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Mortality Among Newly Arrived Mozambican Refugees -- Zimbabwe and Malawi, 1992

An estimated 1.3 million persons have fled Mozambique since 1986 because of civil war in that country. More than 1 million refugees have sought asylum in Malawi and approximately 230,000 in Zimbabwe (Figure 1); of the combined total, an estimated 130,000 (10%) fled during January-September 1992. The rate of exodus accelerated during 1992 because of a severe drought that affected most of southern Africa. During August-September 1992, the Bureau for Refugee Programs of the U.S. Department of State and CDC, in collaboration with the Office of the United Nations High Commissioner for Refugees, assessed the impact of the drought on the health status of refugees in the region through observations of refugee conditions and examinations of data in refugee camps in Zimbabwe and Malawi. This report summarizes the findings of the assessment.

In Zimbabwe, most newly arriving refugees were placed in Chambuta camp (in south Zimbabwe); the population in this camp increased from 6700 in January to its capacity of 25,000 in August. In Malawi, refugees were placed in Lisungwe Camp, which opened in November 1991; the population of this camp reached 65,000 by the end of August 1992. From July through September, the number of new arrivals each month in Lisungwe ranged from 6000 to 20,000. Because of limited space in Lisungwe in September, approximately 16,000 Mozambican refugees were detained at border posts and temporary reception centers in other camps in Malawi with inadequate shelter, sanitation, and water. Crude Mortality

In Chambuta, detailed records on deaths were compiled by health center staff. During August 1-20, 1992, the crude mortality rate (CMR) was 3.5 deaths per 10,000 population per day. Although age-specific data were not available, most deaths were reported anecdotally to have occurred in children aged less than 5 years. During the first 4 weeks after refugees arrived in camp, daily death rates increased from 7.3 per 10,000 population to 8.2, after which rates were inversely related to duration of stay. However, the CMR for refugees who had resided in the camp for more than 6 months was three times the CMR (0.5 per 10,000 per day) reported by the United Nations Children's Fund (UNICEF) for nondisplaced persons in Mozambique (1).

In Lisungwe, mortality data were collected by Malawian health surveillance assistants and compiled by Medecins Sans Frontieres (MSF)/France, a private voluntary organization. From January through September 1992, the average daily CMR ranged from 1.0 to 3.6 per 10,000 population. For children aged less than 5 years, the daily death rate peaked in June at 5.0 per 10,000 population. CMRs in Lisungwe were compared with those in Chifunga, a neighboring camp with comparable environmental conditions and a similar surveillance system but that had not received new arrivals during 1992. From January through September, the monthly CMR in Lisungwe was 4.5 times higher than that in Chifunga. Cause-Specific Mortality

In both Chambuta and Lisungwe, diarrhea (including cholera-associated), dehydration, malnutrition, and measles accounted for 75% of all reported deaths. In both camps, diarrhea-specific death rates were substantial (1.5 and 1.6 per 10,000 per day in Chambuta and Lisungwe, respectively), and coverage rates for household latrines were low: in August 1992, latrines were present in approximately 22% of households in Chambuta and 13% of households in Lisungwe. The daily measles-specific death rate was higher in Chambuta (0.9 per 10,000) than in Lisungwe (0.1 per 10,000). Prevention Effectiveness

The costs were determined for programs to prevent deaths associated with measles and diarrheal disease in Chambuta and Lisungwe. The cost for measles vaccine provided by UNICEF and administered using disposable syringes was 30 cents U.S. per 0.5-cc dose delivered (2). Assuming that 8170 children aged less than 15 years arrived during January-July 1992 *, the estimated cost of vaccinating all eligible children in Chambuta (new arrivals aged 6 months-15 years and children reaching the age of 6 months while in the camp) during January-September 1992 would have been $2451, plus $708 for the cost of two full-time health workers to administer vaccine. During June and July, measles caused 113 deaths in this largely unvaccinated population. ** Assuming a vaccination rate of 90% and a two-dose schedule for children aged less than 9 months (resulting in a vaccine efficacy of 85%), the cost of averting 86 of the 113 measles deaths would have been approximately $37 per death.

The presence of a latrine in the residential setting reduces diarrhea-associated morbidity and mortality by approximately 36% (3). In Malawian camps, the cost of an installed latrine, using refugee-donated labor, is $8. Thus, the cost of providing a latrine to each household in Lisungwe from January through August would have been $54,309 and would have averted 54 deaths *** and 1408 (36%) of 3911 reported episodes, an investment of approximately $1004 for each death averted and $38 for each diarrheal episode averted. Assuming that the CMR remained constant through 1992 (based on the mean January-August CMR), then declined to 0.5 per 10,000 per day and that the fraction of deaths attributable to diarrhea remained constant over time, the cost per death averted would be $85 over the 5-year expected duration of the latrine****. This analysis does not consider the other social and health-related benefits associated with latrine availability (3,4).

In both Zimbabwe and Malawi, the severe drought diminished food supplies available for established resident populations and strained medical and social programs for citizens of both countries. Because of the problems these conditions posed for the Malawian and Zimbabwean governments and for international and nongovernmental relief organizations, recommended measures included

  1. accelerating efforts to ensure that every child aged 6 months-15 years is vaccinated against measles on arrival in a camp; 2) increasing resources for family latrine construction; and 3) providing refugees in reception centers with adequate soap, water, buckets, latrines, and shelter.

Reported by: Office of the United Nations High Commissioner for Refugees; Regional Medical Office, Ministry of Health; Medecins Sans Frontieres, Blantyre, Malawi. Office of the United Nations High Commissioner for Refugees; Ministry of Health, Harare, Zimbabwe. Bur for Refugee Programs, Washington, DC. Technical Support Div, International Health Program Office, CDC.

Editorial Note

Editorial Note: In Africa, an estimated 5 million refugees have fled war and civil conflict in their homelands. In addition, more than 10 million persons are "internally displaced" in countries such as Liberia, Mozambique, Somalia, and Sudan. The high death rates and the major causes of death among refugees newly arrived from Mozambique are consistent with rates reported for other refugee populations in Africa during the early phase of displacement (5).

Diarrheal diseases and measles are particular health risks for refugee populations in Africa. Enteric pathogens may be spread in refugee camps because of exposure to human excrement resulting from insufficient availability of latrines, water supplies, and other sanitation resources (i.e, buckets and soap). In addition, the crowded conditions of refugee camps may promote the transmission of measles and other contagious diseases (6).

The prompt and complete vaccination of susceptible children against measles may be difficult in the setting of massive influxes of new refugees. For example, in Chambuta, many new arrivals may not have been screened or vaccinated because camp health staff were often overwhelmed by such influxes and could not arrange for vaccination coverage. In Lisungwe, most new arrivals aged 6 months- 12 years were vaccinated against measles, but deaths may have occurred among persons who had been infected in Mozambique and had entered the camp while already incubating measles.

Cost estimates in this report indicate that targeting prevention efforts to refugee populations can be highly cost effective. In the camps in Malawi and Zimbabwe, the estimated cost per death averted was 10-100 times less than World Bank estimates for averting measles and diarrhea-associated deaths through country-wide programs (7). To ensure that cost-effective services can be readily provided, even during fluctuating and acute emergencies, refugee health programs should incorporate detailed contingency plans and emphasize the importance of basic preventive services, such as those described in this report (i.e., vaccination programs and latrine construction).


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

  2. World Health Organization. Selection of injection equipment for the EPI. Geneva: World Health Organization, 1986; publication no. WHO/UNICEF/EPI.TS/86.2.

  3. Esrey SA, Potash JB, Roberts LF, Shiff C. Water supply and sanitation: health effects on ascariasis, diarrhoea, Guinea worm, hookworm, schistosomiasis, and trachoma. Bull World Health Organ 1991;69:609-21.

  4. Okun DA. The value of water supply and sanitation in development: an assessment. Am J Public Health 1988;78:1463-6.

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

  6. Toole MJ, Steketee RW, Waldman RJ, Nieburg P. Measles prevention and control in emergency settings. Bull WHO 1989;67:381-8.

  7. Jamison DT. Disease control priorities in developing countries: an overview. Washington, DC: The World Bank, 1993.

    • There were approximately 19,000 new arrivals during this period. Based on the demographics of a neighboring camp (Tongo Garra) for which information was available, an estimated 43% of the population would be less than 15 years of age on arrival and greater than 6 months of age by July 1992. ** The measles-specific death rate during July 25-August 13, 1992, was 0.9 per 10,000 per day, equivalent to 2.7 per 1000 per month. The mean camp population was assumed to be 19,000 in June and 23,000 in July, based on camp administrative data. *** Based on estimated mid-month populations and reported CMRs. Based on June data, it was assumed that 45% of all deaths were from some form of diarrheal disease. None of the malnutrition-associated deaths were assumed to be preventable through sanitation. Of the estimated 7803 families in Lisungwe at the end of August, 6789 (87%) did not have a latrine. **** This assumes that 1) the mean January-September CMR of 0.7 per 10,000 per day continued through the end of 1992; and 2) the 45,000 refugees who had arrived through August (and who were provided with latrines) had a constant CMR of 0.5 per 10,000 per day during the years 1993-1996, based on the CMR reported in the nearby stable Chifunga camp during 1992 and among nonrefugee Mozambicans in 1989 (1).

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