S o u t h e r n S u d a n

NUTRITIONAL ANTHROPOMETRIC SURVEY

CHILDREN UNDER 5 YEARS OLD BUGAYA

MABAN PROVINCE EASTERN UPPER NILE (LATJOR STATE)

JULY 24TH – AUGUST 8TH 2003.

Carol Njogu- Nutritionist Action Against Hunger USA

(ACF USA) Mary Karanja- Nutritionist.

Tearfund.

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TABLE OF CONTENTS INTRODUCTION............................................................................................................. 9 METHODOLOGY ......................................................................................................... 13

1. Type of survey and sample size................................................................................. 13 2. Sampling methodology.............................................................................................. 13 3. Data Collection.......................................................................................................... 13 4. Indicators, guidelines and formulas used .................................................................. 14

4.1. Acute Malnutrition .............................................................................................. 14 4.2. Mortality.............................................................................................................. 15

5. Field work.................................................................................................................. 15 6. Data analysis.............................................................................................................. 16

RESULTS ........................................................................................................................ 16 1. Distribution by age and sex ....................................................................................... 16 2. Anthropometric analysis............................................................................................ 17

2.1. Acute malnutrition............................................................................................... 17 Distribution of malnutrition in Z-score......................................................... 17 Distribution of malnutrition in percentage of the median............................. 19

2.2. Risk to Mortality: Children’s MUAC ................................................................. 20 2.3. Adult Malnutrition: Caretaker’s MUAC............................................................. 21

3. Measles vaccination coverage ................................................................................... 21 4. Household status........................................................................................................ 22 5. Composition of the household................................................................................... 22 6. Mortality rate ............................................................................................................. 22 7. Causes of mortality.................................................................................................... 23

DISCUSSION-RECOMMENDATIONS ...................................................................... 24 APPENDIX ...................................................................................................................... 27

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SUMMARY

1. OBJECTIVES

To evaluate the nutritional status of children aged 6 to 59 months To estimate the measles immunization coverage of children aged 9 to 59 months To evaluate the nutritional status of the sampled children’s caretakers using MUAC To estimate the crude and under-five mortality rates through a retrospective survey To assess the extent of household movement

Specific objective:

To identify groups at higher risk to malnutrition: age group and sex. 2. METHODOLOGY The survey was conducted from 24th July to August 8th 2003 in Maban Province, Latjor State, Eastern Upper Nile (20 km south from the border of Southern Blue Nile). The area is flat with many seasonal rivers, savannah vegetation and forest in between rocky and gently sloping hills. The soil type is clay/loam,1 and is productive. Maban Province is one of the five provinces in Latjor State and consists of three districts namely Beneshowa, Kewaji and Maban. At the time of the survey, total population estimates for the County were 26,7212. The target population was 5345 children below 5 years old, calculated as 20% of the total population. The sample size was 720 children, giving a cluster size of 24 children for 30 clusters. This sample size was taken to provide estimates of the prevalence of malnutrition with a 95% confidence interval. The sampling frame consisted of Bugaya and Bawac villages (15 km apart) within a 4 hours walk from the center of Bawac village. Within each cluster, households were randomly selected to be included in the survey. Constraints encountered in the field • Due to the low level of literacy in the area, only three teams conducted the survey. Each team

was supervised at one point during the survey. However, it was not possible to supervise all teams all the times, due to large distances and accessibility difficulties. The selected teams were seen to be following the proper methodology.

• The SRRC secretary was newly appointed and did not have adequate information on village locations and distances. Information was therefore collected from surveyors and the civil authority.

• The training and central point for the survey took place in Bawac village, and not in Bugaya where the largest number of the population including IDP’s have settled. The airstrip in Bugaya is not cleared by OLS security. However the community with the assistance of GOAL was currently working on it to improve its status.

1 Joint Agency assessment of Mabaan County Upper Nile by CEAS and CARE. 2 Estimates given by SRRC in Bugaya.

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3. RESULTS

Age Group Indicator RESULT

Global Acute Malnutrition H/W< -2 z and or oedema

13.1% (9.8% – 17.1%)*

Z-score Severe Acute Malnutrition H/W < -3 z and/or oedema

1.9% (0.8% – 4.1%)

Global Acute Malnutrition H/W< -80% and or oedema

8.2% (5.6% – 11.7%) 6-59 N= 734

% Median Severe Acute Malnutrition H/W< -70% and or oedema

0.4% (0.0% – 2.0%)

Global Acute Malnutrition H/W< -2 z and or oedema

18.0% (12.9% – 24.6%)

Z-score Severe Acute Malnutrition H/W < -3 z and/or oedema

2.9% (1.1% – 6.8%)

Global Acute Malnutrition H/W< -80% and or oedema

11.1% (7.1% – 16.8%) 6-29 N=377

% Median Severe Acute Malnutrition H/W< -70% and or oedema

0.5% (0.0% – 3.4%)

Acute Malnutrition

Oedema 0.0% Mother’s MUAC <185mm

185 – 219mm >=220mm

Malnourished ‘At risk’ ‘Well nourished’

1.1% 10.5% 88.4%

Under-five retrospective mortality (last 3 months) 8.9 /10,000 /day Crude retrospective mortality (last 3 months)

4.4/10,000 /day

Measles immunization coverage By card According to caretaker** Total

0.0% 0.0% 0.0%

*: Expressed over a 95% confidence interval **: When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker.

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DISCUSSION The rates of Global Acute Malnutrition for children aged 6 to 59 months (13.1%) and Severe Acute Malnutrition (1.9%) according to Z-scores3, are below the emergency level (15% for GAM and 4% fro SAM). Nevertheless, the mortality rate for under five (8.9/10,000/day) and the crude mortality rate (4.4/10,000/day) are more than twice the emergency cut of rate (4/10,000/day and 2/10,000/day respectively). The main presumed cause of death for the under-five was bloody diarrhea4(30%), malnutrition (17%) and fever (16%). Among the over five, the main causes were bloody diarrhea (15%), and lower respiratory infection (11%). As no previous assessment has been done in this province, it is difficult to know whether the situation is now improving, which could explain the reasonable prevalence found in this survey. As most of the deaths cases were found in the under five group (117 cases out of 174 in total), this indicates that the under-five, who usually are the most vulnerable age group in any population, were the first to be affected. Statistical comparative analysis of malnutrition rates for children aged 6-29 months and 30-59 months indicate a significance difference between the 2 age-groups (p<0.05). The 6-29 age group is at higher risk than those who are in the 30-59-age bracket, with a relative risk equal to 2,30 (C.I. 95%: 1,52 – 3,48) to be malnourished. Sex has no incidence on the rates of malnutrition. MUAC results for the children show that 4.0% of children are moderately to severely malnourished. In addition, 8.4% are at risk to malnutrition, while 87.6% are well nourished. It is likely that the well nourished may slip into the group at risk while those at risk may slip to the severely malnourished group if the situation does not improve. The nutritional situation is not revealing an emergency situation, as compared with the rates observed in other areas in southern Sudan. Nevertheless, malnutrition is a worsening factor of any other pathology, for children below 5 years more particularly, and according to the high mortality rate, it remain an issue to be followed up. HEALTH The lack of preventive health care coupled with long distances for referral’s cases are a hindrance to get proper health care. This may explain the very high mortality rates, that are consequent to preventable causes among the children, as shown during the survey. Indeed, the main suspected cause of death found in the mortality survey for both under five’s (30%), and over five’s (15%) was bloody diarrhea. March-June 2003 morbidity reports from the GOAL PHCU in Bugaya confirm this information: it indicates that watery diarrhea (25%)5, malaria (16.9%) and bloody diarrhea (9.2%) were the main morbidity causes for under five. The main morbidity causes recorded for over five were malaria (22.9%), watery diarrhea (18.4%) and lower respiratory infection (12.2%). The children were seen to have largely protruding bellies, possibly due to worms infection, as well as reddish colored hair, that may possibly be caused by micro nutrients deficiency. Measles immunization coverage for children aged 9 to 59 months is non-existent (0.0% of immunized children according to both caretaker and EPI card). This should be addressed as a

3 WHO classification of wasting prevalence in populations. 4 Diarrhea is defined as the passage of abnormally loose or fluid stools more frequently than normal causing death due to infection. 5 GOAL morbidity reports March-June 2003.

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matter of urgency: it poses the risk of a measles outbreak, as 2 cases of death due to measles have been recorded in this survey. This may be worsened by the fact that the houses are very close to each other and overcrowded. Vaccination would greatly reduce the possibility of an epidemic and consequently decrease the number of children susceptible to secondary infection. Measles is also know to be a factor of malnutrition. WHO did a polio immunization campaign in March/April this year, and plans to do a supplementary immunization campaign in October/November. A joint agency assessment, done by CEAS and CARE in January 2003, reported that all the mothers reported that their children have been born at home, without any trained assistant. Moreover, almost all mothers reported the death of at least one of their children at birth. This is an indication that there are no trained / traditional midwives, which contributes to the high mortality rate at childbirth. The lack of health facilities and the high level of preventable diseases in the area surveyed are the major issue revealed during the survey. The high mortality rates observed, even with the lack of precision due to the poor knowledge of the caretakers, highlight the urgent need of an intervention in the field of health. FOOD SECURITY In 2002, CEAS (Church Ecumenical Action in Sudan) conducted a one month training for 7 food security extension workers in Yabus. They are currently doing agriculture extension education among the community. The problems cited as affecting cultivation are attacks by pests/diseases and a lack of pesticides. Other issues of concern include birds attack, low rainfall and a lack of a availability of tools. The tools used the most by the community are the ones locally made by the blacksmith: local hoe (alla), ax, panga, and sickle. The major limitation in accessing adequate tools is the lack of raw materials. The community also expressed the desire of having ox-plough training, which would enable them to cultivate larger farms. No other action has been recorded until August 2003. Food security is also an issue to be addressed. Further investigations would required to be done to know whether the coming harvests will fulfill the population needs, and if the seeds will remain enough for next year. In between, the global food distribution by WFP is recommended to remain at 75% level. WATER AND SANITATION. Water and sanitation seems to be the main cause of the sanitary situation in the areas, as the high mortality rates are mostly due to water-related or water-born diseases. An interview with the medical assistant in Bugaya PHCU indicated an urgent need for hygiene promotion, as patients seem to present repeated incidences of disease. There has been no hygiene/water sanitation activities conducted previously in the area: previous attempts to conduct some were stopped by the security personnel of the area. During the time of the survey, Oxfam GB was conducting a two-weeks hygiene promotion and malaria prevention program, and looking at the possibility of partnering with Servants heart to dig bore holes. The training classes seemed to go on smoothly, without interference, and were conducted in both Bawac and Bugaya villages. Latrines are inexistent. The water and sanitation situation is critical and needs to be addressed urgently. An assessment is required to be done, and beside any intervention in this field, health and hygiene education have to be provided.

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6. RECOMMENDATIONS • GOAL/ OXFAM/MEDAIR to improve quality of health care delivery by introducing hygiene

promotion, de-worming, and community outreach activities. • GOAL /MEDAIR/OXFAM to institute a measles immunization campaign and training of

traditional birth attendants • GOAL / TEARFUND /ACF-USA to open a therapeutic feeding center since the under-five

mortality rate is above emergency level and due to the high prevalence of diarrhea disease. • WFP should continue food aid delivery at 75% ration level. • ACF-USA/TEARFUND to maintain nutritional surveillance through surveys. • UNICEF/OXFAM/Servant Heart to provide safe water through installing bore holes in both

villages. • FAO/CARE to closely monitor the food situation of the population in the area and introduce

ox-plough training. • Dissemination of results and recommendation to local community on the ground.

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ACKNOWLEDGEMENTS ACF USA / TEARFUND acknowledges the invaluable support and assistance of the following: UNICEF/OFDA for funding the survey, Sudan Relief and Rehabilitation Commission (SRRC), both at Lokichoggio and field level: for facilitating the work in the field, The local surveying teams for working tirelessly in poor weather, Last but not least, thank you to the local community, particularly mothers/caretakers, for their cooperation.

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INTRODUCTION Bugaya is a village situated in Maban Province, Latjor State, Eastern Upper Nile, 20 km south of Southern Blue Nile and 52 km south west of Yabus. Maban province is one of the five provinces in Latjor State and consists of three districts namely Beneshowa, Kewaji, and Maban. The only other village of the province is Bawac. The area is flat with many seasonal rivers, savannah vegetation and forest in between rocky and gently sloping hills. The soil type is clay/ loam, and is productive. The administrative structure in Bugaya is composed of a Sultan (paramount chief) who is the overall, followed by Payam administrators (UMDA s), chiefs and sub chiefs. The total population of Maban county is 26, 7216, with an estimated under five population of 5345 (calculated as 20% of the population). FOOD SECURITY Agriculture is the main livelihood for the people living in Bugaya. The area is fertile and has traditionally produced surplus crops7.They also keep a variety of livestock including shoats8, pigs, ducks and a few cattle. The community hunts a variety of both large and small wild animals. The livestock seemed to be healthy and to have enough pasture and water sources. The goats and cattle seemed to have sufficient milk, which is accessible to their owners. Mothers were seen to be weaning their children on goat’s milk as a supplementary food to breast-feeding. Mothers start weaning their children for between one and two years. Fishing is not commonly practiced among the Bugaya communities. It is more commonly practiced in the Liang villages along the Kurmuk river, 35 km away. Fishing occurs mainly in the dry season, from August to November, extending to April after the rains. The main crops grown by the Bugaya population are maize and sorghum. The cropping season is between May and October for sorghum, and April to August for maize. The Bugaya population grows also a variety of other crops including simsim, groundnuts, beans, cassava, green grams, okra, tomatoes, carrots and Soya bean. There used to be two planting seasons, but last year the crops were attacked by pests, and were affected by erratic rainfall, which led to a poor harvest this year. This is matching with ANA9 prediction for Latjor State, that expected to have numerous non-cultivation pockets, as a result of unfavorable weather coupled with insecurity. A big variety of wild food is part of the diet: a wide variety of vegetables (ghello, kolo, gora, mulla, jato, bang, shar, saba, ogora, jati, mulla, lemnai, kudr, kola, bang and panda), mushrooms, wild fruits (meu, lianya, tone, kuongyo, buolo, yeno, nyamo, nyanta, langany, meu), and wild potatoes/tulips (lyanyan, miawo, tuornyon, nyanta, dwocon, pata, and lyanyan). The wild food was seen to be easily available and accessible. In June this year, CARE distributed seeds and tools for the June planting season, to assist the community: maize (5.35 Mt), sorghum (1 Mt), groundnuts (0.5 Mt) maloda’s (1000 pieces), sickles (500 pieces) and panga’s (50 pieces). Unfortunately, after planting, the crops were attacked by pests (worms) during the early stages of growth, and affected by insufficient and erratic rainfall The harvest is therefore expected to be less than last year.

6 Population estimates given by SRRC on ground. 7 Joint Agency assessment of Maban county Upper Nile by CEAS and CARE. 8 Sheep and goats. 9 Latjor State 2002/03 Annual Needs Assessment Report.

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Apart from wild foods, the population was seen to be eating the food from WFP, dropped in July, targeting 20,000 beneficiaries out of 26,721 people, at 75% ratio level. This distribution consisted of 200.9 Mt of cereals (maize and sorghum), 18.8 Mt of pulses, and 16.8 Mt of oil. The following table shows the ration scale of the WFP food basket.

Table 1

Food Items Amount as received.

75% ratio (g/day) 100% ratio (g/day) Daily needs

Cereals (wheat/maize) 337.5 450 Pulses (lentils) 37.5 50 CSB (Corn Soya Blend) 37.5 50 Vegetable oil 22.5 30 Salt 0 5 Calories (kcal)* 1432.5 1910 2200 % of protein in kcal 12 16.0 10-15 % fat in kcal 14.25 19.0 30-35

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

*: Calorific value calculated using ‘WFP commodity list and corresponding nutritional value’ – WFP’s Food and Nutrition Handbook. Considering the calorie-content of the 100% level ration, the current level (75%) is not sufficient to fulfill the nutrition needs of the population. The survey was carried out during the end of the hunger gap period, and harvest of maize was expected mid August. HEALTH Health services in Bugaya are provided by a PHCU in Bugaya village, ran by GOAL. It opened in March this year and offers only curative service. The clinic has a constant supply of essential drugs. Supplies are brought from the GOAL PHCC in Yabus, 43 km away on a monthly basis during the dry season, and quarterly basis during the wet season, as the area is inaccessible. Referral cases are sent to the PHCC in Yabus. People in Bawac village complained about the inaccessibility of health services, as they have to walk 15 km to reach Bugaya and get medical attention. They requested a similar clinic be set up in Bawac. In August this year, MEDAIR supported the clinic with 4 PHCU kits. IDP POPULATION The movement of IDP’s is due to insecurity, mainly from villages neighboring oil fields. These people have been displaced by the GOS, who has been progressing towards their villages. The main displacement took place in 1997, when the GOS entered into Maban County. Large numbers of Maban people fled to Ethiopia (Serekola refugee camp), from where the majority drifted back into different parts of Southern Blue Nile. The cited reasons for leaving the refugee camp were unfavorable conditions, such as a lack of sufficient food and lack of land on which to cultivate.

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Others IDP’s came from Bellatuma and Adar, and have settled in Bugaya due to insecurity reasons10. Apart from the Maban IDP people, there are also 738 Renk Dinkas IDP’s from Melut and 140 from Shilluk, displaced in Bawac11. Bugaya locality has had no security incidence since people settled in, seven years ago. It is a relatively new settlement, and the SPLA and civil authority in the area are encouraging people who fled to the refugee camp to come back and settle down. A large number of IDP’s have been settling in Bugaya village, as there is plenty of land on which to cultivate, and the soil is fertile. The IDP’s have had to depend heavily on the host community for food and accommodation. This has caused a strain in terms of food availability, and the population were found to depend on wild foods. EDUCATION A primary school ran by CEAS closed last year due to lack of funding. Servant’s hearts intends to support one school in Bugaya. The school, which was not opened during the time of the survey, counts two trained teachers and is attended by around 700 children. An interview with the teachers indicates the lack of school materials, the lack of teachers as well as the lack of proper training for them. WATER AND SANITATION There are no boreholes in the area. The community uses shallow wells, dug at underground springs, as a source of water .The water collected is dirty, and the process of collecting water, time consuming. The women take one hour to fill one Jerry can of water as they have to wait in turns to access the shallow wells, and then wait for the water collection from underground. The water collected is not processed in any way or covered before use in the homes. At the time of the survey, Oxfam was on the ground to work together with Servants heart (a non-OLS NGO) to dig bore holes in the area. No latrines were seen, excepted those in the NGO’s compounds, and one in the civil authority residential compound. ACTIONS TAKEN BY THE NGOs The communities of Bawac and Bugaya have received several distributions of IDP kits (buckets, mosquito nets, plastic sheeting, coocking pots,…). 421 kits were distributed by ECHO in January, 1255 kits by UNICEF in July, 100 kits by Tearfund, 300 kits by MEDAIR in August and 4000 pieces of buckets, mosquito nets and Guinea worm filters were distributed by Oxfam in August. This brings to total a number of 5776 kits distributed since the beginning of the year. The population seemed to have access to the market in Yabus to buy non-food items through barter trade.

10 Joint Agency Assessment of Mabaan County County Upper Nile by CEAS and CARE. 11 Rapid Assessment report from Mabaan County, Eastern Upper Nile July 2003.

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The following table summarizes NGO activities in the area:

Table 2

Agency Activities GOAL • Health: Operation of 1 PHCU WFP • Targeted Food Aid distribution and monitoring OXFAM • Hygiene/sanitation

• Training in hygiene and malaria prevention • Training for village hygiene motivators and water program

technical staff • Distribution of Non Food Items • Support drilling of two boreholes and three hand dug wells

TEARFUND • Distribution of 100 kits MEDAIR • Distribution of 300 kits

• Supply of 4 PHCU kits ACF USA / TEARFUND • Nutritional surveillance. UNICEF • Lend OXFAM Geo-physical survey equipment

• Distribution of 1255 kits ECHO • Distribution of 421 kits Servants Heart • Construction of hand-dug well in collaboration with

OXFAM.

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METHODOLOGY

1. Type of survey and sample size The target population of the survey was children aged 6-59 months. The area covered was restricted to a maximum of four hours walking distance from the center of Bawac village. A map showing the area is included in the Appendix. A two-stage cluster sampling to include 732 (using the adjusted sample size) children was planned. At the time of the survey, the total population of the area was estimated at 26,72112 with an under-five population of 5345 (estimated at 20% of the total population). Once on the field, the population was found to be much less: after consultation of the local authorities and community leaders, a total of 2000 children under five was estimated. Then, a sample size of 720 children aged 6-59 months (with a height of 65 cm – 115 cm) is required. This sample size was calculated to provide estimates of prevalence of malnutrition with a 95% confidence interval. 2. Sampling methodology The first sampling frame consisted of recording all the villages within a 4 hours-walk radius from the Bawac village center. Clusters were selected in these villages, so that the probability of being selected proportional to their population size (see appendix for village list and estimated populations). The second level of sampling, is the households selection, once in the selected clusters. The team went to the center of the chosen cluster and randomly selected a direction by spinning a pen. The first household visited was the one that the tip of the pen pointed toward. The remaining households were selected by proximity; with the nearest house in the direction the pen pointed being selected. Where a family consisted of more than one caretaker (a family was defined as people who shared a ‘cooking pot’), only one caretaker was randomly selected. For each caretaker selected, all children aged from 6 to 59 months, with a height between 65 and 115 cm were measured. 3. Data Collection (See appendices for questionnaires) For each child chosen, aged 6 to 59 months old: Age: Recorded with help of a local calendar of event (See appendix for calendar). Sex: Recorded. Weight: Children were weighed without clothes, with SALTER balance 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 children and the mother of the measured child (precision of 1 mm). 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.

12 Estimates given by SRRC on ground.

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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: For each child included in the survey, teams inquired who the caretaker was, their sex and relationship to the children noted 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 in the last 3 months, and if any, the presumed cause of death. 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 NCHS13 references. WFH indices were expressed both in Z-scores and in 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 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 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 13 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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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.14 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, crude mortality rate) and children under 5 years (U-5MR) old. The defined limits are as follows15: 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 10,000people/ day. 5. Field work All participants underwent a four days training, which included a pilot survey. The number of clusters covered by teams in a day varied depending on the location of the villages. Teams were able to cover between one and two clusters in a day. The survey (including training) lasted for a period of 14 days. Three teams of three people each executed the fieldwork.

14 April 13th 1998, Lokichokio 15 Health and nutrition information systems among refugees and displaced persons, Workshop report on refugee’s nutrition, ACC / SCN, Nov 95.

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6. Data analysis Data processing and analysis were carried out using EPI-INFO 5.0 program and EPINUT 2.2 computer software.

RESULTS 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 80 44.2% 101 55.8% 181 24.7% 0.79 18 – 29 93 47.4% 103 52.6% 196 26.7% 0.90 30 – 41 77 51.3% 73 48.7% 150 20.4% 1.05 42 – 53 61 49.2% 63 50.8% 124 16.9% 0.97 54 – 59 46 57.8% 35 42.2% 83 11.3% 1.37

Total 359 48.9% 375 51.1% 734 100.0% 0.96

The distribution by sex shows a slight imbalance with there being more girls than boys in the 6-17 months and more boys than girls in the 54-59 months age groups. The statistics analysis show

-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 S ex

Bugaya August 2003

BoysGirls

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that these differences are not significant and are a sampling artifact (p>0,05). The overall sex ratio of 0.96 allows the validation of the sample selection.

Age distribution shows no significant imbalance. All age groups are equally represented. It is very important to note that the age of the children as given by mothers, was subject to strong recall bias, as dates of birth were not known. A local calendar had to be used to estimate the ages. To a large extent, inclusion of children in the sample was based on satisfaction of the height criteria of 65 – 115cm. 2. Anthropometric analysis 2.1. Acute malnutrition

Distribution of malnutrition in Z-score

Table 4 WEIGHT FOR HEIGHT DISTRIBUTION by AGE

In Z-SCORE

AGE (In months)

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

N N % N % N % N % 06-17 181 7 3.9% 29 16.0% 145 80.1% 0 0.0% 18-29 196 4 2.0% 28 14.3% 164 83.7% 0 0.0% 30-41 150 2 1.3% 10 6.7% 138 92.0% 0 0.0% 42-53 124 0 0.0% 8 6.5% 116 93.5% 0 0.0% 54-59 83 1 1.2% 7 8.4% 75 90.4% 0 0.0%

TOTAL 734 14 1.9% 82 11.2% 638 86.9% 0 0.0%

20% 25% 30%

54-59

42-53

30-41

18-29

06-17

Figure 2A g e D ist r ib ut io n

B ug aya A ug ust 2 0 0 3

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Table 5 WEIGHT/HEIGHT vs. OEDEMA

< -2 SD ≥ -2 SD

Oedema YES Marasmus/Kwashiorkor 0 0.0%

Kwashiorkor 0 0.0%

NO Marasmus

96 13.1% Normal

638 86.9% According to this sample, marasmus is the only form of malnutrition; no kwashiorkor has been found.

There is a slight displacement of the sample curve to the left of the reference curve, indicating a slightly poorer nutritional situation in this population than in the reference one. The mean Z score of the sample -0.68 (SD: 1.29) indicating a fairly under nourished population. The peak in the sample curve indicates a significant number (11.5%) of the children distributed between -3 Z-scores and -2 Z-scores, and therefore at risk to slipping into severely malnourished state.

Table 6

GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP In Z-score

6-59 months (n = 810) 6-29 months (n =261)

Global acute malnutrition 13.1% (10.1%-17.5%) 18.0% (12.9%-24.6%) Severe acute malnutrition 1.9% (0.8%-4.1%) 2.9% (1.1%-6.8%)

The rate of global malnutrition is 13.1% for the children aged 6 to 59 months. Statistically, there is a significant difference between the malnutrition rates of the 6-29 months and the 30-59 months old children: the 6-29 months old present a relative risk 2.30 (1.52-3.48 with 95% Confidence Interval) higher than the 30-59 months old to be malnourished.

Figure 3Z score distribution - Weight-for-Height

Bugaya August 2003

0

5

10

15

20

25

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

Reference

SexCombined

19

Table 7 NUTRITIONAL STATUS BY SEX

In Z-Score

Boys Girls Nutritional status Definition N % N %

Severe malnutrition Weight for Height < -3 or oedema 10 2.8% 4 1.1%

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

44 12.3% 38 10.1%

Normal -2 ≤ Weight for Height and no oedema 305 84.9% 333 88.9%

TOTAL 359 100% 375 100%

The statistics analysis shows that boys and girls present the same risk to be severely or moderately malnourished (p>0.05). The differences observed in the table above are not significant.

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 centers.

Table 8 WEIGHT/HEIGHT: DISTRIBUTION BY AGE

In percentage of the medians AGE

(In months) < 70% ≥ 70% & < 80% ≥ 80% Oedema

N N % N % N % N % 06-17 181 0 0.0% 21 11.6% 160 88.4% 0 0.0% 18-29 196 2 1.0% 19 9.7% 175 89.3% 0 0.0% 30-41 150 1 0.7% 8 5.3% 141 94.0% 0 0.0% 42-53 124 0 0.0% 4 3.2% 120 96.8% 0 0.0% 54-59 83 0 0.0% 5 6.0% 78 94.0% 0 0.0%

TOTAL 734 3 0.4% 58 7.8% 674 91.8% 0 0.0%

Table 9

WEIGHT FOR HEIGHT Vs OEDEMA

< -2 SD ≥ -2 SD

Oedema YES Marasmus/Kwashiorkor 0 0.0%

Kwashiorkor 0 0.0%

NO Marasmus

60 8.2% Normal

674 91.8%

20

Table 10 GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP

In percentage of the median 6-59 months (n = 810) 6-29 months (n = 261) Acute global malnutrition 8.2%(5.6%- 11.7%) 11.1%(7.1%- 16.8%)

Severe acute malnutrition 0.4%(0.0%-2.0%) 0.5%(0.0%-3.4%) As observed is the Z-scores analysis, the 6-29 months old children are more about to be malnourished than the 30-59 months old ones. The relative risk in percentage of the median is 2.21 (1.30 – 3.76 with 95% Confidence Interval).

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 2 0.6% 1 0.3% Moderate malnutrition 70% ≤ Weight for Height < 80% and no

oedema 27 7.5% 30 8.0%

Normal 80% ≤ Weight for Height and no oedema 330 91.9% 344 91.7% TOTAL 359 100% 375 100%

The statistics analysis shows, as previously, that boys and girls have the same probability to be malnourished. 2.2. Risk to Mortality: Children’s MUAC As MUAC overestimates the level of under nutrition in children less than 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

Nutritional

status Total 75 to 90 cm height 90 to 115 cm

height Criteria

N % N % N % <110 mm Severe

malnutrition 3 0.5% 2 0.7% 1 0.3%

110 mm >=MUAC<120mm

Moderate malnutrition

22 3.5% 20 7.4% 2 0.6%

120 mm >=MUAC<125 mm

At risk of malnutrition

52 8.4% 44 16.2% 8 2.3%

MUAC>=125 Normal

543 87.6% 205 75.7% 338 96.8%

TOTAL 620 100% 271 100% 349 100%

21

According to the MUAC measurement, 0.5% of the children are severely malnourished and therefore at high risk to mortality. 3.5% are moderately malnourished, and 8.4% are at the ‘border’ line and, therefore, at risk to malnutrition. 2.3. Adult Malnutrition: Caretaker’s MUAC

A total of 532 caretakers have been measured: as all the children of each caretaker were included in the survey, there are less caretakers than children measured.

Table 13 MUAC DISTRIBUTION ACCORDING TO NUTRITIONAL STATUS

Criteria Nutritional status N %

<185 mm Malnourished 6 1.1%

185 mm >=MUAC<220mm At risk to malnutrition 56 10.5%

MUAC>= 220mm ‘Well Nourished’ 470 88.3%

TOTAL 532 100%

Although the proportion of the caretakers that are wasted is not very high [1.1%], the proportion of those that are energy deficient is significant [10.5%]. Considering that 95.4 % of the caretakers were mothers, this poor nutritional status is likely to have a negative impact on their collective roles and duties such as child-care provision and ensuring household food security.

Table 14 CORRELATION BETWEEN CARETAKER AND CHILDREN NUTRITIONAL STATUS

W / H < -2 for the child W / H >=-2 for the childMUAC < 22.0 cm for the caretaker 45 220 MUAC >=22.0 cm for the caretaker 51 418 TOTAL 96 638 The statistical analysis shows a positive correlation between the nutritional status of the caretaker and the one of the child. The relative risk for a child to be malnourished is 1.56 times higher if his caretaker is at risk of malnutrition, that if the caretaker is well nourished. On the 734 children, 528 of them were in charge of a female (521 mothers or 7 other), and 18 were in charge of a male (fathers or other). No correlation was found between the sex of the caretaker and his/her link with the child (mother, father or other), and the nutritional status of the children (p>0.05). 3. Measles vaccination coverage Measles vaccination is administered from the age of 9 months. Children 9-59 months were included in the analysis. A total of 687 children were included in the analysis. Measles vaccination coverage is non existent (0.0% according to EPI card and 0.0% according to the mother).

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4. Household status Table 14

Status N % Residents 504 94.8% Temporary Residents (in transit) 14 2.6% Internally Displaced 14 2.6% Total 532 100%

The larger proportion of the surveyed families (94.8 %) is from households resident in the area. 2.6% of them are temporary residents, and 2.6 % are internally displaced. From this last category, most were coming from the Renk Dinkas tribe, and others from Shilluk kingdom, and settle down in Bawac as their areas were insecure.. No statistical difference has been observed between the status of the family and the nutritional status of the children (p>0.05). 5. Composition of the household

Table 15

Age group N % 0 to 59 months 1259 32.9 Adults 2559 67.1

Total 3,818 100

Six hundred and thirty five (635) households were visited during the survey, who had or not children below 5 years old. The mean number of under-five per household is 1.99 (SD: 0.97) and the mean number of the over five per household is 4.04 (SD: 1.59). 6. Mortality rate - Under Five There were 1259 children under 5 years old alive on the day of the survey, and 117 children under 5 had died within the preceding 3 months. Mortality Rate (MR) = (117/((1259+1259+117)/2) x 10,000) /90 = 8.88/10,000 people/day According to the above formula, the under-five mortality rate is 8.9/10,000/day.

- Crude mortality rate (CMR) There were 3818 people alive during the survey period and 174 people had died within the preceding 3 months. MR= ((174/((3818+3818+174)/2) x 10,000) /90 = 4.44 /10,000 persons/day According to the above formula, the CMR is 4.4/10,000/day.

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7. Causes of mortality

- Under five Table 16

CAUSE OF DEATH Cause of Death N % Bloody diarrhea 35 29.9Malnutrition 20 17.0Fever 19 16.2Lower respiratory infection 18 15.4Simple diarrhea 13 11.1Other 6 5.2 Accident 4 3.5 Measles 2 1.7 TOTAL 117 100 Other causes include gunshot wound (1), drown (1), sudden unknown death (1), paralysis (2) and stomach pain (1). - Above five

Table 17 CAUSE OF DEATH

Cause of death N % Bloody diarrhea 18 31.6Lower respiratory infection. 13 22.7Fever 11 19.3Other 14 24.6Diarrhea 1 1.8 Malnutrition 0 0 Total 57 100

‘Other’ causes included gunshot wound (6), accident (5), shooting oneself (1) and lightening (2).

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DISCUSSION-RECOMMENDATIONS DISCUSSION The rates of Global Acute Malnutrition for children aged 6 to 59 months (13.1%) and Severe Acute Malnutrition (1.9%) according to Z-scores16, are below the emergency level (15% for GAM and 4% fro SAM). Nevertheless, the mortality rate for under five (8.9/10,000/day) and the crude mortality rate (4.4/10,000/day) are more than twice the emergency cut of rate (4/10,000/day and 2/10,000/day respectively). The main presumed cause of death for the under-five was bloody diarrhea17(30%), malnutrition (17%) and fever (16%). Among the over five, the main causes were bloody diarrhea (15%), and lower respiratory infection (11%). As no previous assessment has been done in this province, it is difficult to know whether the situation is now improving, which could explain the reasonable prevalence found in this survey. As most of the deaths cases were found in the under five group (117 cases out of 174 in total), this indicates that the under-five, who usually are the most vulnerable age group in any population, were the first to be affected. Statistical comparative analysis of malnutrition rates for children aged 6-29 months and 30-59 months indicate a significance difference between the 2 age-groups (p<0.05). The 6-29 age group is at higher risk than those who are in the 30-59-age bracket, with a relative risk equal to 2,30 (C.I. 95%: 1,52 – 3,48) to be malnourished. Sex has no incidence on the rates of malnutrition. MUAC results for the children show that 4.0% of children are moderately to severely malnourished. In addition, 8.4% are at risk to malnutrition, while 87.6% are well nourished. It is likely that the well nourished may slip into the group at risk while those at risk may slip to the severely malnourished group if the situation does not improve. The nutritional situation is not revealing an emergency situation, as compared with the rates observed in other areas in southern Sudan. Nevertheless, malnutrition is a worsening factor of any other pathology, for children below 5 years more particularly, and according to the high mortality rate, it remain an issue to be followed up. HEALTH The lack of preventive health care coupled with long distances for referral’s cases are a hindrance to get proper health care. This may explain the very high mortality rates, that are consequent to preventable causes among the children, as shown during the survey. Indeed, the main suspected cause of death found in the mortality survey for both under five’s (30%), and over five’s (15%) was bloody diarrhea. March-June 2003 morbidity reports from the GOAL PHCU in Bugaya confirm this information: it indicates that watery diarrhea (25%)18, malaria (16.9%) and bloody diarrhea (9.2%) were the main morbidity causes for under five. The main morbidity causes recorded for over five were malaria (22.9%), watery diarrhea (18.4%) and lower respiratory infection (12.2%). The children were seen to have largely protruding bellies, possibly due to worms infection, as well as reddish colored hair, that may possibly be caused by micro nutrients deficiency.

16 WHO classification of wasting prevalence in populations. 17 Diarrhea is defined as the passage of abnormally loose or fluid stools more frequently than normal causing death due to infection. 18 GOAL morbidity reports March-June 2003.

25

Measles immunization coverage for children aged 9 to 59 months is non-existent (0.0% of immunized children according to both caretaker and EPI card). This should be addressed as a matter of urgency: it poses the risk of a measles outbreak, as 2 cases of death due to measles have been recorded in this survey. This may be worsened by the fact that the houses are very close to each other and overcrowded. Vaccination would greatly reduce the possibility of an epidemic and consequently decrease the number of children susceptible to secondary infection. Measles is also know to be a factor of malnutrition. WHO did a polio immunization campaign in March/April this year, and plans to do a supplementary immunization campaign in October/November. A joint agency assessment, done by CEAS and CARE in January 2003, reported that all the mothers reported that their children have been born at home, without any trained assistant. Moreover, almost all mothers reported the death of at least one of their children at birth. This is an indication that there are no trained / traditional midwives, which contributes to the high mortality rate at childbirth. The lack of health facilities and the high level of preventable diseases in the area surveyed are the major issue revealed during the survey. The high mortality rates observed, even with the lack of precision due to the poor knowledge of the caretakers, highlight the urgent need of an intervention in the field of health. FOOD SECURITY In 2002, CEAS (Church Ecumenical Action in Sudan) conducted a one month training for 7 food security extension workers in Yabus. They are currently doing agriculture extension education among the community. The problems cited as affecting cultivation are attacks by pests/diseases and a lack of pesticides. Other issues of concern include birds attack, low rainfall and a lack of a availability of tools. The tools used the most by the community are the ones locally made by the blacksmith: local hoe (alla), ax, panga, and sickle. The major limitation in accessing adequate tools is the lack of raw materials. The community also expressed the desire of having ox-plough training, which would enable them to cultivate larger farms. No other action has been recorded until August 2003. Food security is also an issue to be addressed. Further investigations would required to be done to know whether the coming harvests will fulfill the population needs, and if the seeds will remain enough for next year. In between, the global food distribution by WFP is recommended to remain at 75% level. WATER AND SANITATION. Water and sanitation seems to be the main cause of the sanitary situation in the areas, as the high mortality rates are mostly due to water-related or water-born diseases. An interview with the medical assistant in Bugaya PHCU indicated an urgent need for hygiene promotion, as patients seem to present repeated incidences of disease. There has been no hygiene/water sanitation activities conducted previously in the area: previous attempts to conduct some were stopped by the security personnel of the area. During the time of the survey, Oxfam GB was conducting a two-weeks hygiene promotion and malaria prevention program, and looking at the possibility of partnering with Servants heart to dig bore holes. The training classes seemed to go on smoothly, without interference, and were conducted in both Bawac and Bugaya villages. Latrines are inexistent.

26

The water and sanitation situation is critical and needs to be addressed urgently. An assessment is required to be done, and beside any intervention in this field, health and hygiene education have to be provided. RECOMMENDATIONS • GOAL/ OXFAM/MEDAIR to improve quality of health care delivery by introducing hygiene

promotion, de-worming, and community outreach activities. • GOAL /MEDAIR/OXFAM to institute a measles immunization campaign and training of

traditional birth attendants • GOAL / TEARFUND /ACF-USA to open a therapeutic feeding center since the under-five

mortality rate is above emergency level and due to the high prevalence of diarrhea disease. • WFP should continue food aid delivery at 75% ration level. • ACF-USA/TEARFUND to maintain nutritional surveillance through surveys. • UNICEF/OXFAM/Servant Heart to provide safe water through installing bore holes in both

villages. • FAO/CARE to closely monitor the food situation of the population in the area and introduce

ox-plough training. • Dissemination of results and recommendation to local community on the ground.

27

APPENDIX Appendix 1 Nutritional Survey Cluster Selection Bugaya August 2003

Village Walking distances

Est. population

Est. <5 population

Cumulative <5 population

No. Assigned

Clusters

Leeka 2 hr 293 58 58 1-58 - Yawaaje 2 hr 326 65 123 58-123 1 Dangani 1 2 hr 473 94 217 123-217 2,3 Dangani 2 2 hr 338 67 284 217-284 4 Ballaji 2 hr 293 58 342 284-342 5 Batil 3 hr 772 154 496 342-496 6,7 Bounkany 2hr 619 123 619 496-619 8,9 Hilafull 3 hr 307 61 680 619-680 10 Buny 0 hr 130 26 706 680-706 11 Bawac/ Gama 20 min 228 45 828 783-828 12 Korfar 2 hr 881 176 1004 828-1004 13,14,15 Keiwaji 0 min 924 184 1188 1004-1188 16,17 Banyenen 2 hr 236 47 1235 118-1235 18 Banulga 2 hr 737 147 1382 1235-1382 19,20 Jamam 2 hr 926 185 1567 1382-1567 21,22,23 Gega 2 hr 572 114 1681 1567-1681 24,25 Kwolgon 2 hr 476 95 1776 1681-1776 26 Adar 2 0 min 783 156 1932 1776-1932 27,28,29

Tibil 2 2 hr 157 31 1963 1932-1963 - Banetu 2hr 170 34 1997 1963-1997 30

1st randomly drawn # =65 sampling interval = 66.5 According to these data, the selected clusters were: One cluster in Yawaaje, Dangani 2, Ballaji, Hilafull, Buny, Bawac/ Gama, Banyenen, Kwolgon, Banetu Two clusters in Dangani 1, Batil, Bounkany, Keiwaji, Banulga, Gega Three clusters in Korfar, Jamam, Adar 2. Calculation of the number of children to survey: The following formula is used: Total number= 2x [n / (1+(n/N))] Where: N= the number of the total targeted population. Here, 2000 children under 5. n= the number of children required for a survey in a total population 2 is the multiplication factor due to the cluster sampling. So Total number= 2x [450 / (1+ (450+2000))] = 731,7=732. As 30 clusters are surveyed to ensure that the sample is representative, the number of children per cluster is 732/30=24.4=25.

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Appendix 2 DATE: TEAM N°.: VILLAGE: CLUSTER N°.:

CHILDREN

CARETAKER

N°. Family N°.

Age Mths

Sex M/F

Weight Kg

Height cm

Oedema Y/N

MUAC

mm

EPI Card Y/N

Measles C/M/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 village (cattle camp, water point,…) Parental link**: 1=mother, 2=other person Measles***: C=according to EPI card, M=according to mother, N=not immunized against measles

ANTHROPOMETRIC SURVEY QUESTIONNAIRE

29

DATE: TEAM LEADER:

VILLAGE: TEAM NUMBER : < 5 YEARS > = 5 YEARS

N° Number of < 5

Years alive today

Number of dead in last 3

months CAUSE*

NUMBER >/= 5 Years alive

today

Number of dead>/=5 years in the last 3 months

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 *1= Diarrhea (simple), 2=Diarrhoea (bloody), 3=Measles, 4=Fever, 5=Lower Respiratory Infection, 6=Malnutrition, 7=Accident, 8=Other (write presumed cause of death)

MORTALITY SURVEY QUESTIONNAIRE

30

Appendix 3 Community Prioritization of Needs

1. Health. 2. School. 3. Food. 4. Agricultural tools. 5. Feeding centre. 6. Water. 7. Mosquito net. 8. Fishing nets.