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Health and Nutritional Status of Liberian Refugee Children -- Guinea, 1990

Since December 1989, civil strife in Liberia has caused mass displacement of persons to neighboring Guinea and Ivory Coast (Figure 1). Liberian refugees initially settled in the Forest Region of Guinea and shared food and shelter with members of the same ethnic groups (mainly Gio and Mano) already residing in the area. The number of refugees overwhelmed the capacity of affected villages to provide basic needs, and camp-like settlements were established that received substantial external relief. In May 1990, to determine appropriate priorities for relief assistance, the health and nutritional status of Liberian refugees in the Forest Region of Guinea was assessed by CDC for the U.S. Department of State's Bureau for Refugee Programs. In May, an estimated 80,000 refugees were in the area; by December, the number had increased to an estimated 400,000. This report summarizes findings of the health and nutritional assessment of Liberian refugee children.

Thirty clusters were selected from a list of villages and camps with refugee populations greater than 50; the sampling probability was proportional to population size. In each cluster, one household was randomly chosen as the starting point, and adjacent houses were visited until 30 children aged 6 months to 5 years were identified. The survey included Liberian refugees and Guineans and assessed weight and height (recumbent length in children less than 85 cm), measles vaccination status (by history and vaccination card), presence of pretibial edema (indicative of kwashiorkor), and the occurrence of diarrheal episodes and other diseases. Clinical signs of avitaminosis A (Bitot spots and/or xerophthalmia) were assessed in a nonrandomly selected subsample of 200 children.

Anthropometric results were determined using z-scores and percentages of the median of the National Center for Health Statistics/World Health Organization/CDC reference population (1,2); acute malnutrition was defined as weight-for-height z-score less than -2 or weight-for-height less than 80% of the median of the reference population. Based on both measures, the prevalence of malnutrition was similar in both Guinean residents and Liberian refugees (Table 1). Severe malnutrition (weight-for-height less than 70% of the median of the reference population) was present in 0.3% and 0.5% of Guinean and Liberian children, respectively. Pretibial edema was detected in 1% of children. None of the children in the subsample had clinical signs of avitaminosis A.

In March 1990, an assessment by Medecins Sans Frontieres Belgium (MSF) determined that 3.1% of children were acutely malnourished (defined as weight-for-height less than 80% of the median of the reference population) (J. Van der Heyden, MSF, unpublished data, 1990) compared with 5.3% in the CDC survey (confidence intervals for the two surveys overlap).

Distribution of dry food rations to refugees began in April, coinciding with the rainy season in the Forest Region of Guinea--a period when local food stocks normally diminish rapidly. The influx of Liberian refugees accelerated depletion of local food supplies, affecting food availability for both refugees and resident Guineans. However, rations were not provided to the resident Guineans.

Based on responses from mothers, measles vaccination coverage rates were 27% and 47% in Guinean and Liberian children, respectively. However, the coverage rates based on vaccination record cards were 9% for Guineans and 14% for Liberians. Sixty-five percent of the mothers reported that their children had had an episode of diarrhea during the 2-week period before the survey; 11%, an acute respiratory illness; and 40%, a febrile episode.

Consistent with current recommendations for refugee populations, beginning in February, MSF and local health authorities began to immunize all children aged 6 months to 5 years against measles; in July, MSF reported a measles vaccination coverage level of 70%, indicating substantial improvement over previous levels (N. Keitha, Regional Ministry of Health, unpublished data, 1990).

Recommendations of the assessment team included the need to accelerate food distribution; strengthen surveillance systems for food availability, nutritional status, morbidity, and mortality; improve the existing primary health-care structure (i.e., provide ready access to health workers); intensify promotion of oral rehydration therapy; and improve the water supply. Reported by: Bur for Refugee Programs, US Department of State. Medecins Sans Frontieres, Belgium. Technical Support Div, International Health Program Office, CDC.

Editorial Note

Editorial Note: Media coverage of the situation in Liberia had emphasized the civil strife but did not address the public health problems of refugees in Guinea and Ivory Coast. The response by the international donor community was probably delayed by limited awareness and lack of reliable data on the extent of problems.

Despite these delays in international aid, the prevalence of acute malnutrition in both Liberian refugees and local Guineans is similar to rates reported for African populations in noncrisis situations (3). However, as food availability declines while the refugee influx continues, the affected population will become more dependent on external relief. The most recent harvest began in December but did not provide sufficient quantities of food. Moreover, the establishment of a reliable food distribution system is still hampered by logistic constraints (e.g., lack of coordination between donor agencies and inadequate roads and bridges). Deterioration in the nutritional status and associated mortality in Guineans and Liberian refugees can be prevented only through regular distribution of adequate food rations (4). Ongoing surveillance of the nutritional status of these groups is essential to allow immediate detection of changes.

The risk for measles outbreaks is high in refugee settings because of overcrowding and the constant influx of susceptible persons (5). Thus, further efforts are needed to increase measles vaccination coverage to prevent outbreaks. The high incidence of reported diarrheal disease probably reflects poor sanitation and unsafe water sources.

Early access to information by host countries and international donors should facilitate planning and effective coordination of relief assistance to refugee populations. The problems described in this report underscore the importance of early assessment of refugee situations (6).


  1. World Health Organization Working Group. Use and interpretation of anthropometric indicators of nutritional status. Bull WHO 1986;64:929-41.

  2. 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.

  3. Serdula MK, Seward J. Diet, malnutrition, and mortality in Sub-Saharan Africa. Les Annales de l'IFORD 1988;12:35-63.

  4. Toole MJ, Waldman RJ. Prevention of excess mortality in refugee and displaced populations in developing countries. JAMA 1990;263:3296-302.

  5. Toole MJ, Steketee RW, Waldman RJ, Nieburg P. Measles prevention and control in emergency settings. Bull WHO 1989;67:381-88.

  6. World Health Organization. Rapid health assessment in sudden population displacements. Geneva: World Health Organization, 1990; no. ERO/EPR/90.1.7.

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