile. The livestock restocking process that started in 1999 has continued to significantly improve mainly as a result of peace agreement between the Dinka and the cattle rustling communities of Murles, Nuer and Mondari. As result livestock numbers in south Bor rose from 45,000 – 50,000 to 250,000 –300,000 in 2000. At the time of the survey, the people of Athoac were experiencing a hunger gap (This is a normal occurrence at this time of the year). However unlike in previous hunger periods were people have grains for consumption both in their household and also in the markets, this time around, households had exhausted their grain reserves and no grain was seen being sold in the markets. The main food sources at the time of the survey were lalop and water lily. The exchange /bartering of grains for animals with the Murles was mentioned by individuals in this community as one of the factors that could have contributed to this situation. The UN’s World Food Programme (WFP) targets the population with food aid channelled through micro projects. The last food distribution in Padak was carried out in May 2002, it targeted 3,000 beneficiaries (returnees) with 50% of the full ration for a period of one month.

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The table below shows the ration scale of the WFP food basket indicating the composition of 50% and 25% ration levels.

Table 1

Food items Amount as received (g) Full ration (g) 50% 25% 100% Cereals (wheat/Maize) 225 112.5 450 Pulses (lentils) 25 12.5 50 CSB (Corn Soya Blend) 25 12.5 50 Vegetable oil 0 0 30 Salt 0 0 5 Calories (Kcal)* 922 460 2136 % of protein 16.1 16.2 22.9 % fat 5.2 4.8 18

: The calorific value for cereal indicates the caloric content in wheat.

*: Calorific value calculated using food composition tables from ‘Joint WFP/UNHCR Guidelines for Estimating Food and Nutritional Needs in Emergencies’, December 1997. Agencies operating in the area include the following:

Table 2

Agency Activities CARE • Food Security activities

WFP

• Targeted Food Aid distribution and monitoring

MEDAIR • Health services and Water & Sanitation

JARRAD • Dykes Rehabilitation

WUDRAND • Assists orphans and widows

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OBJECTIVES General objectives of the survey were: To evaluate the nutritional status of children aged 6 to 59 months To evaluate the measles immunisation coverage of children aged 9 to 59 months To evaluate the nutritional status of caretakers using the MUAC To estimate the crude and under-five mortality rates To assess the extent of household movement Specific objectives are: To identify groups at higher risk to malnutrition: age group and sex

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METHODOLOGY 1. Type of survey and sample size At the time of the survey, the total population in Athoac region was 50,960 with an under five population of 10163 (estimated at 20% of the total population). This population was settled in two Payams of Jalle and Baidit. (See annex for villages and walking distances). Given the size of the target population and its geographic distribution, a two-stage cluster sampling methodology was used. The minimum sample size, which allows a reasonable precision of the prevalence of malnutrition (whatever the prevalence) is 900 children aged 6 to 59 months (30 clusters of 30 children each), when the target population is greater or equal to 5000 in size. Therefore, 900 children constituted the final sample size. 2. Sampling methodology The target population in this survey were children aged 6 to 59 months with a height of 65-115cm. The availability of population figures at village level enabled systematic random selection of clusters to be done according to villages. All randomly selected villages, that were easily accessible within the limits of this survey, constituted the first sampling frame (unit). (see appendix for cluster selection). In the second degree of sampling, selection of the families was done in the selected clusters at the respective households. The team went to the centre of the chosen cluster and randomly determined a direction by pen spinning. The first household visited was the one encountered first in the randomly selected direction. The remaining houses were chosen by proximity, always taking the houses on the right hand side. Where more than one family [caretaker] resided in a homestead (a family was defined as people represented by one caretaker and share a ‘cooking pot’), only one family [caretaker] was randomly selected. For each selected family [caretaker], all children aged from 6 to 59 months, with a height between 65 and 115 cm were measured. 3. Collected data For each child chosen, aged 6 to 59 months old: Age: recorded with help of a local calendar of events. Sex: recorded. Weight: (SALTER balance of 25 kg, precision of 100g). Children were weighed without clothes. Height: (Shorr 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: precision of 1 mm). MUAC was measured at mid-point of left upper arm for children and the mother of the measured child. Bilateral oedema: assessed by the application of normal thumb pressure for at least 3 seconds to both feet. Measles vaccination: This was assessed according to the response given by the mother/caretaker as to whether the child had received measles vaccination or not.

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Household status: For the surveyed children, households were asked if they were permanent residents, temporarily in the area or displaced. Caretaker information: At each household with under- five children, teams inquired who the caretaker was, their sex was noted, their relationship to the children and their MUAC was measured. Retrospective mortality: At all households (with or without under five), teams inquired for the number of household members alive per specified age groups (see mortality questionnaire in appendix). Additionally, it was inquired how many people had died, if any, 3 months preceding the survey. (The departure of Mediar from Baidit in February 2002 was used as reference point). If any child had died in that period the presumed causes of death were noted down. 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 (W/H) index values combined with the presence of oedema. The W/H indices are compared with NCHS2 references. W/H indices were expressed both in Z-scores and in percentage of the median. The expression in Z score 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 programmes and both will be reported. Guidelines for the results expressed in Z Score: • 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. 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 therefore defined as the proportion of children presenting with a weight for height index less than –2 z scores (or less than 80% in the percentage of median) with/without oedema.

Mid-Upper Arm Circumference (MUAC) Children’s 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

2 NCHS: National Centre for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics. 165, 11-74.

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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 severe malnutrition and high risk of mortality MUAC>=110 mm and <120 mm moderate malnutrition and moderate risk of mortality MUAC>=120 mm and <125 mm high risk of malnutrition MUAC>=125 mm and <135 mm moderate risk of malnutrition MUAC>=135 mm ‘adequate’ nutritional status Caretaker’s MUAC Common cut-offs for the two sexes have also been suggested at 185mm to define global acute malnutrition and 160mm to define severe acute malnutrition (Collins, 1996) and these cut-offs have been accepted by the agencies working in South Sudan during a task force meeting.3 Additionally, a cut-off of 220mm for women and 230mm for men has been proposed as delineating energy deficiency (James et al, 1994). 4.2. Mortality The mortality rate (MR) is determined for both the whole population (CMR) and children under 5 years (U-5MR) old. The defined limits are as follows4: U-5MR Alert level: 2/10 000 people/day Emergency level: 4/10 000 people/day CMR Alert level: 1/10 000 people/day Emergency level: 2/10 000 people/day The death rate (DR), for U-5s or the whole population, is calculated as follows: If : n = the number of deaths (in the last 3 months) And: N = the number alive the day of the survey Then: DR = n/ [((n+N) + N) /2] The RMR = (DR x 10 000) /number of days in the period. The period corresponds to 3 months (90 days) preceding the survey. Therefore, RMR = (DR x 10 000) /90. It is expressed per 10 000 people/ day. 5. Field Work

3 April 13th 1998, Lokichokio 4 Health and nutrition information systems among refugees and displaced persons, Workshop report on refugees nutrition, ACC / SCN, Nov 95.

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Six teams of three people each executed the fieldwork. All participants underwent a five days training, which included a pilot survey. On average, teams were able to cover one cluster (30 children) in a day. The survey lasted for a period of 10 days. 6. Data Analysis Data processing and analysis were carried out using EPI-INFO 5.0 and EPINUT 2.2 computer software programmes.

RESULTS The final sample consists of 900 children aged from 6 to 59 months. No data has been discarded due to aberrant values. Analysis of results is, therefore, focused on 900 children.

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1. Distribution by age and sex

Table 3 DISTRIBUTION BY AGE AND SEX

AGE

(In months) BOYS GIRLS TOTAL Sex

ratio N % N % N %

06 – 17 89 45.6% 106 54.4% 195 21.7% 0.84 18 – 29 96 48.5% 102 51.5% 198 22.0% 0.94 30 – 41 106 54.4% 89 45.6% 195 21.7% 1.19 42 – 53 90 54.2% 76 45.8% 166 18.4% 1.18 54 – 59 72 49.3% 74 50.0% 146 16.2% 0.97

Total 453 50.3% 447 49.7% 900 100.0% 1.01

The distribution by sex shows some slight imbalance: there are more boys in both the 30-41 and 42 –53 age groups, while the number of girls is slightly more in the 54-59 age group. Though the above distribution could be true, it may also be due to selection bias by teams. In addition, it is extremely rare for mothers/caretakers to know the exact birth-dates of their children in the surveyed community. Therefore, a local events calendar was used to assist in the estimation of ages but the children’s ages as stated by mothers/caretakers subject to recall bias. However, the overall sex ratio of 1.01 and allows us to validate the sample selection.

-60%-50%-40%-30%-20%-10% 0% 10%20%30%40%50%60%

54-59

42-53

30-41

18-29

06-17

Figure 1Distribution by Age and SexPadak - south Bor, May 2002

BoysGirls

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Age distribution shows a slight imbalance, with age group 42 -53 being under represented. While this could be a true demographic reality in this population, reasons are discussed above (see distribution by age and sex). Furthermore, it should be remembered that inclusion of the children in the sample was more dependent on satisfaction of the height criteria (actually measured) as opposed to age (estimation). 2. Anthropometric analysis

0% 5% 10% 15% 20% 25% 30%

54-59

42-53

30-41

18-29

06-17

Figure 2Padak - south Bor 2002

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2.1. Acute malnutrition

Distribution of malnutrition in Z-score

Table 4 Weight/Height: Distribution by Age

In Z-Score

AGE (In months)

< -3 SD ≥ -3 SD & < - 2 SD ≥ -2 SD Oedema

N N % N % N % n % 06-17 195 13 6.7% 62 31.8% 117 60.0% 3 1.5% 18-29 198 13 6.6% 54 27.3% 131 66.2% 0 0.0% 30-41 195 7 3.6% 53 27.2% 133 68.2% 2 1.0% 42-53 166 8 4.8% 50 30.1% 108 65.1% 0 0.0% 54-59 146 13 8.9% 61 41.8% 72 49.3% 0 0.0%

TOTAL 900 54 6.0% 280 31.1% 561 62.3% 5 0.6%

Table 5 WEIGHT/HEIGHT vs. OEDEMA

< -2 SD ≥ -2 SD Marasmus/Kwashiorkor Kwashiorkor YES 5 0.6% 0 0.0% Oedema Marasmus Normal NO 334 37.1% 561 62.3%

In the surveyed sample, 37.1% of the undernourished children are marasmic, while 0.6% are suffering from marasmic-kwashiorkor.

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The sample curve is significantly displaced to the left of the reference curve. This is concurrent with the higher prevalence of acute malnutrition observed from the survey. In addition, the mean Z score of the sample is –1.43 (SD: 1.06) characteristic of a poorly nourished population. The noticeable peak in the sample curve indicates high proportions of moderately under -nourished children distributed between –3 SD and –2 SD.

Table 6 GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP

In Z-score 6-59 months (n = 900) 6-29 months (n = 393) Global acute malnutrition 37.7% [33.1% ↔ 42.4%] 36.9% [30.1% ↔ 44.2%] Severe acute malnutrition 6.6% [4.5% ↔ 9.4%] 7.4% [4.2% ↔ 12.3%] The rate of global malnutrition is very high for both children aged 6 to 59 months and 30 – 59 months. Statistical analysis tests reveal no significant difference (p>0.05) between the two age groups. This means all children are at equal risk to malnutrition irrespective of their age.

Figure 3Z score distribution - Weight-for-Height

Padak - south Bor 2002

0

5

10

15

20

25

-5 -4 -3 -2 -1 0 1 2 3 4 5

Reference

SexCombined

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Table 7 NUTRITIONAL STATUS BY SEX

In Z-Scores

Nutritional status Definition Boys Girls N % N %

Severe malnutrition Weight for Height < -3 or oedema 38 8.4% 21 4.7% Moderate

malnutrition -3 ≤ Weight for Height < -2 and no

oedema 149 32.9% 131 29.3%

Normal -2 ≤ Weight for Height and no oedema

266 58.7% 295 66.0%

TOTAL 453 437 While statistical tests show no significant difference between the nutritional status of the boys and girls (p>0.05), from the above table, boys are almost twice as severely malnourished as girls are. This is worth noting.

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Distribution of malnutrition in percentage of the median Cut-offs for acute malnutrition expressed in percentage of the median are commonly used in determining admission criteria in feeding centres.

Table 8 WEIGHT/HEIGHT: DISTRIBUTION BY AGE

In percentage of the median

AGE (In months)

< 70% ≥ 70% & < 80% ≥ 80% Oedema

N N % n % N % n % 06-17 195 4 2.1% 49 25.1% 139 71.3% 3 1.5% 18-29 198 7 3.5% 42 21.2% 149 75.3% 0 0.0% 30-41 195 2 1.0% 34 17.4% 157 80.5% 2 1.0% 42-53 166 2 1.2% 35 21.1% 129 77.7% 0 0.0% 54-59 146 5 3.4% 47 32.2% 94 64.4% 0 0.0%

TOTAL 900 20 2.2% 207 23.0% 668 74.2% 5 0.6%

Table 9 WEIGHT FOR HEIGHT Vs OEDEMA

< 80% ≥ 80% Marasmus/Kwashiorkor Kwashiorkor YES 4 0.4% 4 0.1% Oedema Marasmus Normal NO 227 25.2% 668 74.2%

Table 10 GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP

In percentage of the median

6-59 months (n = 900) 6-29 months (n = 321) Acute global malnutrition 25.8% [21.8% ↔ 30.2%] 26.7% [20.7% ↔ 33.7%] Acute severe malnutrition 2.8% [1.5% ↔ 4.9%] 3.6% [1.5% ↔ 7.6%]

Survey results expressed in percentage of the median also indicate that the children aged 6 to 29 and 30-59 months are at equal risk to malnutrition. Statistical tests reveal that there is no significant difference (p>0.05) in malnutrition rates between the two age groups.

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Table 11 NUTRITIONAL STATUS BY SEX

In percentage of the median

Nutritional status Definition Boys Girls n % n %

Severe malnutrition Weight for Height < 70% or oedema 14 3.1% 11 2.5% Moderate

malnutrition 70 ≤ Weight for Height < 80 and no

oedema 108 23.8% 99 22.1%

Normal 80% ≤ Weight for Height and no oedema

331 73.1% 337 75.4%

TOTAL 453 447 There is no significant difference as regards the nutritional status (in percentage of the median) between boys and girls (p>0.05). 2.2. Risk to Mortality: Children’s MUAC As MUAC overestimates the level of under nutrition in children under 1 year old, the analysis refers only to children having height equal to or greater than 75cm.

Table 12 MUAC DISTRIBUTION ACCORDING TO NUTRITIONAL STATUS

For children of height greater or equal to 75cm

Criteria Nutritional status N %

<11.0 cm Severe malnutrition 10 1.3% 11.0 cm >=MUAC<12.0cm Moderate malnutrition 38 4.9%

12.0 cm >=MUAC<= 13.5 cm Mild malnutrition 328 42.4% MUAC>13.5 Normal 397 51.4%

TOTAL 773

According to the MUAC measurement, 6.2% of the children are acutely malnourished and therefore at high risk to mortality. Of much concern is that 42.4% are mildly under nourished and at the ‘borderline’.

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2.3. Adult Malnutrition: Caretaker’s MUAC

Table 13 MUAC DISTRIBUTION ACCORDING TO NUTRITIONAL STATUS

Criteria Nutritional status N %

<18.5 cm Malnourished 3 0.4% 18.5 cm >=MUAC<22.0cm At risk to malnutrition 208 27%

MUAC>= 22.0cm ‘Well Nourished’ 555 72.5% TOTAL 766

Acute malnutrition prevalence is low (0.4%) amongst the caretakers. However, a significant proportion (27%) are chronically energy deficient and existing in a state that poses a threat to their health, normal physiological functions and physical activity levels. Considering that 86.8% of caretakers were women, negative impacts on pregnancy, lactation, as well as domestic roles can be expected. 3. Measles vaccination coverage Measles vaccination coverage for children aged 9 to 59 months is low, 42.1% of the children in the surveyed sample are vaccinated according to the card. However measles vaccination according to the card and mothers declaration indicate that 81.2% of the children are vaccinated. It should be noted that measles vaccination according to mothers word is not so reliable because given the polio vaccination campaigns that were done in this population, mothers could have got confused when the measles vaccination question was posed since vaccination cards were lost or not issued. Furthermore, EPI card possession was very low, only 34.2% possessed immunisation card. 4. Household Status and caretaker information 87.2% of the surveyed children are from resident households. 86.8% of the children had female caretakers and 56.8% of the children had their mothers responding to the questions. 5. Retrospective mortality survey Mortality rate - Under Five There were 712 children under 5 years old alive on the day of the survey and 11 children under 5 had died within the preceding 3 months Mortality Rate (MR) = (0.015 x 10 000) /90 = 1.7 /10 000 people/day According to the above formula, the under five-mortality rate is 1.7/10 000/day/.

- Crude mortality rate (CMR) There were 762 people alive during the survey period and 4 people had died within the preceding 3 months.

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MR= (0.0052 x 10 000) /90 = 0.6 /10 000 persons/day According to the above formula, the CMR is 0.6/10 000/day/. 5.3. Causes of mortality

- Under five

Table 14 CAUSE OF DEATH

Cause of Death N %

Simple diarrhoea 3 27.3 Bloody diarrhoea 1 9.1

Fever 2 18.2 Respiratory infections 5 45.5

TOTAL 11

According to caretakers (mothers) the main illness classified as ‘fever’, above was malaria. ‘Other’ causes include neonatal deaths or sudden deaths. - Above five

Table 15 CAUSE OF DEATH

Cause of Death N %

Simple diarrhoea 1 25.0 Respiratory infections 2 50.0

Other causes 1 25.0 TOTAL 4

‘Other causes’ included old age and sudden deaths.

DISCUSSION-RECOMMENDATIONS

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The prevalence of acute malnutrition for children aged 6 to 59 months as manifested in this survey is alarmingly high5 and it exists at a global rate of 37.7% according to the z-score index. The results also reveal very high prevalence of severe acute malnutrition at a rate of 6.6%. This implies, for every 100 children, seven children are vulnerable to mortality resulting malnutrition. Further analysis of survey results, reveals that statistical comparative analysis of malnutrition rates between children aged 6 to 29 and 30 to 59 months, indicate no significant difference (P>0.05). This implies that malnourished children in our sample are evenly distributed in both age groups. This scenario, points to a worrying nutrition state of this population considering that nutritional insecurity is not only limited to younger children but also the older children are equally at risk. Z-score index distribution analysis, reveals that a considerable proportion of children (31%) in the surveyed sample are moderately under- nourished (-2SD =<WFH>-3SD), while 28% of those who appear to be “adequately nourished” are at the borderline (distributed between –2SD and –1SD). In the event of a lengthy period of a hunger gap, the borderline children are likely to slip into a moderate state while the moderate slip into a severe state, adding to an already difficult situation. Thus the need to address the problem before it deteriorates further. MUAC results, further reveals that 6.2% of the under-five population are identified to be “at high risk of mortality due to malnutrition” while 42.4% are at moderate risk. As regards the caretakers, 27% are chronically energy deficient. In consideration of mothers’ roles at household level in this community, this poor nutritional state is likely to affect quality of childcare provided by the mothers as well as their ability to effectively ensure household food security. This is a matter of concern in view of the prevailing hunger gap. According to this survey, crude and under five retrospective mortality rates are low and below emergency levels. The main presumed causes of death were respiratory tract infections (45%) followed by diarrhoea diseases (27.3%) amongst the under five’s while in the above five population, respiratory tract infections again featured as the highest causes of mortality. Bor County was reported food secure by the ANA 2001/2 because of improved crop production, restocking process and improved access to trade and markets. However a 5% food deficit in poor households was predicted this year for the period of May –July. Consequently, food aid interventions for this region were planned and channelled through food for work micro projects starting in January this year4. With the exception of the registered returnees, who are still receiving food aid (3000 beneficiaries in May 2002), the last food distribution in this place occurred in July last year. 3980 beneficiaries were targeted with a 50% food ration meant to cover two months. However at the time of the survey, the food security situation of this population appeared threatened. From observations and discussions, non-pastoral communities settled far from the Nile and its tributaries appeared to be most hit since they possess no livestock and have little access to fish. Although the consumption of wild foods had increased at the time of the survey, it seemed not to be sufficient. 5 WHO classification of wasting prevalence 4 WFP-TSU Southern Sudan

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In addition, although the population had access to markets, it was noticed that little or no grain was available to potential buyers. During the survey, it was reported that individuals with the grain were withdrawing it from the market for own consumption. In addition, there was an unexpected influx of population (returnees) into the area last year. Though some of them were registered and accounted for, discussions with the people on the ground revealed that, a considerable number came in unregistered. These unregistered self-returnees, as well as the Murle population that came after the peace agreement appear to have had an immense impact on the overall availability of food in the population. (A lot of grain was exchanged for cattle from the Murles who are traditionally nomadic and exchange / sell animals for grain). In addition, discussions with individuals in this community revealed that Athoac region received the second rains late (normally they are received in October), this appears to have led to reduced grass availability for cattle and thus decreased milk production. The late and finally excessive second rains, at a critical moment led to flooding of low lands and caused reduced grain harvest also. (As result, Amul is said to have been extremely affected). In addition to the hunger gap there are aggravating factors that have a strong likelihood of contributing to the deterioration of the nutritional status. These include poor child weaning practises (Children are only breast fed till they are 2-3 years), raw milk consumption (this is potentially dangerous because of raw milk borne infections associated with animal ill health). Differential intra-household food distribution, inadequate personnel and environmental hygiene, poor health care seeking practises, absence of affective preventive health services, are problems, among others, that are likely to impact negatively on the nutritional status of the population2. Medair provides primary health care services through 1 PHCC and 9 PHCUs. At the time of the survey, 23 TB patients were reportedly admitted and receiving treatment in the Primary health care center manned by Medair5. Important to note is that, mortality resulting from respiratory tract infections could be associated with Tuberculosis disease infections that are predominant in this community. The spreading of T.B in this community is believed to be exacerbated by over crowding, inadequately ventilated houses and sharing of smoking pipes. In addition, the high incidences of diarrhoea related mortality could be linked to poor hygiene and sanitary conditions. According to the EPI card, measles immunization coverage for children aged 9 to 59 months is low at 42.1%. However measles vaccination according to the card and mothers declaration is 81.2%. However, due to recall bias, this result should be interpreted with caution. Given the polio vaccination campaigns that were done in this population, mothers could have got confused when the measles vaccination question was posed since vaccination cards were lost or not issued. Considering the interaction between malnutrition and infections, the presence or potentiality of such preventable and communicable diseases is likely to have a severe impact on the under- five population. It is 2 Observation and discussions with health personnel. 5 Discussion with Medair personnel

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worth mentioning, that a well -nourished population is more likely to resist to such life threatening diseases in contrast to a malnourished one. It is thus a matter of great importance to correct the nutritional status of this population.

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RECOMMENDATIONS First line intervention • To continue and improve treatment of severe acute malnutrition cases in Padak PHCC as already

started. • To open supplementary feeding programme during the hunger gap until the first harvests are realized to

prevent severe malnutrition and treat moderate malnutrition. • To establish a nutritional surveillance and reference system using the existing health structures and the

community to obtain a better coverage of the feeding programs, detect and monitor the evolution of malnutrition in children under five.

• General family ration has to be supplied to the most vulnerable in order to avoid relapses, prevent

moderate malnutrition and meet the household food needs. This should be done through out the hunger gap until the first harvests are realized.

Second line intervention • There is need to monitor closely the food security situation of this population to try to avoid food gaps. • There is need for the implementation of food security programs that are adapted to the population way

of life and to enhance their coping mechanisms in situations of food stress. • Preventive health care services available in the community be strengthened and improved through

provision health education focusing on child/maternal nutrition and nutritional follow up plus personnel/ environmental hygiene and sanitation.

• Maintain the EPI coverage by carrying out regular EPI campaigns with specific emphasis on measles. • A more in depth study should be conducted in the area to allow better understanding of this community

way of food utilization, preparation, conservation, intra-household distribution…

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Appendix 1 - Nutritional Survey Cluster Selection Padak May 2002

Village Total Pop Estimated Pop<5years CummulativePop Attributed

Numbers Clusters

Mathiang 1139 228 228 1- 228 Anya 1134 227 455 229 - 445 1

Thoibek 1134 227 682 456 - 682 1 Thonjok 1138 228 910 683 - 910 Gameth 1120 224 1134 911-1134 1 Bathony 1144 229 1363 1135 -1363 1

Akoldi\Kurkour 1068 214 1577 1364-1577 Boik Ayaar 1200 240 1817 1578 -1817 1

Apoor 1262 252 2069 1818 -2069 1 Pariak\Pakeer 1258 252 2321 2070 -2321 1

Buoth 1358 272 2593 2322-2593 Ayuira\Pakeer 1154 231 2824 2594 - 2824 1

Konabuk\Magok 1262 252 3076 2825 - 3076 1 Diggrut 1258 252 3328 3077-3328

Makolcuei 834 167 3495 3329-3495 1 Thiong piny 820 164 3659 3496-3659 Panmaketh 837 167 3826 3660-3826 1

Pacholo\Meder 820 163 3962 3827-3962 Panomaboth 837 165 4127 3963-4127 1

Tong 785 157 4284 4128-4284 Wurthong 760 152 4436 4285-4436 1 Yeeping\ 780 156 4592 4437-4592

Magal 775 155 4747 4593-4747 1 Pagok 780 156 4903 4748-4903

Natinga 775 155 5058 4904-5058 1 Kolmerek 3726 745 5803 5059-5803 2 Anakdiar 3526 705 6508 5804-6508 2

Jalle 3890 778 7286 6509-7286 2 Pathunol 3870 774 8060 7287-8060 2

Akuaideng 1983 397 8457 8061-8457 2 Pammom 1982 396 8853 8458-8853 1

Bayieu\Yomcir 1982 396 9249 8854-9249 1 Kuei 1569 314 9563 9250-9563 1

Panlueth 1600 320 9883 9564-9883 1 Aweil\Bior 1400 280 10163 9884-10163 1

Total 50960 30

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Appendix 2 – anthropometric questionnaire

DATE: TEAM N°.: VILLAGE: CLUSTER N°.: Children from 65 to 115 cm

CHILDREN CARETAKER

N°. Family N°.

Age mths Sex M/F Weight

kg Height

cm Oede-ma

Y/N MUAC

mm EPI Card

Y/N Measles

Y/N Status * Parental

Link With The Child

** Sex M/F MUAC

mm

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Status*: 1=resident, 2=displaced, 3=family temporarily resident in the village (cattle camp, water point..) Parental link**: 1=mother, 2=other person

ANTHROPOMETRIC SURVEY QUESTIONNAIRE

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Appendix 3 – mortality questionnaire

.

DATE: TEAM Nb: CLUSTER N°: VILLAGE: TEAM LEADER:

< 5

YEARS >= 5 YEARS

N° Family N°

NUMBER ALIVE < 5

YEARS

NUMBER DEAD * < 5 YEARS

CAUSE**NUMBER >= 5 and < 12 YEARS

NUMBER >=12 and

< 18 YEARS

NUMBER of ADULTS

NUMBER of

ELDERLY

NUMBER DEAD* >= 5 YEARS

CAUSE**

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

* Death(s) during the last 3 months: September, October, November 2001 ** 1= Diarrhoea(simple), 2= Diarrhoea(bloody), 3= Measles, 4= Fever, 5= Lower Respiratory Infection, 6= Malnutrition, 7= Accident, 8= Other (write presumed cause of death)

MORTALITY QUESTIONNAIRE IN THE LAST THREE MONTHS*(July)

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