Abstracts of Selected IERHB Nutrition Studies
Abstract: Clinical trial to determine the most effective method to treat moderate anemia among refugee children in Kigoma region, Tanzania.
Background: Anemia is an important cause of morbidity and mortality among African children. Among Burundian refugees < 5 years of age in Tanzania, the anemia-specific mortality in 1997 was four times the baseline rate for all-cause mortality in developing countries. Treatment of anemia was ineffective. CDC, in collaboration with the Tanzanian Ministry of Health,the UN High Commissioner for Refugees (UNHCR), CARE, and the International Rescue Committee (IRC), initiated a study to test alternative therapies from March through September 1998.
Methods: In a randomized, double-blind intervention trial, 215 anemic children were evaluated to determine an effective and feasible treatment for moderate anemia. After initial treatment for helminth infection with mebendazole and malaria infection with sulfadoxine-pyrimethamine (SP), all children received oral doses of iron and folic acid thrice weekly for 12 weeks, one dose per week of which was given as directly observed therapy at a home visit. Group I received a vitamin placebo thrice-weekly and treatment with chloroquine for any diagnosed malaria infection. Group II received a vitamin placebo and monthly malaria treatment with SP. Group III received vitamins A and C (VAC) thrice-weekly plus SP monthly. Outcome measures included hemoglobin and transferrin receptor (TfR) levels.Results: The mean hemoglobin level for all children increased by week 12, and the prevalence of anemia (hemoglobin < 11.0 g/dL) decreased from 100% to 66%. There were no significant differences in hemoglobin levels among groups. In contrast, a greater proportion of children in Group III had normal iron stores (TfR < 8.5 ug/mL) at 12 weeks than those in Group II, whose therapy differed only by vitamin intervention (35.4% versus 27.4%)[p < 0.05]. Children in Group II who received SP monthly had lower mean TfR levels (10.5 ug/mL) than those in Group I who did not receive SP monthly (12.0 ug/mL) [p < 0.05].
Conclusions:Initial malaria and helminth treatment, followed by thrice- weekly iron and folic acid therapy resulted in substantial hemoglobin increase. We recommend this therapeutic approach for similar settings. Although the addition of monthly doses of SP or vitamins did not result in enhanced hemoglobin recovery, it did contribute independently to improved iron stores. The addition of vitamins to the above-mentioned therapy may be indicated in select subgroups of similar populations. Initial malaria and helminth treatment, followed by thrice- weekly iron and folic acid therapy resulted in substantial hemoglobin increase. We recommend this therapeutic approach for similar settings. Although the addition of monthly doses of SP or vitamins did not result in enhanced hemoglobin recovery, it did contribute independently to improved iron stores. The addition of vitamins to the above-mentioned therapy may be indicated in select subgroups of similar populations. Initial malaria and helminth treatment, followed by thrice- weekly iron and folic acid therapy resulted in substantial hemoglobin increase. We recommend this therapeutic approach for similar settings. Although the addition of monthly doses of SP or vitamins did not result in enhanced hemoglobin recovery, it did contribute independently to improved iron stores. The addition of vitamins to the above-mentioned therapy may be indicated in select subgroups of similar populations. Initial malaria and helminth treatment, followed by thrice- weekly iron and folic acid therapy resulted in substantial hemoglobin increase. We recommend this therapeutic approach for similar settings. Although the addition of monthly doses of SP or vitamins did not result in enhanced hemoglobin recovery, it did contribute independently to improved iron stores. The addition of vitamins to the above-mentioned therapy may be indicated in select subgroups of similar populations. Initial malaria and helminth treatment, followed by thrice- weekly iron and folic acid therapy resulted in substantial hemoglobin increase. We recommend this therapeutic approach for similar settings. Although the addition of monthly doses of SP or vitamins did not result in enhanced hemoglobin recovery, it did contribute independently to improved iron stores. The addition of vitamins to the above-mentioned therapy may be indicated in select subgroups of similar populations.
Abstract: Prevalence of and causal factors for anemia among adolescents in Kakuma and Dadaab refugee, camps, Kenya.
Background: Adolescents have not traditionally been considered at elevated nutritional risk in emergency situations or in displaced populations. However, because stature and muscle mass during the peak of the adolescent growth spurt, the iron requirement of adolescents is substantially higher than that for school-age children or adults. For this reason, adolescents may be at greater risk than others for iron deficiency anemia. A survey in April 1997 identified anemia as a severe public health problem among adolescents in Kakuma refugee camp in Kenya; 78% of camp residents 6-20 years of age were anemic, and 25% had hemoglobin levels <8 mg/DL. In order to reassess the importance of anemia in this population and to evaluate interventions implemented since the prior survey, UNHCR and IRC asked CDC to measure the prevalence of anemia among adolescents in Kakuma camp.
Methods: A systematic random sample of residents who lived in Kakuma camp was chosen from computerized registration data. Selected persons were asked to report to a study site, where they were asked questions about their dietary habits and risk factors for anemia. In addition, hemoglobin concentration was measured in fingerstick blood using a Hemocue photometer.
Results/Conclusions: The mean hemoglobin level among the 391 study subjets was 11.8 gm/DL (standard deviation = 2.1). Using WHO-recommended age- and sex-specific criteria, study workers found that 184 (47.2%) of the adolescents had anemia and 7 (1.8%) had severe anemia (hemoglobin <7 mg/DL). Anemia prevalence did not differ by sex, age, or participation in the school supplemental feeding program. Study subjects who lived in Kakuma camp 4 years or more had a higher prevalence of anemia (97 [58%] of 167) than those who had lived in the camp 3 or fewer years (86 [39%] of 221) (p<0.05, chi square). Adolescents who lived alone or in groups with other adolescents had a higher prevalence of anema (25 [61%] of 41) than those living with relatives (146 [46%] of 317) (p=0.1, chi square).
Although the study populations and definitions of anemia are not strictly comparable, the prevalence of anemia, especially severe anemia, among adolescents in Kakuma camp appears to be somewhat lower than that found in 1997. Nonetheless, anemia is still quite common and remains an important health problem.
Abstract: Prevalence of protein-energy malnutrition in refugee camps in Kenya and the reliability of BMI-for-age in this population.
Background: Children less than 5 years of age have traditionally been considered the population subgroup at greatest nutritional risk in emergency situations or in displaced populations; however, recent emergencies in Europe and Central Asia have highlighted the nutritional vulnerability of other population subgroups, such as elderly adults. Adolescents in refugee camps in Kenya, including Kakuma camp and three camps in Dadaab District, may be at elevated nutritional risk for many reasons. Many adolescent boys in Kakuma camp are unaccompanied and, therefore, may lack important social and familial networks which offer material support in times of shortage. Moreover, many adolescents do not have access to coping mechanisms used by others in these camps, such as the ability to grow additional food in kitchen gardens or to earn money to purchase extra food. A survey of Kakuma adolescents in April 1997 found that 55% of 320 girls 9-17 years of age and 75% of 1011 boys 9-20 years of age had a body-mass index (BMI) below the 5th percentile of the WHO BMI-for-age reference population.
Methods: Two systematic random samples of refugee camp residents 10-19 years of age were chosen from UNHCR computerized registration data. One sample included residents of Kakuma camp, and one included residents of the three camps in Dadaab District. Selected study subjects were asked to come to central study sites where their weight was measured with bathroom-type scales, their height was measured with adult-length height boards, and their mid-upper arm circumference (MUAC) was measured with measuring tapes. Study workers also obtained demographic information and brief dietary histories and examined subjects for lower extremity edema.
Results/Conclusions: The mean BMI was 15.9 in Kakuma camp and 15.4 in the three Dadaab camps. Based on the WHO BMI-for-age reference population, the prevalence of low BMI was 57% (223 of 391) in Kakuma and 61% (237 of 391) in Dadaab. In both surveys, females were significantly less likely to have low BMI than males (Kakuma: RR = 0.45, 95% CI = 0.34, 0.59; Dadaab: RR = 0.52, 95% CI = 0.43, 0.63). In Kakuma, the prevalence of low BMI did not differ between adolescents 10-14 years of age and those 15-19 years of age. In contrast, younger adolescents had a higher prevalence of low BMI (65%) than older adolescents (55%) (p<0.05, chi square). In all camps the general ration distribution had equalled or exceeded the recommended 1900 kcal/person/day for the 8 months prior to the surveys. In addition, recent nutrition surveys of children 6-59 months of age in all camps demonstrated little acute malnutrition in this age group. In Kakuma camp in October 1998, 9.0% of children in this age group had global acute malnutrition; in the three Dadaab camps in September 1998, 6.5-7.1% of children had global acute malnutrition. Mortality rates in all camps were at or below normal levels for settled populations in less-developed countries.
Although these surveys demonstrated relatively high prevalence rates of low BMI-for-age, other data, such as the prevalence of malnutrition among younger children, the amount of food distributed, and the level of mortality, do not support the idea that there is substantial acute malnutrition among adolescents in these populations. The BMI-for-age reference, consisting of adolescents from the U.S., may not be appropriate for defining acute malnutrition in adolescents in some ethnic groups.
