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International Notes Nutritional Status of Somali Refugees -- Eastern Ethiopia, September 1988-May 1989

In summer 1988, as many as 400,000 refugees from northern Somalia entered remote areas of eastern Ethiopia. The refugees were settled in one camp near the hamlet of Hartisheik, one camp in Harshin (about 50 km beyond Hartisheik), and three camps near Aware. There are no wells at any of these locations; however, water can be trucked approximately 100 km from the town of Jijiga (Figure 1).

As part of routine nutritional surveillance in the camps, cluster sample surveys (to measure weight-for-height (Wt/Ht)) of children less than 5 years of age were done in Hartisheik and Harshin between September 1988 and May 1989 (Table 1, see page 461) (1). The surveys were carried out by Save the Children Fund (SCF) (United Kingdom), a private voluntary organization working in collaboration with the Ethiopian government and United Nations (U.N.) agencies. Moderate malnutrition was defined as Wt/Ht between 70% and 79% of the median of the reference population; severe malnutrition, as less than 70%. Only 40% of children identified in the January survey as either moderately or severely malnourished were registered in supplementary feeding programs in the camps.

Also, SCF performed a mass screening of all children less than 5 years of age in Hartisheik in January-February 1989, using mid-upper arm circumference (MUAC) as the anthropometric measurement. When a MUAC of less than 13.5 cm was used as the cutoff value, 28.7% of the 11,191 children screened were found to be moderately or severely malnourished, a finding similar to that in the March survey. During the mass screening, 66,663 persons of all ages were examined by trained community health workers; 1437 refugees (2.1%) were found to have symptoms and/or signs suggestive of clinical scurvy (i.e., bleeding gums and painful, swollen joints). Of a subsample of 538 of these persons, 350 (65%) had the diagnosis of scurvy confirmed by a physician. Thus, the prevalence of scurvy by clinical examination was approximately 1%-2% in Hartisheik. Although mortality reporting was not comprehensive for September 1988-May 1989, 60 cases of hepatitis and four hepatitis-related deaths were reported in March. Identification of the type of hepatitis was not possible; however, enterically transmitted non-A, non-B hepatitis has previously been reported among East African refugees (2).

Between the September and January surveys, deliveries of water to the camps improved; however, delivery of rations (cereal, vegetable oil, and legumes) to Hartisheik was intermittent. Lentils and vegetable oil were not available for regular food distributions, and cereal was the only consistent source of calories. In addition, incomplete census data for the camps contributed to delays in the distribution of rations; consequently, some families may have received only 10-day rations for 3- to 4-week periods. Reported by: Save the Children Fund, London, United Kingdom. Bur for Refugee Programs, US Department of State. Technical Support Div, International Health Program Office; Div of Nutrition, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: In general, refugees are dependent on food rations provided by international donors and transported and distributed by U.N. agencies and the government of the host country. Periodic surveys continue to document the critical problem with malnutrition among Somali refugee children in two camps in eastern Ethiopia. The malnutrition prevalence rates reported for these Somali refugee children are higher than those reported among refugee populations in Malawi and Thailand but are generally comparable with those reported from Somalia and Sudan (Table 2) (3). Children with Wt/Ht measurements less than 80% of the World Health Organization reference population median are at increased risk of mortality (4,5). The malnutrition prevalence rates reported in Hartisheik (March and May) and Harshin (March) are similar to those in refugee situations in which high mortality has been documented (e.g., Somalia and Sudan) (6). Collection of mortality data in refugee emergencies is now a standard recommendation of the Office of the United Nations High Commissioner for Refugees (7). Mortality data are particularly important in settings in which malnutrition rates are high because deaths among the most malnourished can reduce the number and prevalence of malnourished survivors, thereby complicating interpretation of nutritional survey data by relief agencies and organizations (8).

Scurvy, a fatal illness if untreated, has occurred among different East African ref ugee populations in recent years (9-12)--at least in part because rations provided to refugees often fail to provide the minimum daily vitamin C requirement of 6 mg (13). To a great extent, logistic difficulties in delivering sufficient quantities of vitamin C containing foods (e.g., fresh vegetables and fruit) to refugees in remote regions of Africa may be responsible for this problem. Cereals enriched with vitamin C prior to shipment might help to reduce the occurrence of scurvy, although heat stability of vitamin C is known to be a problem.

Effective strategies to improve nutritional assessment and intervention at Hartisheik and Harshin could include 1) regular and complete distribution of rations-- including foods that contain vitamin C, 2) expansion of the system of supplementary and therapeutic feeding programs to achieve better coverage of malnourished children, 3) more complete collection of mortality data, and 4) continued monitoring of children's nutritional status. As of June 1989, the weekly distribution of vitamin C tablets in these camps to all children less than 5 years of age and to pregnant and lactating women and the active enrollment of malnourished children in supplementary feeding programs have been instituted. The Ethiopia Ministry of Health has recently published a revised set of health relief management guidelines (14) that describe principles for the management of relief programs for refugees and disaster-affected populations. Because inaccurate refugee census data are associated with inequitable distribution of rations, sustained and coordinated efforts by all participating relief agencies will be required to solve this problem.

References

1.World Health Organization. Measuring change in nutritional status: guidelines for assessing the nutritional impact of supplementary feeding programmes for vulnerable groups. Geneva: World Health Organization, 1983.

2.CDC. Enterically transmitted non-A, non-B hepatitis--East Africa. MMWR 1987;36:241-4. 3.CDC. Nutritional and health assessment of Mozambican refugees in two districts of Malawi, 1988. MMWR 1988;37:641-3.

4.Chen LC, Chowdhury AKMA, 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.

5.Heywood P. The functional significance of malnutrition--growth and prospective risk of death in the highlands of Papua New Guinea. J Food Nutr 1982;39:13-9.

6.Toole MJ, Waldman RJ. An analysis of mortality trends among refugee populations in Somalia, Sudan, and Thailand. Bull WHO 1988;66:237-47.

7.Office of the United Nations High Commissioner for Refugees. Handbook for emergencies. Geneva: United Nations High Commissioner for Refugees, 1982:100.

8.Nieburg P, Berry A, Steketee R, Binkin N, Dondero T, Nabil A. Limitations of anthropometry during acute food shortages: high mortality can mask refugees' deteriorating nutritional status. Disasters 1988;12:253-8.

9.Magan AM, Warsame M, Ali-Salad A-K, Toole MJ. An outbreak of scurvy in Somali refugee camps. Disasters 1983;7:94-7. 10.Desenclos J-C, Berry AM, Padt R, Farah B, Segala C, Nabil AM. Epidemiologic patterns of scurvy among Ethiopian refugees. Bull WHO (in press). 11.World Health Organization. Nutrition: scurvy and food aid among refugees in the Horn of Africa. Wkly Epidemiol Rec 1989;64:85-7. 12.Seaman J, Rivers JPW. Scurvy and anaemia in refugees. Lancet 1989;1:1204. 13.Brown RE, Berry A. Prevention of malnutrition and supplementary feeding programs. In: Sandler RH, Jones TC, eds. Medical care of refugees. New York: Oxford Univ Press, 1987:113-24. 14.Ethiopia Ministry of Health. Ethiopia: health relief management guidelines. 3rd ed. Addis Ababa: Ethiopia Ministry of Health, 1987.

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