a joint anthropometric, retrospective mortality and estimation of haemoglobin levels survey, eastern...

7/30/2019 A Joint Anthropometric, Retrospective Mortality and Estimation of Haemoglobin Levels Survey, Eastern Chad (July

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A Joint Anthropometric, Retrospective Mortality and Estimation of Haemoglobin Levels Survey Conducted by UNHCR in Collaboration with

UNICEF, WFP, Health and Nutrition organizations

Eastern Chad July August 2008

Lucas Machibya,UNHCR Nutritionist,on mission.


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Table of contents

LIST OF ACRONYMS .............................................................................................................................................4

ACKNOWLEDGEMENT ............................................................................................................................................5

The map of Eastern Chad UNHCR refugee operation.. 6

Executive summary .. 7

1. INTRODUCTION.......................................................................................................................................8

1.1 Background... 81.2 Food aid and coping strategies. .. 81.3 Joint Assessment mission .. 81.4 Selective feeding programme.. 91.5 Expanded programme for immunization (EPI)... 9

1.6 Reproductive health ... 91.7 Morbidity and mortality rates.... 91.8 Iron deficiency anaemia 101.9 Access to clean water and sanitation .. 10

2. GENERAL OBJECTIVE OF THE SURVEY........................................................................................11

2.1 Specific Objectives: ...................................................................................................................................11

3. SUBJECTS AND METHODOLOGY .....................................................................................................11

3.1 Study population ................................................................................................................................11

3.2 Sample size.........................................................................................................................................11 3.3 Sampling method ... 11

3.4 Data collection methods.....................................................................................................................12

3.5 Data analysis ......................................................................................................................................12 3.6 Anthropometric indices among under 5 years children 133.7 Limitation of the survey. 13

4. T ABLE OF RESULTS AND SUMMARY DISCUSSION....................................................................14

4.1 Anthropometric results: (based on NCHS reference 1997)....14

4.2 Prevalence of Wasting........................................................................................................................14 4.3 Prevalence of Stunting .......................................................................................................................16

4.4 Prevalence of Underweight ................................................................................................................18 4.5 Sex prevalence of malnutrition among children aged 6.0 - 59.0 months ......204.6 Comparing NCHS 1997 and WHO 2005 base reference results 214.7 Comparison of GAM from previous surveys .,.. 21

5. CONTRIBUTING FACTORS TO THE INCREASE OF MALNUTRITION 225.1 New refugee influxes 225.2 The inception of IDP camps .. 225.3 Security related factors .. 235.4 Food aid and household food security 235.5 Health and nutrition 245.6 Water and sanitation .. 245.7 Protection issues .245.8 Distribution of non food items .. 24

6. RETROSPECTIVE MORTALITY.........................................................................................................24


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7. IRON DEFICIENCY ANAEMIA............................................................................................................25

7.1 Anaemia among children below the age of five years ..................................................................25 7.2 Anaemia prevalence among women 287.3 Programs to prevent anaemia ... 29

8. MEASLES IMMUNIZATION: ...............................................................................................................30

9. SELECTIVE FEEDING PROGRAMME...............................................................................................30

10. CONCLUSION..........................................................................................................................................33

11. RECOMMENDATIONS ..........................................................................................................................33

12. REFERENCES ..........................................................................................................................................34

List of tablesTable 1: WHO (1995) cut off points to describe survey results for anthropometric indices .....13Table 2: Age and sex distribution ratio..14Table 3: Prevalence of wasting among 6.0 59.0 months based on NCHS 1997..15Table 4: Distribution of wasting by age groups based on NCHS 1997......................................15Table 5: Prevalence of wasting (%median) among 6.0 59.0 months children ...................................16Table 6: Prevalence of stunting among 6.0 59.0 months children ......17Table 7: Distribution of stunting by age groups among 6.0 59.0 months children .....17Table 8: Prevalence of underweight among 6.0 59.0 months children by NCHS 1997

reference values ...............19Table 9: Distribution of stunting by age groups among 6.0 59.0 months children .....19Table 10: Comparison of anthropometric findings based on NCHS 1997 and WHO 2005 reference

values ...21Table 11: Comparing GAM and SAM from previous surveys, 2006 2008 .22Table 12: Crude and < 5 years mortality rates, deaths per 10,000 per day.25Table 13: Mean Haemoglobin levels and prevalence of anaemia among 6.0 59.0...26Table 14: Mean Haemoglobin levels and prevalence of anaemia by age groups .......26Table 15: Protein Energy Malnutrition, mean haemoglobin and prevalence of anaemia among children

6.0 59.0 months ....27Table 16: Mean Haemoglobin levels and prevalence of anaemia among refugee women ..28Table 17: Mean Haemoglobin, % severity of anaemia and physiology status among women28Table 18: Comparing prevalence of anaemia with WHO standards ...29Table 19: Percentage coverage of measles vaccination for =>9.0 - 59.0 months ...30Table 20: Percentage coverage of selective feeding programme by refugee camps ...31Table 21: Trend of SFP performance indicators .....32Table 22: Trend of TFP performance indicators .32

List of figuresFigure 1: Distribution of wasting compared to NCHS 1997 reference values ..16Figure 2: Distribution of stunting compared to NCHS 1997 reference values .18

Figure 3: Distribution of underweight compared to NCHS 1997 reference values ..20Figure 4: Prevalence of wasting among children aged 6.0 59.0 months by sex 20Figure 5: Distribution of anaemia levels among wasted, underweight and stunted children aged

6.0 59.0 months ..27Figure 6: Showing trend of haemoglobin levels among women by physiology status 29


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LIST OF ACRONYMS

ACTEDCBR Crude Birth RateCDC Centre for Disease ControlC.I Confidence IntervalsCMR Crude Mortality RateCOOPI Cooperazione IinternationaleCRT Croix-Rouge TchadienneCSB Corn Soy BlendCTC Community Therapeutic CareEPI Expanded Program for ImmunizationEPI INFO Epidemiology Word Processing Data baseFAO Food and Agricultural Organisation of United NationsGAM Global Acute MalnutritionHb HaemoglobinHFA Height for AgeHIS Health Information SystemIDPs Internally Displaced PersonsIEC Information Education and CommunicationIMC International Medical CorpsIRC International Rescue CommitteeJAM Joint Assessment Mission of UNHCR and WFPLBW Low Birth WeightMDGs Millenium Development GoalsMoH Ministry of HealthMOU Memorundum of UnderstandingMSF Luxembourg Medisan Sans Frontiere - LuxembourgMSF Holland Medisans Sans Frontiere - Holland

NFIs Non Food Items NGOs Non Government Organizations NSC Nutrition Steering CommitteeOCHA Office of the Coordination of Humanitarian AffairsOPEC Organization of Petroleum Exporting CountriesPEM Protein Energy MalnutritionSD Standard DeviationSFP Supplementary Feeding ProgrammeSLM/A Sudan Liberation Movement / ArmySMART Standardized Monitoring and Assessment of Relief and

Transitional protocolsTBAs Traditional Birth AttendantsTFP Therapeutic Feeding ProgrammeWFH Weight for Height percent for medianWHM Weight for Height percent for medianWHO World Health OrganizationUNHCR United Nations High Commissioner for RefugeesUNICEF United Nations Children and education Funds


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ACKNOWLEDGEMENT

I am grateful for the valuable assistance and support provided by many colleagues for this work to be asuccessful. The UNHCR staff from Ndjamena Branch Office played a key role, special thanks goes to UNHCR Sub Office Abeche for an excellent coordination and patronage provided in terms of logistics, administration,funding processing and provision of security assistance during the period this work was undertaken in the 12Sudanese refugee camps along the Eastern Chad boarder. Special thanks go to UNICEF and WFP Abeche Sub

Offices for the strong commitment they had on this work. Further more, thanks go to Health and Nutritionimplementing partners of UNHCR, refugees especially the children under 5 years, women and refugee leaderswho supported the exercise.

I further accord abundant appreciation to the following government institution and non governmentorganizations

1. Abeche School of Nursing2. Agency for Technical Cooperation and Development (ACTED)3. International Medical Corps (IMC)4. International Rescue Committee (IRC)5. Cooperazione Iinternationale (COOPI)6. Croix-Rouge Tchadienne (CRT)7. Medecines Sans Frontieres (MSF) Holland8. Medecines Sans Frontieres (MSF) Luxembourg

Survey team members1. Amine Ndolassoum 2. Haoua Ahmat Mahamat3. Helou Abdalah 4. Houda Mahamat Abdelaziz5. Liliane Ngaradouel 6. Mahamat Bani7. Mahamat Nour Zacharia 8. Mahamat Youssouf Ibetine9. Mahamat Cherif Bakhari 10. Ousmane Cheikhdine11. Tantee Nabaringar 12. Yaya Barka Arabi

Survey supervision and coordination1. Jean Paul Habamungu, Food and Nutrition Officer, UNHCR Abeche2. Lucas Machibya, UNHCR Nutritionist, Tanzania, on mission3. Bonaventura Muhimfura, UNHCR Nutritionist, Abeche4. Djimandoumour Doumbaye, WFP Nutritionist, Abeche5. Diongoto Domaya Esaie, UNICEF Nutritionist, Abeche

Operation coordination1. Catherine Huck, Assistant Representative Operation, UNHCR Chad2. Carolyn Wand, Senior Reintegration Officer, UNHCR Abeche3. Jean Paul Habamungu, Food and Nutrition Officer, UNHCR Abeche4. Lucas Machibya, UNHCR Nutritionist, Tanzania, on mission5. Bonaventura Muhimfura, UNHCR Nutritionist, Abeche

Technical support1. Paul Spigel, Chief of Section, Public Health and HIV Section, UNHCR Geneva

2. Le Guillouzic, Herv, Senior Public Health Officer, UNHCR Geneva3. Fathia Abdala, Senior Nutritionist, UNHCR Geneva4. Hering Heiko, Public Health Information Officer, UNHCR Geneva5. Allison Omer, Senior Food and Nutrition Coordinator, UNHCR Nairobi

Data entry, analysis and report compilation1. Lucas Machibya, UNHCR Nutritionist, Kasulu, Tanzania, on mission2. Bonaventura Muhimfura, UNHCR Nutritionist, Abeche, Chad3. Djimandoumour Doumbaye, WFP Nutritionist, Abeche, Chad4. Diongoto Domaya Esaie, UNICEF Nutritionist, Abeche, Chad

Funding support1. High Commissioners special fund on nutrition project, UNHCR Geneva


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Figure 1: The map of Eastern Chad UNHCR refugee operation


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Executive summary

An Anthropometric, hemoglobin measurements and retrospective mortality survey was conducted in12 Sudanese refugee camps in Eastern Chad. A two stage cluster sampling technique was used. Thesurvey took place from 30 th June to 11 th August 2008. The prime aim of the survey was to determinethe prevalence of protein energy malnutrition, estimate the prevalence of anemia, determine the crudedeath rate and under 5 years death rate in the camps. UNHCR funded this survey under the specialfunds of the High Commissioners project on nutrition. UNICEF, WFP and NGOs participated fullyin the planning and executions of the survey exercise.

Three categories of sampled populations were surveyed, children aged 6.0 59.0 months and 65 110 cm was assessed for anthropometric, measles and feeding programme coverage, sub sample of adult women in the reproductive age and children under 5 years had their hemoglobin levels estimatedusing Haemocue machines. Retrospective crude and under 5 years mortality rate were surveyedcovering the entire family members.

The anthropometric findings in this report are presented using NCHS 1997 in Z-scores and percent for median. The global acute malnutrition rate (weight for height 9.0 59.0 months was 94.6% across the camps.Mile camp had the highest supplementary feeding programme coverage with 73% followed by Djabal66% and Goz Amer had 62%. The therapeutic feeding programme Djabal camp had the highestcoverage of 63% followed by Goz Amer which had 55% coverage. All coverage levels were belowthe recommended target of 90%, it is imperative for the health and nutrition partners to increase theuptake of malnourished children in the feeding programme.

Programs to prevent iron deficiency anaemia are present in the camps; however these need closemonitoring for both children and women. UNICEF and UNHCR are working closely to ensure thatthe measles coverage increases to above 95% in all camps.

Coordination on health and nutrition activities in the camps was emphasized during the fieldmovements and security concerns were mentioned to be a serious obstacle to achieve their objectives

by humanitarian agencies.


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INTRODUCTION

1.1 BackgroundThe East Chad refugee operation provides protection and humanitarian assistance to 243,000Sudanese refugees in 12 camps along the border with Sudan. Refugee influxes in Eastern Chad fromSudan, Darfur region started in April 2003 as a result of the resumption of the fighting betweengovernment army troops supported by Janjaweed Arab militias and Sudan Liberation Movement /Army (SLM/A). By the end of October 2003 about 60,000 refugees had arrived in Eastern Chad

border from Darfur region of Sudan. The refugees ethnicities include Ouaddaian, Massalite, Arabs,Fur, Dadjo and Zagawa.

The on going internal civil conflict in Chad has led to around 170,000 Chadian national to beinternally displaced (IDPs), they are currently settled in camps in Dar Sila, Ouaddai, Assoungha andSalamat. Since 2006, groups possessing weapons including Chadian Janjaweed, Sudanese Janjaweed,Chadian rebels bandits have primary destabilized the civilian characters of the communities along theEastern Chad border with Sudan.

The refugee influxes continued to arrive in Gaga since the end of 2006 (12,402). At the end of July2008 this camp had 19,781 registered refugees and the camp is still open for new arrivals. At the endof 2006 Kounoungou camp, had 13,315 refugees while by the end of July 2008 the camp populationhas increased to 18,167 registered refugees. The increase of refugee influxes is a result of thecontinuous crisis in Darfur.

1.2 Food aid and coping strategiesThe Sudanese refugee camps in Eastern Chad operation depend on food aid support from WFP. Theagreed food ration for this operation is 425 grams cereal, 50 grams pulses, 50 grams of corn soy

blend, 25 grams of vegetable cooking oil, 15 grams of sugar and 5 grams of salt, this ration providesapproximately 2,100 kilocalories. By the end of 2007, WFP provided an average of 1,995 kilocaloriesin the general food distribution.

At the beginning of 2008, a reduced food ration started to be implemented during general fooddistribution in Sudanese refugee camps. The food commodities which are in reduced ration includecereals, pulses, CSB and salt whereas vegetable cooking oil and sugar have been kept at 100%

provisions.

Until the last general food distribution in the fourth week of August 2008, in average 1,734kilocalories per person per day had been provided in the Sudanese camps Eastern Chad, equivalentto 90% of the 2,100 recommended kilocalories. The food distribution in use is the scooping system;until June 2008 food basket monitoring has not been conducted during food distributions.

1.3 Joint assessment missionUNHCR and WFP annually organize joint assessments that observe critically the overall assistancesof the care and maintenance programme for UNHCR and emergency operation programme for WFP. The JAM determines the level of assistance required in terms of food and non food items

provisions. UNICEF, OCHA, FAO, Government of Chad CNAR, donors and cooperate partners of UNHCR and WFP are invited. The last JAM took place in 2006; the next JAM in Chad refugeeoperation is planned to take place in September 2008.


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1.4 Selective feeding programmeThe nutrition programme provides nutritional rehabilitation services to severely and moderatelymalnourished identified children; the community health workers are responsible for identifying andreferring children to the feeding centers for registration in the camps. A feeding programme protocolis available and in use in all camps. As part of the strategies to fight against malnutrition, partnersimplementing nutrition programme in the camps conduct monthly general screening of under 5 yearschildren in order to identify malnourished children and admit them in the feeding programme. Allchildren who are < 80% median weight for height are admitted in the supplementary feeding

programme where they receive a food ration to rehabilitate their nutritional status. Severelymalnourished who are < 70% median weight for height with medical complications, without goodappetite are admitted in the stabilization centre this is normally outside the camps where healthfacilities with admission capacity exist, with an exception of Djabal and Goz Amer camps. Children,who are severely malnourished but pass the appetite test is admitted in the out patient therapeutic

programme they collect food based support and eat at home.

At the beginning of 2007, Community based management (CTC) of malnourished children was rolledout in 9 camps (Iridimi, Touloum, Amnabak, Mile, Oure Cassoni, Kounongou, Gaga, Farchana andBredjing. The camps of Djabal and Goz Amer started CTC at the beginning of 2008.

1.5 Expanded programme for immunization (EPI)In close coordination with UNICEF, EPI is implemented in all camps. The programme providesmeasles vaccination to children from 6.0 months to 15 years during emergency. The target for measlescoverage in 2007 for children aged 6 -59.0 months was => 90.0%. The camps which attained andexceeded this target were Treguine, Iridimi, Touloum, Oure Cassoni, Kounongou and Bredjingwhereas Amnabak registered the lowest coverage, 28.0%. The measles mean coverage was 85.2%across the camps in Eastern Chad. There has been different interventions implemented to raisemeasles coverage including measles immunization campaigns led by the MoH across the countrywhich included refugee camps.

The EPI unit in Abeche is working hard to raise the Polio coverage as one confirmed case wasregistered in Bredjing camp recently. UNHCR and its cooperatives are part of these MoH efforts of which refugee camps are included.

1.6 Reproductive healthThe programme advocates that all deliveries should take place in the health facilities where skilled

personnel are present to attend. In 2007, this indicator was attained better in Goz Amer and Djabalcamps where by above 90.0% of all deliveries where reported to have taken place in the healthfacilities henceforth assisted by skilled personnel. Bredjing and Farchana camps had the highest

percents of deliveries assisted by traditional birth attendants (TBAs), 97.7% and 92.8% respectively.

The target for crude birth rate (CBR) for the programme in 2007 was 10 40 per 1,000 population per year. The highest figures for CBR were found in Goz Amer and Treguine where by these camps had56 and 52 per 1,000 per year respectively. The CBR for Sub Saharan Africa is 44 per population per year 1. It is important to underscore the fact that these camps had the lowest percent of low birthweight (2,500 grams) weighed within 72.00 hours of births. The percent of LBW was 2.9% in GozAmer and 4.3% in Treguine while it was 3.1% in Bredjing camp.

1.7 Morbidity and mortality ratesUNHCR provide health services in the refugee camps in collaboration with UNICEF, WHO and thehealth and nutrition partners, the services are coordinated jointly with the Ministry of Health at

provincial level in locations where refugee camps are established. National treatment guidelines andstandards in terms of staffing and provision of care and treatments are adhered.

1 UNHCR Handbook in Emergencies, February 2007


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The leading causes of morbidity at the time of the survey were acute respiratory infections, with 41%overall camps, acute respiratory infection was very high in Oure Cassoni with 59% of all morbiditiesamong children 2

By the end of 2007 Djabal camp had the highest crude mortality rate (CMR) that stood at 0.32 per 1,000 per month; the lowest recorded crude mortality rate was 0.02 per 1,000 per month in Amnabak camp. Djabal camp had the highest under 5 years mortality rate (


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2. GENERAL OBJECTIVE OF THE SURVEY

The general objective of the survey was to determine the global acute malnutrition, anaemia levels,retrospective mortality, measles and feeding programme coverage in the Sudanese refugee camps inEastern Chad.

2.1 SPECIFIC O BJECTIVES :

1. To estimate the prevalence of both severe and global acute malnutrition including oedema inchildren aged 6-59 months old and/or 65-110 cm height in the refugee camps

2. To estimate the overall crude death rate and under 5 years mortality rate among the refugee population

3. To estimate the prevalence of anaemia and measles coverage among children below the age of five years in the refugee camp

4. To estimate the coverage of the nutrition feeding programme among refugee children attendingthe selective feeding programme in the operation area

3.0 SUBJECTS AND METHODOLOGY

3.1 S TUDY POPULATIONStudy subjects were children below the age of five years ranging between 6.0-59.0 months, weresubjected to anthropometric measurements, measles and feeding programme assessment. For haemoglobin measurements a sub sample of children under 5 years and adult women was drawnwhereas for retrospective mortality heads of families and other family members were included.

3.2 S AMPLE SIZE A total of 11,406 children aged 6.0-59.0 months from all 12 camps were finally included in theanalysis after exclusion of 2% flags in this study. Of these 3,625 children were sampled for Haemoglobin (Hb) testing to establish their haemoglobin levels, henceforth, determination of their iron deficiency anaemia status. Also sampled for the survey were 3346 adult women of which 16% of them were pregnant, 49% were lactating and the rest were neither pregnant nor lactating these

participated in the survey for haemoglobin levels determination. For mortality study a total of 37,108 6 population was involved in the assessment. The average family size used was 5 members per family

3.3 Sampling methodThe cluster sampling method as recommended in the WHO guidelines was used (WHO, 2001). Atotal of 30 clusters, each including 30 children were applied. At least 30 children aged 6.0 59.0months with 65.0 110.0 cm height were sampled in each cluster. Upon arrival at the centre of thecluster, the survey team spinned a pen to decide the direction where to start and then all houses in thatdirection were counted. For example, if there are 20 houses, numbers 1-20 were written down on 20small papers and folded. These folded papers were mixed up in a cup and any young child wasrequested to pick one, the number picked was the first house to start the measurements. The secondhouse sampled was the house on his / her right hand side. The same was repeated for the subsequenthouses. Children who were found not at home were not revisited as time could not permit due tosecurity reasons and yet were not replaced. All sampled children for anthropometric measurementwere as well assessed to establish measles and feeding programme coverage.

The sample size for haemoglobin measurements for the children aged 6.0 59.0 months wascalculated from the following parameters, 40% estimated prevalence of anaemia, and 7% desired

precision and 2 design effect. The same sample size for adult women reproductive age was used.

The sample size for retrospective mortality survey was calculated on the following assumptions;average camp population 20,250, estimated prevalence rate 2 per 10,000 populations per day, 1%

6 Table 5 crude and under 5 years mortality rate


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desired precision, design effect of 2 and 90 days recall period (supported with a locally developedcalendar of events, annex II) therefore, a minimum population of 1,610 was expected to be sampled.

In order to estimate the number of households to be covered for mortality it was assumed that in eachfamily there were 1.5 children aged 6.0 59.0 months. Therefore, 900 children divided by 1.5

provided an average of 600 households to be covered in each camp. This implied that a minimum of 20 households were to be covered in each cluster. It was agreed that if anthropometric measurementsis completed in the cluster, the mortality survey should continue until the 20 households werecovered. This helped to cover a bigger population in all camps than the estimated 1,610 sample

population.

3.4 D ATA COLLECTION METHODS Anthropometric measurements which entail height, weight and age were collected for each child andoedema was assessed. Weight was measured using UNICEF - Salter scales which were recorded tothe nearest 0.1kg decimal point, the weighing scales were calibrated prior to commencement of thesurvey and every morning. The exercise started by checking the weighing scales using the standardweight of 1 kilogram. Height was measured using Shorr portable infant / child height/lengthmeasuring board 7. The age of the sampled children was recorded from the child health card of thechildren, where the road to health cards were not available locally developed calendar of events wasused to help mothers / guardians to estimate the age of the children which then was recorded inmonths to nearest 0.1 month. Oedema was assessed bilaterally from the feet of the children. All teamswere given a VHF radio hand set for communication. It was agreed that a team which sees an oedemacase should call for the supervisors to confirm this prior to recording. The team leaders ensuredquality data were collected, verified and recorded in the data collection sheets. Nutrition and MedicalOfficers from UNICEF, WFP, UNHCR and Health and nutrition NGOs were supervisors during thesurvey.

Haemoglobin levels were measured using a haemoglobinometer (HeamoCue haemoglobinometer,Angelholm, AB, Sweden) and recorded to the nearest 0.1g/dl decimal point for both children andwomen. Measles vaccination status information was extracted from the child health card of eachsampled child. Where cards were not available maternal or guardians confirmation was soughtthrough a recall process. Data on feeding programme coverage were collected based on the response if the children were admitted in the programs. Retrospective mortality information was collected fromthe entire family members of the surveyed households.

3.5 D ATA ANALYSIS Data were entered and managed in EPI-INFO 6.04B version whereas analysis for protein energymalnutrition was done using Nutri-survey programme and the reference value used were NCHS 1997.All three anthropometric indices were used to describe the nutritional status of the children.Malnutrition low weight-for-height (wasting), low height-for-age (stunting) and low weight-for-age(underweight) were defined based on WHO cut off points for global, moderate and severe categories(WHO, 1995). Oedema was also included in the analysis for severe and global acute malnutrition

prevalence.

Anaemia for both children and women were defined based on the recommended WHO cut off points(WHO, 2001) 8. Haemoglobin levels for both children and women were computed and the mean valueswere established.

The data were as well analyzed based on percent for median for weight-for-height since it is anindicator used to admit children in the selective feeding program.

7 How to Weigh and Measure Children written by Irwin J. Shorr for the UN Department of Technical Cooperation for Development and

Statistical Office, New York, 1986.8 WHO Guidelines on the management of severe malnourished children


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Measles coverage was determined from the data recorded on the road to health cards of the childrenand by recall responses from the mothers or responsible guardians found taking care of the children atfamily level.

Estimation of crude and under 5 mortality rates was done based on the SMART programme methodand 90 days recall period was used for each camp. Counting of the recall period was done starting the

previous day of the survey date for each camp. This meant that each camp had its own specific recall period since the camps were surveyed on different days.

3.6 ANTHROPOMETRIC INDICES AMONG UNDER 5 YEARS CHILDRENThe traditional anthropometric indices used to assess the nutritional status of children were used to classifythe nutritional status based on the findings. The results were presented only in Z-scores, quoted, this is adeviation of the individual anthropometric measurement from the median value of the WHO reference for that childs height of age divided by the standard deviation for the reference population (WHO 1995):

a) Weight-for-Height (wasting or thinness): Reflects body weight relative to height. Low weight for height or wasting / thinness usually indicates a recent and severe process of weight loss due to acutestarvation, severe disease or chronic unfavorable conditions. Two categories of low weight for height wereused in presenting the results in the tables; severe and moderate wasting if Z-scores


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4. T ABLE OF RESULTS AND SUMMARY DISCUSSION

4.1 ANTHROPOMETRIC RESULTS (NCHS 1997 reference values)In this survey the global acute malnutrition is defined as


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Table 3 Prevalence of wasting (weight-for-height Z score) among 6.0 59.0 months (based on NCHS reference 1997)

Wasting (% with 95% C.ICamp NSevere(


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Figure 1 Distribution of wasting by sex compared to NCHS reference (1997) values

Table 5 Prevalence of wasting (% median) among children aged 6.0 59.0 months (based on NCHS reference 1997)

Wasting (median % with 95% CI)Camp N Severe (=70% -


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Table 6 Prevalence of stunting (Height-for-age Z score) among children aged 6.0 59.0

months (based on NCHS reference 1997)

NStunting (% with 95% CI)

Camp

Severe(


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Children in the age range 18.0 29.0 months (47.0%) were mostly affected by stunting than other agegroups, followed by 30.0 41.0 age groups with 37.3% prevalence. Stunting decreased as the ageincreases, age groups 42.0 53.0 and 54.0 59.0 had 21.4 and 17.7 percents respectively. Table 6.0

Figure 2.0 shows the graphical presentation of stunting when compared with NCHS reference values by sex

Figure 2 Distribution of stunting by sex compared to NCHS reference1997 values

4.4 P REVALENCE OF U NDERWEIGHT : Underweight is responsible for several deaths, majority of children suffer from this form of malnutrition, mild and moderate state, it is a result of inadequate diets, compromised immunesystems, frequent episodes of diseases including mild diarrhea which go on un-noticed for days.Mildly under weight children are at an increased risk of dying due to diseases as does a child of normal body weight who suffers the hidden hunger of micronutrient deficiency 10.

Underweight (WAZ< -2SD) was analyzed, the overall prevalence was 40.5% (95% C.I 39.1 41.8).The findings indicate that the lowest value for underweight was recorded in Oure Cassoni camp(30.9%) whereas the highest was recorded in Farchana camp, (43.9%). The prevalence of

underweight for all camps is in the very high category according to WHO classification levels 11 asall camps have > 30.0 percents global underweight prevalence. Table 7.0

Comparing underweight results analyzed based on the NCHS 1997 and underweight results analyzed based on the WHO 2005 reference values it was found WHO 2005 based results both moderateunderweight 24.4% (95% C.I 23.5 25.4) and global underweight 31.7% (95% C.I 30.4 32.9) werelower than the results of the same indices presented based on NCHS 1977 reference values, moderateunderweight 32.5% (95% C.I 31.6 33.5) and global underweight 40.5% (95% C.I 39.1 41.8).There was significant difference to both moderate and global underweight with the NCHS 1977 basedresults being higher than the WHO 2005 based results. Table 7 and Annex I.

10 SUSTAIN: Malnutrition over view, technology for better nutrition ht tp://www.sustaintech.org/world.htm11 WHO cut off points for underweight, less than 10% low, 10 19% moderate, 20 29% High and equal and above 30% very high ;Bulletin of WHO, 71(6):703-712 (1993)


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Table 8 Prevalence of underweight among children aged 6.0 59.0 months based on NCHS

reference 1997

underweight (% with 95% CI)Camp N Severe

(


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Figure 3.0: Distribution of underweight by sex compared to NCHS reference 1997 value

4.5 Sex prevalence of malnutrition among children aged 6.0-59.0 monthsThe sex difference on the prevalence of malnutrition was clear among children at the age of 6.0 29.0months. Boys were more susceptible to malnutrition (wasting, underweight and stunting) than girls.As illustrated in figure 5.0 below boys were 2.4 percents more wasted than girls.

Figure 4.0: Sex differences in prevalence of wasting among children aged 6.0 59.0 months

02468

1012141618

20

6-17 18-29 30-41 42-53 54-59 Total

Age gr ou ps - m on ths

% W a s

t i n g

( W F H )

Girls

Boys

Combined

Prevalence of wasting, underweight and stunting increased from age 6.0 24.0 months across thecamps and immediately started to decrease when the age of children exceeded 2 years, figure 5.0. Theabove figure shows how wasting differed between girls and boys in the camps. The above graphshows that malnutrition start developing among refugee children before attaining 1 year. This explainsinadequate child care, infant and young child feeding practices prior to 2 years, a critical period for child growth and development. Much of this can be attributed to poor knowledge, collapsed socialfamily ties and infrastructures due to war 13. Focus group discussions indicated that families lack knowledge on exclusive breastfeeding, do not know the value of colostrums, introducecomplementary foods in most cases at below 3 months, and give tea and water as breast milk is

13 Field Exchange; June 2008: Somali KAP Study on Infant and Young Child Feeding and Health Seeking Practices.


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believed not sufficient. A project on infant and young child feeding in Goz Amer camp is making a positive change as lactating women who are members of the programme are exclusively breastfeedingtheir babies. 8 women interviewed by the reporters who their babies were 3, 4 and 5 months said thatwere exclusively breastfeeding their babies 14, among them was a mother with twins. They wereregistered in the supplementary feeding programme, benefit from the SFP food ration until 6 months

post delivery. Sudanese camps in which exclusive breastfeeding and infant and young child feeding program have been initiated are Goz Amer, Gaga and Oure Cassoni from the OPEC funding support.

4.6 Comparison of NCHS 1997 and WHO 2005 base reference analyzed results

When compared using NCHS 1997 and WHO 2005 reference values, results indicate that the global acutemalnutrition ( Global (


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Table 11 Comparing GAM and SAM from previous surveys 2006 2008 by camps

Global (


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5.3 Security related factorsHumanitarian workers can not move freely in the camps due to increased insecurity levels necessaryto move to move military escort is required; this hinders NGOs staff free executions of their responsibilities. In most cases there is 1 military escort in each camp with several agencies.

The convoy movements posses a logistical and coordination challenge among humanitarian workersto go to the camps in convoys, depart from their base stations latest 8.30 a.m. and arrive around 9.30a.m. in the camps, going to the camps requires military escort by 14.30 pm all workers start departingfrom the camps in convoys escorted by military.

Continuity of programme implementation, monitoring and close follow up is always interrupted dueto high insecurity incidences. In the last 2 years consecutively humanitarian workers have beenevacuated 3 times due to serious security incidences.

Due to high degree of insecurity in the camps humanitarian workers sometime are forced to stay intheir compounds without going to the camps to perform their duties.

Since 2006, when insecurity increased in the region, particularly to the border zones refugee freedomof movements outside the camps for coping activities have been limited especially in the 6 South -Eastern camps.

5.4 Food aid and household food securityIn 2007 WFP provided an average of 1995 kilocalories equivalent to 90% of the agreed andrecommended minimum 2,100 kilocalories and by end August 2008 had provided in average 1743kilocalories. Since the beginning of 2008, refugees have been on reduced food ration. The reducedration if is subjected to other of food losses (30% of the food ration is sold to meet milling costs,losses due to scooping during food distribution) the net food ration that is consumed by the refugees issignificantly reduced from the intended or planned kilocalories.

5.5 Health and nutritionThe health seeking behavior of refugees requires consistent awareness which have been notconducted adequately for 2 years now due to insecurity. Culturally accepted IEC materials have beenlacking in the camps, these are important in helping to transform and motivate refugees to increaseuse of conversional treatments especially to children and women who are at risk.

Some health and nutrition NGOs implement different health policies, guidelines and treatment protocols this has made impossible to standardize treatment protocols. Use of Zinc in treating diarrheacases among under five years children and systematic de-worming is not done in some camps.

There exist different reporting formats, different Health Information Systems (HIS) hence differentsurveillance systems. Harmonization of such monitoring and reporting tools and approaches isnecessary in order to allow common assessment and evaluation of the health and nutrition status of the refugees.

In one of the camp, one agency implement health / curative and preventive health program andanother implements nutrition programme. Holistically health and nutrition projects should bemanaged and implemented by one agency in one camp.

In Oure Cassoni, approximately 60% of under 5 years reported morbidities has been acute respiratoryinfections (ARI). ARI is known as one of the potential disease contributing to high prevalence of malnutrition. Out break of Hepatitis E occurred in the operation area and 1 case of confirmed Poliowas isolated from Bredjing refugee camp.


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5.6 Water and sanitationAccess to safe, clean and adequate water in some of the camps is below 20.0 liters per person per day.In 2007, the highest amount provided was 17.0 liters per person per day equivalent to 85% of therecommended target; this was in Gaga, Bredjing, Treguine and Djabal. Camps of Oure Cassoni,Iridimi, Touloum, Amnabak, Mile and Kounongou received below 55% of the 20 liters, recommendedamount of water.

Low water supply in some of refugee camps is known to cause communicable water born diseases.Program discussions on water supply in the camps are ongoing between UNHCR and the Ministry of water on new approach of rationalization of the limited water resources in the Eastern Chad region toallow both refugees and Chadian nationals rationalize the use.

5.7 Protection issuesFrom end of 2006 freedom of movements to refugees out of the camps has been gravely affected dueto continuously degradation of security in the border line, so access to copping mechanism includinglivestock keeping that could allow refugees to supplement food aid has been severely limited.

5.8 Distribution of non food itemsGeneral distributions of domestic non food items (NFI) are currently targeted to refugees with specificneeds. Fuel wood and other sources of energy are provided in all camps. The last general distributionof NFI took place during refugee influxes, 2004 2005. It is important to consider another generaldistribution of water containers jerry cans, cooking utensils, mats and sanitary materials as they arerelated to the health and nutritional status of the population at large. The program aims to provide amonthly general distribution of soap (250gm/p/month); however soap distribution has not beensystematically done. This affects the personal hygiene status of the refugee population.

6. RETROSPECTIVE MORTALITY

This survey also included a mortality survey which was retrospectively assessed. As the priority for the health surveillance system is to produce reliable information of mortality rates. Two mortalityindicators were studied namely, crude mortality rate (CMR) and


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Table 12 Crude and < 5 years mortality rates as expressed by 10,000 people per day

Death rates calculated at 10,000 / dayCamp Population CMR survey

resultsCMR HISreport

0 5 Year death rate


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Table 13 Mean haemoglobin levels and prevalence of anaemia among children aged 6.0 59.0months

Severity of anaemia - %Camps N Mean Hb Severe Moderate mild Total

anaemic

Goz Amer 457 11.6 0.2 6.6 18.8 25.6Djabal 273 11.4 1.1 9.9 17.2 28.2Gaga 276 11.3 0.7 11.2 18.1 30.1Farchana 344 11.3 0.9 14.0 17.2 32.0Bredjing 388 11.6 1.0 11.3 21.9 34.3Treguine 355 11.4 0.6 11.0 22.3 33.8OureCassoni

341 11.4 1.8 10.6 25.5 37.8

Amnabak 252 11.7 0.8 8.3 18.7 27.8Touloum 216 11.6 0.9 12.0 13.4 26.4Iridimi 210 11.7 0.5 9.0 15.2 24.8Mile 246 11.3 1.6 17.5 15.0 34.1Kounongou 267 11.2 1.1 14.6 19.9 35.6Combined 3625 11.5 0.9 11.3 18.6 30.9

The mean haemoglobin levels for all camps were within the acceptable WHO cut off points for anaemia levels; it ranged from 11.2 for Kounongou camp and 11.7 for Iridimi and Amnabak camps.According to WHO, overall the prevalence of anaemia found in this study is within the moderatecategory (20-39.9%). Table 13

Table 14 Mean haemoglobin levels and prevalence of anemia among children aged 6.0 59.0months

Severity of anaemia - %Age group N Mean

Hb severe moderate Mild Totalanemic Normal6.0 17.0 828 11.5 1.1 12.8 16.4 30.3 69.718.0 29.0 948 11.4 0.8 12.9 18.5 33.0 66.830.0 41.0 854 11.5 1.1 11.2 18.9 31.1 68.942.0 53.0 620 11.7 0.5 10.7 20.6 29.8 70.254.0 59.0 374 11.5 1.1 10.1 19.3 29.5 70.6Combined 3,624 11.5 0.9 11.3 18.6 30.9 68.9

Majority of the under 5 years children are mildly anaemic across the age groups. The prevalence of mild anaemic cases is almost two folds of moderately anaemic cases. The mostly affected age groupswere the first three age groups, 06 17, 18.0 29.0 and 30.0 41.0 months, children aged 18.0 29.0

months were highly affected by Iron deficiency anaemia. Table 14


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Table 15 Protein energy malnutrition, mean haemoglobin and prevalence of anaemia amongchildren aged 6.0 59.0 months

Severity of anaemia - %

Wasting N Mean

Hbsevere moderate mild Total

anemic Normal

Severe 305 11.7 0.0 3.6 32.1 35.7 64.3Moderate 1126 11.6 0.5 13.0 20.4 33.9 66.1Global 2194 11.5 1.0 10.9 18.8 30.7 69.3Combined 3625 11.6 0.9 11.3 18.6 30.9 69.2

UnderweightSevere 305 11.5 0.7 12.1 21.1 35.1 64.9Moderate 1126 11.5 1.0 12.5 17.1 32.5 66.4Global 2194 11.6 0.9 10.1 18.2 28.1 70.7Combined 3625 11.5 0.9 11.3 18.6 30.9 67.3

StuntingSevere 305 11.5 1.2 11.1 13.3 25.6 74.4Moderate 1126 11.4 1.8 13.1 17.4 32.4 67.6Global 2194 11.6 0.6 11.0 18.7 29.7 70.3Combined 3625 11.5 0.9 11.3 18.6 30.9 69.1

Further analysis indicated that 35.7 and 35.1 percent of severely wasted and underweight childrenwere anemic respectively. Consequences of anemia to protein energy malnourished children includes,decreased physical activity like playing, impaired cognitive development of infants and children,decreased body immunity and hence makes children more susceptible to diseases like malaria, acuterespiratory infections, diarrhea and measles which are the main causes of mortality in emergencies 18.Table 15

Figure 5 Distribution of anaemia levels among wasted, underweight and stunted children aged 6.0 59.0 months

26.5

27

27.5

28

28.5

29

29.5

30

30.5

31

Wasting Underweight Stunting

PEM

% T o

t a l a n e m

i a

18 UNHCR Handbook for Emergencies, Third Edition, 2007


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Of the severely and moderately wasted children 35.7% and 33.9% of them were anemic respectively.35.1% of the severely underweight children were anemic whereas 32.5% of the moderatelyunderweight children were anemic. 25.6% of the severely stunted under 5 years children were anemicand 32.4% of the moderately stunted children were anemic. This indicates that iron deficiencyanaemia is a serious public health problem to all children suffering from any form of PEM. The meanvalue of the severely wasted children was higher (11.7) than the severely underweight (11.5) andstunted (11.5) children.

7.2 Anaemia prevalence among women3,350 women had there haemoglobin levels assessed, of them 530 were pregnant, 1,651 were lactatingand the rest were neither pregnant nor lactating. Overall Farchana camp had the highest prevalence of anaemia, 39.6% among women. The lowest value was found in Goz Amer camp, 18.4%. As it was for children the most prevalent form of anaemia among women were moderate and mild, Table 16.0

Table 16 Mean haemoglobin levels and prevalence of anaemia among refugee women

Severity of anaemia by %Camps N Mean Hb Severe moderate mild Total

anaemicGozamir 304 12.3 0.3 9.5 8.6 18.4Djabal 237 11.9 1.7 11.0 10.1 22.8Gaga 275 11.7 1.1 10.2 16.0 27.4Farchana 338 11.4 0.3 16.6 22.8 39.6Bredjing 351 11.5 2.8 15.4 19.9 36.5Treguine 355 11.9 1.4 11.3 18.0 30.7OureCassoni

347 11.6 1.2 11.2 19.6 32.5

Amnabak 229 11.8 0.9 6.6 18.3 25.8Touloum 205 11.7 0.5 16.1 15.7 31.2Iridimi 207 11.4 1.0 12.1 18.0 28.3

Mile 238 11.9 0.4 6.3 19.8 25.5Kounongou 262 11.8 1.1 13.7 17.6 32.4Combined 3348 11.7 1.2 12.7 17.1 30.9

The mean haemoglobin level for women ranged between 12.3 in Goz Amer and 11.4 in Farchanacamps. Of the pregnant women 36.7% were anaemic. 27.6% of the lactating women were anaemic.Iron deficiency anaemia is responsible for low production in the community, women in the Sudaneserefugee camps are known to contribute the significant family labour force. Table 17

Table 17 Mean haemoglobin, % severity of anaemia and physiology status among women

Severity of anaemia - %PhysiologyStatus

N MeanHb

severe moderate mild Totalanemic Normal

Pregnant 530 11.3 1.5 16.0 19.2 36.7 73.4Lactating 1651 11.9 1.0 11.0 15.6 27.6 72.4

Normal 1169 11.8 1.2 11.0 16.4 28.6 71.4Combined 3350 11.7 1.2 12.7 17.1 30.9 72.4


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Table 18 Comparing prevalence of anaemia with WHO standards

Indicator Standards Pregnant womenresults

Lactating womenresults

Children results

Normal 40.0

The prevalence of anaemia to both categories of women surveyed and under 5 years children fallswith the moderate category of WHO classifications. Table 18

Figure 6 Showing trend of haemoglobin levels among women by physiological status

0

5

10

15

20

25

30

35

40

pregnant lactating normal combined

Women - by category

% T

o t a l a n a e m

i a

7.3 Program to prevent iron deficiency anaemia

The operation implements different programs to preventive and control iron deficiency anaemia,these programs includes;

Treatment of malaria using MoH treatment protocols, malaria is known to causesanaemia

Systematic de-worming of children using mebendazole as per MoH policy on de-worming, twice in a year de-worming campaigns are organized

Pregnant women receive Iron supplementation tablets and fansidar during antenatal period The food ration given comprises of CSB that is fortified with iron, CSB is the only

major source of micronutrients given systematically to the general population Kitchen gardening programs exist to some camps Livestock keeping, some refugee populations keep goats, sheeps and camels, meat is

good source of iron Pregnant women receive SFP food package (comprised of CSB) immediately from

the time they book in the antenatal program to 6 months post delivery Distribution of impregnated long lasting mosquito nets to prevent and reduce malaria

prevalence


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8. MEASLES IMMUNIZATION:

A total of 10,900 children whose age was equal and above 9.0 months were involved in the analysisfor establishing measles coverage. Their road to health cards were studied and verified if had gotmeasles vaccination, henceforth recorded. Where it was found not recorded mothers / guardians wereasked if the child had got measles shot previously. Results indicated that 94.6% of the children hadreceived measles vaccination (77.2% had their cards recorded and 17.4% their mother confirmed tohave received measles vaccination) at the time of the survey. Overall children who did not receivemeasles vaccination were 5.4% across the camps.

The programme target coverage for measles for 2007 and 2008 was to achieve 95.0%. From thefindings, 94.6% coverage is very close to 95.0% it can be concluded that in general the programachieved this target, however, efforts needs to be directed to 5 camps which have not attained thistarget. Table 19

Table 19 Percentage coverage of measles vaccination for children aged =>9.0 59.0 months

% of measles coverage; children aged =>9.0 monthsCamp N By card By recall =>9 months Not vaccinatedGoz Amer 912 68.5 27.6 96.1 3.9Djabal 918 48.8 39.2 90.9 12.0Gaga 920 84.5 7.5 92.0 8.0Farchana 918 67.5 21.4 88.9 11.1Bredjing 900 72.8 19.6 92.4 7.7

Treguine 910 83.1 12.1 95.2 4.8Oure Cassoni 919 82.7 14.8 97.5 2.5Amnabak 917 85.2 12.3 97.5 2.5Touloum 855 86.8 10.1 96.9 3.2Iridimi 942 81.5 15.1 96.6 3.4

Mile 870 83.4 14.3 97.7 2.3Kounongou 919 80.6 13.9 94.5 5.4All camps 10,900 77.12 17.3 94.6 5.4

UNHCR advocates that measles vaccination coverage should be as close as 100% (and must begreater than 90% to be effective) 19, in this case, UNHCR and UNICEF as per the joint plan of actionhave been working jointly with the partners to raise measles vaccination coverage in Farchana(88.9%), Gaga 90.7%), Bredjing (92.4%) and Kounongou (94.5%) camps. Table 19

9. SELECTIVE FEEDING PROGRAMME

The selective feeding programme is implemented in all camps by health and nutrition agencies. The

purposes of this programme is to rehabilitate severely and moderately malnourished children, reducemortality and morbidity and provide medical treatment where required. This study assessed the

participation of both severely and moderately malnourished children in the feeding programme,findings indicate that Mile camp had the highest coverage on SFP, 73.0%; followed by Djabal(66.0%), Goz Amer (62%) and Treguine (62%).

The highest coverage for TFP was recorded in Djabal camp with 63% coverage. This level is belowthe programme target of 90%.

In Bahai refugee leaders expressed concerns on the SC as it is outside the camp, this requires mothersto go and stay with one malnourished child for some days in Bahai leaving other children and other

19 UNHCR Handbook for Emergencies; measles page 351


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households responsibilities unattended. This situation deters parents to cooperate in the feeding programme. This is the case for most of the camps where SC requires children and guardians to moveout side the camps.

Table 20 Percentage coverage of selective feeding programme by refugee camps

Camp N SFP TFPGozamir 912 62% 55%Djabal 919 66% 63%Gaga 964 51% 50%Farchana 973 35%Bredjing 948 Nil Nil

Treguine 960 62% No TFPOure Cassoni 968 47% 30%Amnabak 978 43% No TFPTouloum 905 Nil No TFPIridimi 989 Nil No TFPMile 923 73% No TFPKounongou 967 54% No TFP

In 2008, the selective feeding strives to achieve 90.0% coverage in both supplementary andtherapeutic feeding programme. (Note: Therapeutic feeding programme in this report includescommunity based management of severely malnourished children CTC). The table belowsummarizes performance indicators for the feeding programme from 2005 to June 2008:

Table 21 Trend of SFP performance indicators

Year 2005 2006 2007 Mid year 2008Total admission 13822 9137 10040 3561Recovery rate 63.7% 81% 83% 89.4%Death rate 0.2% 0% 1% 0.2%Defaulter rate 25.4% 10% 6% 5.7%Transfer rate 5.3% 4% 6% 3.9%

The feeding programs performance indicators show there has been an increasing trend on the recoveryrate since 2005 to date in both SFP and TFP. As of mid June 2008 the entire selective feeding

programme had above 89 percent recovery rates across the camp. Table 21

Table 22 Trend of TFC performance indicators

Year 2005 2006 2007 Mid year 2008Total admission 2910 1528 1803 428Recovery rate 75.3% 83% 78% 89.7%Death rate 4.6% 3% 5% 2.4%Defaulter rate 13.2% 6% 10% 3.4%Transfer rate 5.7% 6% 7% 4.5%

The recovery, death and defaulter rates remained within the Sphere acceptable standards andindicators. The SPHERE standards performance indicators for SFP are as follows; coverage >90%,

recovered >75%, deaths


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recommended by SPHERE are as follows; coverage >90%, recovered >75%, deaths


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10. CONCLUSION

As compared to 2006 the nutritional status of the refugees has relatively deteriorated through 2007 to2008. The prevalence of GAM falls in the serious category as per WHO. It calls for serious concertedefforts in order to maximize the utilization of the allocated available resources for the programmehence forth the program achieves its objectives.

It has been noted that security concerns could be the leading cause of the deterioratednutritional status of Sudanese refugees in the Eastern Chad.

11. RECOMMENDATIONS

These recommendations are made in line with the findings related to the actual camp based situation:

1. Considering the number of malnourished children not registered in the feeding programs in the camps, it is strongly recommended that the monthly exhaustive

screening of under 5 years in all camps is adequately supervised by qualified staff (nutritionist, nurses) in order to ensure that all malnourished children are registered inthe appropriate feeding programs.

2. It is recommended that the NSC in Abeche which current is not active be immediatelyrevived with an action plan to reduce the current level of malnutrition;

3. The agreed general food ration be reinstated to a 100% of which will reduce the lossesdue to milling cost and scooping effects during food distribution;

4. The prevalence of anaemia to children under 5years, pregnant and lactating women fallswithin the moderate category as per WHO standards. As this value includes a huge

population across the camps, it is important to closely monitor and improve programsgeared to prevent and control prevalence of anaemia.

5. The coverage of measles vaccination in some of the camps is below the recommendedstandards, UNHCR and UNICEF should intervene jointly as per global MOU. The aimshould be to raise measles coverage to above 95% and where possible closer to 100%.

6. As malnutrition start to attack children at the age of below 2 years, programs on infantand young child feeding should be continued with emphasis on exclusive breastfeedingand child care up to 2 years.

7. The community services sector is in the process of identifying the vulnerableindividuals, a common strategy drawn by the sectors can help to reduce the currentlevel of GAM. It is therefore recommended that this process be prioritized jointly withthe community services, health and nutrition.

8. Increase assistance and support on WATSAN sector and provision of fire wood toidentified vulnerable refugee households.

9. Jointly with WFP conduct a household food economy assessment to determine theexistence and contributions of the coping mechanisms available in the Sudanese

population in Eastern Chad.10. Capacity building to national staff in the food and nutrition sector with a view to

increase presence and coverage of service providers as this will increase directimplementation, monitoring and reporting of activities undertaken in the camps.


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12. REFERENCES

1. Emergency Nutrition Assessment Guidelines for field workers, SCF UK, 20042. Field Exchange; June 2008: Somali KAP Study on Infant and Young Child Feeding and

Health Seeking Practices.3. Health Information System monthly report June 2008 Note that4. How to Weigh and Measure Children written by Irwin J. Shorr for the UN Department of

Technical Cooperation for Development and Statistical Office, New York, 19865. The world wide magnitude of protein energy malnutrition: an overview from the WHO

Global Database on Child Growth. M. de Onis, C. Monteiro, J.Akre and G. Clugston6. SUSTAIN: Malnutrition over view, technology for better nutrition

http://www.sustaintech.org/world.htm7. UNHCR Hand book for Emergencies: Crude Mortality Rates; Benchmarks: 1.0 deaths / 10,000 / day Relief programme:very serious situation, 345 pg

8. UNHCR Handbook for Emergencies; measles page 3519. UNHCR Handbook in Emergencies, February 200710. UNHCR standard and indicators for crude mortality rate is


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ANNEX I

RESULTS PRESENTED BASED ON WHO 2005 REFERENCE VALUES P REVALENCE OF W ASTING :

Table 2.0: Prevalence of wasting (weight-for-height Z score) among 6.0 59.0 months (based onWH0 2005 reference)

Wasting (% with 95% C.ICamp NSevere(


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P REVALENCE OF STUNTING :

Table 5.0 Prevalence of stunting (Height-for-age Z score) among children aged 6.0 59.0 months(based on WH0 2005 reference)

NStunting (% with 95% CI)

CampSevere(


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Annex IILocally developed calendar for anthropometric measurements

Month Event to refer 2003 2004 2005 2006 2007 2008January Sudan

Independentday

54 42 30 18 6

February 53 41 29 Arrivalof IDPs inGoz Beida

17

March 52 40 28 16 TieroandMorenoattacked

April 51 39 27 15May 50 38 26 14June 49 37 25 13Juily 48 36 24 12August Chad

Independence59 47 35 23 11

September 58 46 34 22 10October 57 45 33

Ramadan21Ramadan 9

Ramadan November 56

Ramadan44Ramadan

32 20 attack in Abeche

8

December Noel 55 end of Ramadan

43 end of Ramadan

31 19 attack inBiltine

7

Annex IIILocally developed calendar for retrospective mortality measurements

Month Weeks Monday Tuesday Wednesday Thursday Friday Saturday SundayApril 2008 Week 14 100 99 98 97 96 95 94

Week 15 93 92 91 90 89 88 87Week 16 86 85 84 83 82 81 80Week 17 79 78 77 76 75 74 73

May 2008 Week 18 72 71 70 69 68 67 66Week 19 65 64 63 62 61 60 59Week 20 58 57 56 55 54 53 52Week 21 51 50 49 48 47 46 45Week 22 44 43 42 41 40 39 38

June 2008 Week 23 37 36 35 34 33 32 31Week 24 30 29 28 27 26 25 24Week 25 23 22 21 20 19 18 17Week 26 15 14 13 12 11 10 9

July 2008 Week 27 8 7 6 5 4 3 2Week 28 1Week 29


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Annex IV

2008 Nutrition Survey Time table; a collaboration with UNICEF, WFP and WHO

Dates Activities /Period Places Over nightRemarks(

Needs)

3-Jun-08 Depart Tanzania to Chad

5-Jun-08 Arrival Ndjamena - Chad Ndjamena

Administrativeprocedures

delayed

17-Jun-08 Arival in Abeche & Briefing Abeche Abeche Nutrition team,

18-19 June 2008

Preparatory activities ( Adoption of nut survey documents,protocol of survey,final budget, training programme, invitations

letters, official communication of survey schedule)) Abeche Abeche Nutrition team,

20--23 June 2008 Preparatory activities ( Printing documents, logistic packages)) Abeche Abeche Nutrition team,

24--26 June 2008 Training of nutrition team leaders( Surveyors) Abeche Abeche Ecole de la sant

27-28 June 2008 Training of supervisors of UN Agencies and IPS on SMART

software. Abeche Abeche Ecole de la Sant

30-Jun-08 En route to Koukou Koukou Koukou COOPI

1st July 2008 Training of CHWs in Goz-amer camp Koukou Koukou COOPI

2d July 2008 Nutrition Survey in Goz-Amer camp Goz-amer Koukou COOPI

3d July 2008 En route to Gozbeida Farchana camp FarchanaUNHCR Gozbeida

04-Jul-08 Training of CHWs in Djabal Gozbeiida Gozbeida COOPI

5-6 July 2008 Nutrition surveys in Djabal Djabal Gozbeida COOPI

07-Jul-08 En route to Abeche Djabal Gozbeida

UNHCR

Gozbeida08-Jul-08 En route to Amleyouna Amleyouna Amleyuna Nutrition team,

09-Jul-08 Training CHWs in Gaga camp Gaga Amleyuna IMC

10-11 July2008 Nutrition Survey in Gaga Gaga Amleyuna IMC

12-Jul-08 En route to Farchana Farchana FarchanaUNHCR Farchana

13-Jul-08 Training of CHWa in Farchana camp Farchana Farchana MSF-H/IMC

14-15 July /2008 Nutrition Survey in Farchana camp Farchana Farchana MSF-H/IMC

16-Jul-08 En route to Bredjing and Training of CHWs in Bredjing camp Bredjing HadjerHadid IRC

17-18 July 2008 Nutrition survey in Bredjing camp Bredjing

Hadjer

Hadid IRC

19-Jul-08 Training of CHWs in Treguine camp TreguineHadjerHadid FICR/CRT

20-21 July 2008 Nutrition survey in Treguine camp TreguineHadjerHadid FICR/CRT

22-Jul-08 En route to Abeche Abeche Abeche Nutrition team,

23-Jul-08 En route to BahaiOure Cassoni

camp Bahai Nutrition team,

24-Jul-08 Training of CHWs in Oure Cassoni campOure Cassoni

camp Bahai ACTED/IRC

25-26 July 2008 Nutrition survey in Oure Cassoni campOure Cassoni

camp Bahai ACTED/IRC

27-Jul-08 En route to Iriba Iriba Iriba Nutrition team,

28-Jul-08 Training of CHWs in Amnabak camp Amnabak Iriba IMC


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29- 30 July 2008 Nutrition survey in Amnabak camp Amnabak Iriba IMC

31-Jul-08 Training of CHWs in Iridimi & Touloum camps Iridimi Iriba MSF-L

1-3 Aug 2008 Nutrition survey in Iridimi & Touloum camps Iridimi Iriba MSF-L

04-Aug-08 En route to Guereda Guereda Guereda UNHCR Iriba

05-Aug-08 Training of CHWs in Mile camp Mile Guereda IMC

6 -7 Aug 2008 Nutrition survey in Mile camp Mile Guereda IMC

08-Aug-08 Training of CHWs in Konoungou camp Kounoungou Guereda IMC

9-10 Aug 2008 Nutrition Survey in Konoungou camp Kounoungou Guereda IMC

11-Aug-08 En route to Abeche Abeche Abeche Nutrition team,

12-14Aug 2008 Data entry -Cleaning & analysis Abeche Abeche Nutrition team,

15-20 Aug 2008 Data interpretation & Report writing Abeche Abeche Nutrition team,

21-Aug-08 Presentation of results findings to partners Abeche Abeche Nutrition team,


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