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International Notes Nutritional and Health Assessment of Mozambican Refugees in Two Districts of Malawi, 1988

Since January 1987, over 400,000 displaced persons from Mozambique have emigrated to Malawi, a country in southern Africa with a population of 7.9 million people. This mass population migration is considered to be a consequence of armed conflict in Mozambique. Displaced families have settled primarily along the international border in southern Malawi, and several large refugee camps have been established in this area. In May 1988, the Office of the United Nations High Commissioner for Refugees and the Bureau of Refugee Programs of the U.S. Department of State requested assistance from CDC to evaluate the nutritional status of refugees from Mozambique. A nutritional assessment was conducted of Mozambican and Malawian children living in Ntcheu and Nsanje, two districts in Malawi where refugees had concentrated. Additional information was gathered on immunization status and recent diarrheal disease.

The nutrition survey targeted children 6 months to 5 years of age or, if no docu- mentation of age was available, children 65-110 cm in height. Two-stage cluster sampling methods were used (1). The sampling frame for Malawians was based on 1977 census data adjusted for estimated population growth; for Mozambicans, it was based on recent refugee registration lists. Thirty villages or camp sectors in each district were randomly chosen from a cumulative population list. The probability of an individual site being included in the survey was proportional to its population. Within each site, the survey proceeded from a randomly selected starting point to the next nearest household until 30 eligible children were identified. Each child was weighed, measured for height, and examined for signs of vitamin deficiencies.

Evidence of acute undernutrition (less than 80% of the World Health Organization (WHO)/ National Center for Health Statistics reference median weight-for-height) (2) was similar in Mozambican and Malawian children in both districts, although Mozambican children had slightly higher levels (Table 1). Severe undernutrition (less than 70% of the median weight-for-height) was found in none and in 0.6% of children in Ntcheu and Nsanje Districts, respectively. In Nsanje District, which had a recent large influx of refugees, undernutrition was less among Mozambican children who had lived in Malawi for greater than or equal to3 months than among those who had arrived more recently (Table 2). More than 95% of refugee families in the two districts (97.1% in Ntcheu, 95.7% in Nsanje) reported receiving food rations during the 4 weeks preceding the survey. Signs of vitamin C deficiency (hemorrhagic gingivitis) were seen only in Ntcheu District (0.2% of children), and signs of vitamin A deficiency were seen only in Nsanje District (0.2% had either a history of night blindness or visible Bitot's spots).

Because diarrhea and measles are important causes of mortality among refugee children (3), these illnesses were also assessed. In the 2 weeks before the survey, 17.7% of refugee children in Ntcheu and 16.6% of those in Nsanje were reported to have had diarrhea. Similar rates of diarrhea were observed in Malawian children. Nearly half (49.8%) of children 12-23 months of age had been immunized against measles (57.9% in Ntcheu, 42.9% in Nsanje). Immunization policy includes an attempt to require vaccinations in families applying for food distribution. In both areas, Mozambican children had substantially higher measles vaccination coverage than Malawian nationals--53% vs. 33% in Ntcheu, 68% vs. 37% in Nsanje. Reported by: GW Lungu, MD, Office of the United Nations High Commissioner on Refugees, Blantyre; JR Sulger, International Rescue Committee, Lilongwe; A Renneson, M*$$*Aaedecins Sans Fronti*$$*Ageres, Blantyre, Malawi. Technical Support Div, International Health Program Office; Nutrition Epidemiology Br, Div of Nutrition, Center for Health Promotion and Education, CDC.

Editorial Note

Editorial Note: The levels of childhood undernutrition reported here are consistent with levels reported during noncrisis periods from developing countries in Africa (4) and are substantially lower than those reported from other recent refugee situations in Africa and southeast Asia (Table 3). Malawi enjoyed a bountiful harvest in mid-1988, and the ready availability of fruits, vegetables, and grains in the affected districts may have enhanced the nutritional status of both local and refugee populations at the time of the surveys. Continued provision of rations should prevent any worsening of childhood undernutrition, and ongoing surveillance may help detect deterioration in the nutritional status of children as local food supplies diminish during the year. Although the prevalence of Vitamin A deficiency was low, vitamin A prophylaxis (200,000 International Units of vitamin A every 6 months for infants and children, for lactating women, and for women beyond the first trimester of pregnancy) is indicated, according to WHO guidelines (8).

Measles and diarrhea are major causes of childhood morbidity and mortality in refugee populations. Childhood immunization levels reported here are unlikely to prevent further measles outbreaks. Despite attempts to link childhood immunizations to food distributions, reinforced efforts will be required to improve coverage levels in susceptible children. In addition to the current policy of providing measles immunization to susceptible Mozambican children greater than 6 months of age at the time of registration, other recommendations included immunizing susceptible children at every health contact and assuring the immunization status of severely undernourished children enrolled in therapeutic feeding programs. To lower diarrheal morbidity and mortality, early detection of diarrheal illness and treatment with oral rehydration therapy was also emphasized.


  1. Henderson RH, Sundaresan T. Cluster sampling to assess immunization coverage: a review of experience with a simplified sampling method. Bull WHO 1982;60:253-60.

  2. Lavoipierre GJ, Keller W, Dixon H, Dustin J-P, ten Dam G, eds. Measuring change in nutritional status: guidelines for assessing the nutritional impact of supplementary feeding programmes for vulnerable groups. Geneva, Switzerland: World Health Organization, 1983:86-97.

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

  4. Serdula MK, Aphane JM, Kunene PF, et al. Acute and chronic undernutrition in Swaziland. J Trop Pediatr 1987;33:35-42.

  5. Glass RI, Cates W Jr, Neiburg P, et al. Rapid assessment of health status and preventive- medicine needs of newly arrived Kampuchean refugees, Sa Kaeo, Thailand. Lancet 1980; 1:868-72.

  6. CDC. Health status of Kampuchean refugees--Khao I-Dang. MMWR 1979;28:569-70.

  7. Shears P, Berry AM, Murphy R, Aziz Nabil M. Epidemiological assessment of the health and nutrition of Ethiopian refugees in emergency camps in Sudan, 1985. Br Med J 1987;295: 314-8.

  8. Nieburg P, Waldman RJ, Leavell R, Sommer A, DeMaeyer EM. Vitamin A supplementation for refugees and famine victims. Bull WHO (in press).

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