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Emergency Public Health Surveillance in Response to Food and Energy Shortages -- Armenia, 1992

Living conditions in Armenia have deteriorated since 1988 as a result of an economic blockade related to a territorial conflict between Armenia and a neighboring country. The effects of this blockade -- a drastic reduction in available food, heating fuel, gasoline, electricity, health services, drugs, and vaccines -- have placed residents of Armenia at increased risk for morbidity and mortality from nutritional deficiencies, infectious diseases, and hypothermia. To assess and monitor the current health and nutritional status of residents of Armenia, the Armenian National Institute of Health, the U.S. Agency for International Development (USAID), and CDC have developed the Emergency Public Health Information Surveillance System (EPHISS). This report summarizes preliminary results for 1992.

Although existing data collection systems maintained by the Ministry of Health (MOH) of Armenia monitor many health indicators, these systems do not monitor nutritional status or market indicators that might serve as early warning signs of food shortages. The EPHISS was designed to retrospectively and prospectively monitor these indicators.

EPHISS staff collected anthropometric (i.e., height and weight) data from medical records for children born in July and August of 1990, 1991, and 1992 from selected pediatric clinics in the capital, Yerevan. The comparison of data from each of these years in two pilot clinics indicated that the nutritional status of infants and young children had deteriorated: the prevalence of wasting (weight-for-height less than 2 standard deviations below the median of CDC's National Center for Health Statistics/World Health Organization growth reference) was 5.3% during the last half of 1992, compared with less than 1% during the previous 2 years (1).

To assess food security among elderly pensioners living on a fixed income, EPHISS staff repeated a nutritional needs survey in December for comparison with results obtained in a similar survey in April 1992 (2). Among the elderly, 308 (89%) of 347 pensioners surveyed reported having insufficient money to buy food; 291 (84%), insufficient food; 279 (80%), no savings; and 71 (21%), less than 1 day's food supply at home. The survey suggested that conditions had deteriorated since the previous survey: increases were noted in the percentage of persons who reported selling personal possessions to buy food (from 18% to 37%) and the percentage with weight loss of 5 kg or more during the previous 6 months (from 45% to 62%) (Table 1).

Data from the MOH were used to assess communicable disease occurrence and crude and infant mortality rates. From April through October 1992, the MOH reported that monthly incidence rates of measles had increased by 60%, diarrheal illness by 61%, viral hepatitis by 163%, and tuberculosis by 75%. During 1991, the infant mortality rate was 17.9 deaths per 1000 live births; data for 1992 are not yet available.

Data on economic and environmental indicators, including the market cost of a standard 1-month basket of food items, and other key items (e.g., cost of gasoline and ruble/dollar exchange rate), indicated an overall inflation rate of 360% from April through December 1992. In comparison, the monthly pension for the elderly increased by 250%, reflecting a loss of real purchasing power. As of December 1992, the monthly pension in Armenia was 1200 Soviet Union rubles (SUR), while the cost of a 1-month basket of food items was 23,000 SUR.

Surveillance data on the health of refugees, including nutritional markers, will be gathered in collaboration with the International Committee of Red Cross during distribution of relief supplies.

Reported by: V Davidiants, MD, Institute of Public Health and Div of Epidemiology, Armenian National Institute of Health, Yerevan, Armenia. SG Olds, MPH, US Agency for International Development, Yerevan, Armenia. Div of Field Epidemiology, Epidemiology Program Office; Div of Nutrition, National Center for Chronic Disease Prevention and Health Promotion; Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The 15 republics of the former Soviet Union are undergoing extraordinary economic and political change. The instability of the ruble, coupled with shifts to privatization of land and businesses, have imposed severe hardships on the populations of all 15 republics (3). Armenia is particularly vulnerable because of an ongoing territorial dispute that has resulted in an influx of approximately 300,000 ethnic Armenian refugees from Azerbaijan and because of the economic blockade imposed by neighboring republics, which has effectively terminated any substantive importation of fuel and food.

As of December 1992, no fuel oil had been received in Armenia for 3 months, and the fuel supply for the power system was adequate for only 8 days. The shortage of fuel also prevents distribution of commodities and cooking. Power blackouts of 12 hours or more per day throughout the country have reduced availability of running water and, by compromising sanitation, increased the risk of certain infectious diseases (e.g., hepatitis A, enterovirus, giardiasis, and shigellosis). These conditions also may result in adverse health effects related to nutritional deficiencies, cold exposure, inadequate vaccination levels, and inadequate drinking water supplies.

The monthly EPHISS public health bulletin reports critical markers of health and nutritional status that have an impact on the health of persons residing in Armenia and the condition of refugees. The bulletin describes trends in "leading" and "intermediate" indicators of changes in economic, social, and environmental factors that anticipate the evolution of food shortages and famine. Detection and reporting of such changes can trigger early interventions aimed at ensuring adequate food supplies for the population (4). Although a surveillance system based on population-based "sanitary epidemiology" stations has existed since 1922 in republics of the former Soviet Union, reporting of data lacks timeliness (CDC, unpublished data, 1993). Because of critical deficiencies in transportation and communications networks in Armenia, selected simple data-gathering techniques have been identified to enable timely, accurate reporting. Targeting selected communicable diseases allows prioritization of scarce resources among competing health needs (e.g., vaccine-preventable diseases and provision of safe drinking water).

This collaborative surveillance effort is promoting the prompt dissemination of information of public health importance during this period of profound change in Armenia. With USAID support and CDC technical assistance, ministries of health in other republics (i.e., Krgyzstan, Russia, and Uzbekistan) are also working to strengthen dissemination of essential public health information.


  1. CDC. Famine-affected, refugee, and displaced populations: recommendations for public health issues. MMWR 1992;41(no. RR-13):11-

  2. CDC. Nutritional needs surveys among the elderly -- Russia and Armenia, 1992. MMWR 1992;41:809-11.

  3. Chen LE, Rohde JE, Jolly R. A looming crisis: health in the Central Asian Republics. Lancet 1992;339:1465-7.

  4. CDC. Famine-affected, refugee, and displaced populations: recommendations for public health issues. MMWR 1992;41(no. RR-13):4-

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