International Notes Health Assessment of the Population Affected by Flood Conditions -- Khartoum, Sudan

In early August 1988, severe floods struck Khartoum, the capital of the Democratic Republic of the Sudan. Khartoum, situated at the junction of the White Nile and Blue Nile rivers, has an estimated population of 4.5 million. Approximately 1.5 to 2 million of these persons have been displaced from the southern and western regions of Sudan.

On August 4, the Khartoum area received 8.4 inches (210 mm) of rain in 24 hours, more than twice the usual annual rainfall. Heavy rains also fell on August 11 and 13. The rains and subsequent ground flooding destroyed an estimated 127,000 dwellings that had housed approximately 750,000 inhabitants (most of whom were displaced persons). In addition, food and water supplies, sanitation, transportation, and communications were seriously disrupted. The Sudanese Ministry of Health (MOH), with the concurrence of the U.S. Agency for International Development (USAID), asked CDC to assist in assessing the health and nutritional status of the flood-affected Khartoum population. Beginning in August, this assessment was performed in collaboration with the Sudanese MOH, USAID, World Health Organization (WHO), and private volunteer agencies.

A disease surveillance system was established in the three urban districts by using 24 health facilities and three hospitals as sentinel sites. The sites, which were not chosen randomly, included many clinics that served displaced persons. A standardized reporting form was used to monitor the number of patients (by age group) with watery diarrhea, dysentery, jaundice, malaria, measles, acute respiratory infections, and "other diseases," as well as hospital and clinic mortality. Three mobile health teams collected these forms on alternate days from the sentinel sites and also assisted in evaluating case management and instituting oral rehydration units. As part of the surveillance for diarrheal disease, alkaline peptone water and Cary-Blair medium were distributed to the health facilities and three hospitals for use in obtaining stool specimens from persons suspected to have cholera and dysentery. Specimens were processed at the central public health laboratory. Disease trends were monitored by calculating daily proportional morbidity, i.e., the number of patients in each disease category/total number of patients seen that day. The MOH received surveillance reports each day, and other health agencies were provided information on alternate days.

In the areas most severely affected by the flood, 16 mobile teams from the MOH Expanded Program on Immunization provided measles immunizations, vitamin A supplementation, and nutritional surveillance. Nutritional status was assessed by measuring the mid-upper-arm circumference (MUAC) of all children 1-5 years of age in these areas. To determine the prevalence of malaria, the MOH conducted fever surveys (with thick/thin blood smears) in three communities and two clinics.

Although 15 suspected outbreaks were investigated between August 21 and August 31, no outbreaks of typhoid, cholera, or measles were confirmed. Diarrhea was the most common specific cause of morbidity, accounting for 9217 (31%) of 29,526 reported visits (Figure 1). Shigella boydii was isolated from one of 38 stool cultures from a survey of diarrheal illness at a sentinel site; the patient had bloody diarrhea. None of the 48 stool specimens from patients with severe diarrhea yielded Vibrio cholerae. In the three hospitals surveyed, the case-fatality rate in August 1988 for hospitalized patients with diarrheal illness was 11% (68/623), compared with 9% (42/447) in August 1987.

Malaria accounted for 20% of morbidity reported by sentinel sites between August 18 and August 31 but rose to 30% of total morbidity in the first week of September. Surveys showed that malaria prevalence rates ranged from 11% to 19% (febrile and afebrile) in the community and from 21% to 46% in (febrile) clinic patients.

Nutritional assessment of 17,639 children aged 1-5 years indicated that 1682 (10%) were severely undernourished (MUAC less than 12.5 cm) and that 2391 (14%) were moderately undernourished (MUAC 12.5 cm-13.4 cm). The proportion of children severely and moderately undernourished in each of the three districts was approximately equal. In follow-up, between September 17 and October 8, 1988, the MOH performed random cluster sample surveys in 19 high-risk areas using weight-for-height measurements. Of 5517 children less than 5 years of age measured, 270 (4.9%) were severely undernourished, and 767 (13.9%) were moderately undernourished, i.e., greater than 3 standard deviations and 2-3 standard deviations, respectively, below the median of the WHO reference population.

In flood-affected areas, measles vaccine was administered to approximately 40,000 (73%) of an estimated 55,000 unimmunized children between the ages of 6 months and 5 years, raising overall measles vaccine coverage from 55% to 85%.

Recommendations emphasized: 1) increased distribution of basic rations in the most severely affected areas and supplementary feeding for vulnerable groups in all flood-affected areas, 2) ongoing nutritional surveillance through weight-for-height surveys in selected populations, 3) early diagnosis and presumptive chloroquine treatment for persons with fever to reduce malaria mortality, 4) increased distribution of measles vaccine and oral rehydration salts, and 5) establishment of a rapid response epidemiology unit within the MOH that would help coordinate future health emergency relief efforts. Reported by: Div of Epidemiology, Div of Medical Statistics, National Program for the Control of Diarrheal Diseases, Expanded Program on Immunization, Malaria Control Program, Div of Nutrition, Sudanese Ministry of Health. US Agency for International Development, Khartoum, Sudan; Office of Foreign Disaster Assistance, US Agency for International Development, Washington, DC. Technical Support Div, International Health Program Office; Div of Immunization, Center for Prevention Svcs; Div of Field Svcs, Epidemiology Program Office; Enteric Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Poor nutritional status appeared to be the main health problem for displaced persons and others in Khartoum. The prevalence of moderate/severe undernutrition (24%) in children aged 1-5 years is substantially higher than that reported from developing countries in Africa during noncrisis periods (0.4%-4.4%) (1). Because MUAC is not an exact indicator of nutritional status (2-4), the MOH decided to monitor nutritional status by obtaining weight-for-height measurements on random samples of 300 children in each of 19 flood-affected areas. The results of the follow-up survey confirmed the high rates of undernutrition in these areas. The direct impact of the flood disaster on the nutritional status of the assessed children is difficult to evaluate without prior survey information; however, the extent of their current undernutrition is associated with an increased risk of mortality (5,6).

Despite the poor water supply and sanitation in the flood-affected areas, cholera and typhoid outbreaks did not occur. Relief efforts appropriately focused on disease surveillance and case detection, along with appropriate case management that included the use of oral rehydration for diarrheal disease (7,8). Recommendations did not include mass vaccination campaigns against cholera and typhoid for the following reasons: 1) no documented large-scale outbreaks have occurred following natural disasters elsewhere; 2) typhoid and cholera vaccines offer only low and short-term individual protection and little or no protection against spread of disease; the provision of clean drinking water is more appropriate to prevent transmission; 3) reported vaccine efficacies of 50% for cholera and 70%-90% for typhoid usually occur after the second dose, and two doses would have been difficult to administer to a large proportion of the population under emergency conditions; 4) a massive typhoid and cholera vaccination program would have diverted scarce resources from other high-priority activities; and 5) mass vaccination for cholera and typhoid may provide a false sense of security about the risk of disease, resulting in the neglect of effective control measures (8).

Measles is a serious threat to undernourished persons, especially to those living in refugee/displaced person camps and other densely populated settings with large numbers of young children (9,10). The absence of measles outbreaks after the Sudan floods may have resulted from the relatively high rates of vaccine coverage in Khartoum before the floods and the additional targeted coverage achieved by the mobile teams.

Given the environmental conditions, the increase in malaria prevalence may have been predicted (11). Case detection and prompt treatment is the preferred malaria control strategy in a disaster setting. When this control measure has been completed, additional strategies, such as larvicidal and insecticidal programs, might be considered. References

1. Serdula MK, Aphane JM, Kunene PF, et al. Acute and chronic undernutrition in Swaziland. J Trop Pediatr 1987;33:35-42. 2.Rees DG, Henry CJK, Diskett P, Shears P. Measures of nutritional status: survey of young children in north-east Brazil. Lancet 1987;1:87-9. 3.Briend A, Rowland MGM, Wojtyniak B. Measures of nutritional status (Letter). Lancet 1987;1:1098-9. 4.Trowbridge FL, Staehling N. Sensitivity and specificity of arm circumference indicators in identifying malnourished children. Am J Clin Nutr 1980;33:687-96. 5.Chen LC, Chowdhury A, Huffman SL. Anthropometric assessment of energy-protein malnutrition and subsequent risk of mortality among preschool aged children. Am J Clin Nutr 1980;33:1836-45. 6.Trowbridge FL, Sommer A. Nutritional anthropometry and mortality risk (Letter). Am J Clin Nutr 1981;34:2591-2. 7.Spencer HC, Campbell CC, Romero A, et al. Disease surveillance and decision-making after the 1976 Guatemala earthquake. Lancet 1977;2:181-4. 8.Seaman J, Leivesley S, Hogg C. Epidemiology of natural disasters. In: Klingberg MA, Papier C, eds. Contributions to epidemiology and biostatistics. Vol 5. New York: Karger, 1984:49-69,140-56. 9.Shears P, Berry AM, Murphy R, Nabil MA. Epidemiological assessment of the health and nutrition of Ethiopian refugees in emergency camps in Sudan, 1985. Br Med J 1987; 295:314-8. 10.Toole MJ, Steketee RW, Waldman RJ, Nieburg P. Measles prevention and control in emergency settings. Bull WHO (in press). 11.Mason J, Cavalie P. Malaria epidemic in Haiti following a hurricane. Am J Trop Med Hyg 1965;14:533-9. 

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