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Nutrition and Mortality Assessment -- Southern Sudan, March 1993

During the last 5 years of Sudan's decade-long civil war, increased fighting and food shortages in southern Sudan have led to displacement of large numbers of persons. In late 1992, the United Nations (UN), the government of Sudan, and factions of the Sudanese People's Liberation Army negotiated increased access for delivery of relief aid to civilians in southern Sudan. To assist in the targeting of food and other relief aid, CDC and the U.S. Agency for International Development's Office of Foreign Disaster Assistance conducted rapid assessments of nutritional status (children aged less than 5 years) and mortality (persons of all ages) during March 7-19, 1993, at four sites in three states: Ame (Eastern Equatoria), Ayod and Kongor (Upper Nile), and Akon (Bahr el Ghazal) (Figure 1). This report summarizes findings of the assessments.

Ame, Ayod, and Kongor were selected as assessment sites because of known food shortages. Ame camp, established in early 1992, had an estimated 47,000 displaced persons; however, reliable census data were not available for any of the four assessment sites. Ayod and Kongor are in the current epicenter of famine in southern Sudan. Airlifts of food to airstrips in Ayod and near Kongor began in late December 1992 but subsequently were sporadic because of security and logistical constraints. The sizes of the populations around these airstrips have fluctuated in relation to delivery of food. The Akon area suffered a famine in 1988 and heavy flooding with crop destruction in 1991 and 1992, increasing the potential for another famine.

Modified cluster-sample surveys were conducted in Ame and Ayod and in the countryside around Akon. Every fifth household (Ame and Ayod) or consecutive households (Akon) were selected within three to six clusters to produce sample sizes of 43-58 households. In Ame and Ayod, the samples were drawn from the presumed total population; the representativeness of the clusters and households selected in the Akon area was unknown. In Kongor, the sample consisted of children who gathered at the UN compound in response to messages from local and relief officials and, therefore, might not have been representative of all children in the area aged less than 5 years.

In each sample, assessment teams measured the height, weight, and mid-upper arm circumference (MUAC) of children 65-110 cm tall (proxy for 6-59 months of age). Two indicators of severe undernutrition were used: low weight-for-height (WFH) or wasting (WFH less than 2 standard deviations below the National Center for Health Statistics/CDC/World Health Organization reference median {1,2}; Z-score less than -2) and low MUAC ( less than 12.5 cm) (3,4). In Ame, Ayod, and Akon, household interviews were conducted with survivors to assess mortality and apparent causes of death.

A total of 371 children were measured at the four sites; 23 other potentially eligible children were unavailable or too sick. The prevalence of wasting (Z-score less than -2) was high at all sites, particularly in the areas known to have food shortages (75%-84% in Ame, Ayod, and Kongor) (Table 1). At these three sites, 40%-44% of the children were critically undernourished (Z-score less than -3), the mean Z-score ranged from -2.8 to -3.0, and the mean MUAC ranged from 11.4 to 11.8 cm. At all four sites, the prevalence of low MUAC was lower than that of low WFH (Table 1). Based on stratified analysis, the prevalence of low MUAC (using a fixed cutoff of 12.5 cm, regardless of age) decreased as height (age) increased, whereas the prevalence of low WFH (a height-adjusted and therefore age-adjusted indicator) was relatively stable.

Based on household interviews in Ame, Ayod, and Akon, crude mortality rates (CMRs) for the preceding 12 months were 234, 276, and 164 deaths per 1000 persons, respectively (Table 2). In Ayod, the average daily CMR was higher during the preceding 40 days (at least 20 deaths per 10,000 population in February and March 1993) than during the rest of the year (six deaths per 10,000 population during March 1992- January 1993). At all three sites, half (48%-50%) the deaths were attributed to starvation. In Ame and Ayod, diarrheal disease was the second most commonly specified cause of death. In the three sites, one death was attributed to measles and three to homicide.

Priority recommendations for food aid emphasized the provision of basic rations and supplementary feeding for vulnerable groups and the need for stockpiling maximum amounts of food before the spring rains impede food delivery. Other priorities included strengthening surveillance for undernutrition and mortality, providing measles vaccine for children aged 6 months-12 years, and establishing oral rehydration units for appropriate case management of diarrheal disease.

Reported by: Office of Foreign Disaster Assistance, US Agency for International Development, Washington, DC. US Agency for International Development, Sudan. Div of Field Epidemiology, Epidemiology Program Office; Div of Nutrition, National Center for Chronic Disease Prevention and Health Promotion; Div of Technical Support, International Health Program Office; Div of Parasitic Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The prevalence rates of severe undernutrition in Ame, Ayod, and Kongor are among the highest ever documented (3). In comparison, rates in central and southern Somalia during 1991 and 1992 ranged from 50% to 81% and 32% to 75%, respectively (CDC, unpublished data); reported prevalences of low WFH during noncrisis periods in Africa and elsewhere generally have been less than 5% (3,5,6). In general, prevalences greater than or equal to 5% have been associated with increased mortality (3,7). Therefore, the data in this report indicate that nutritional emergencies exist in all four survey sites, including Akon, a famine-prone area in which the next harvest is not expected until August.

In general, the prevalence of undernutrition in a random sample of children aged less than 5 years can be used as an indicator of this condition in the population (3). The primary indicator of nutritional status in these assessments was WFH. Although persons of Nilotic tribes in southern Sudan are among the tallest in the world, this genetic characteristic should not substantially influence WFH (in contrast to height-for-age). In addition, WFH Z-scores less than -2 represent a degree of thinness that typically is associated only with protein energy malnutrition or severe disease. The consistency of low WFH across height strata supports the conclusion that severe undernutrition in Sudan has affected other groups in addition to very young children (i.e., aged less than 2 years); older children and adults were probably similarly affected.

In these assessments, the high prevalences of severe undernutrition were associated with substantial excess mortality. The annual CMRs in Ame, Ayod, and Akon were markedly higher than those reported for the Horn of Africa during nonfamine times (20-24 deaths per 1000 persons) (8). In addition, the average daily CMR in Ayod during February-March 1993 was similar to that in Baidoa, Somalia, during November-December 1992 (23.4 deaths per 10,000 population) (9). The recent increase in the CMR in Ayod reflects, in part, the suspension of food airlifts during an 18-day period in February. Although no outbreaks of measles had been reported recently at any of the survey sites, the potential for such outbreaks is high because of the high prevalences of severe undernutrition and the low vaccination coverage rates.

The recently negotiated increased access to southern Sudan provided this opportunity to assess problems of long duration. Although the generalizability of the findings in this report can be addressed only by similar assessments elsewhere in Sudan, famine of this magnitude usually is geographically widespread. The high malnutrition and mortality rates documented in these assessments underscore the association between civil strife and famine and the need for prompt action to ensure availability of sufficient and appropriate food and medical supplies.


  1. NCHS. NCHS growth curves for children: birth-18 years -- United States. Hyattsville, Maryland: US Department of Health, Education, and Welfare, Public Health Service, NCHS, 1977; DHEW publication no. (PHS)78-1650. (Vital and health statistics: data from the National Health Survey; series 11, no. 165).

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

  4. de Ville de Goyet C, Seaman J, Geijer U. The management of nutritional emergencies in large populations. Geneva: World Health Organization, 1978.

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

  6. Carlson BA, Wardlaw TM. A global, regional and country assessment of child malnutrition. New York: United Nations Children's Fund, 1990; UNICEF staff working paper no. 7.

  7. Person-Karell B. The relationship between child malnutrition and crude mortality among 42 refugee populations {Thesis}. Atlanta: Emory University, 1989.

  8. United Nations Children's Fund. The state of the world's children, 1991. New York: United Nations Children's Fund, 1992.

  9. CDC. Population-based mortality assessment -- Baidoa and Afgoi, Somalia, 1992. MMWR 1992;41:913-7.

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