South Sudan

ANTHROPOMETRIC NUTRITION SURVEY CHILDREN UNDER FIVE YEARS OLD

PANOMDIT AND CHUEI PAYAMS SOBAT COUNTY

January 21st – February 1st 2003

Jessica Brooten – Nutritionist Carol Njogu – Nutritionist

Action Against Hunger – USA (ACF-USA) South Sudan

2

TABLE OF CONTENTS SUMMARY .........................................................................................................................................................................................3

ACKNOWLEDGEMENTS ...............................................................................................................................................................7

INTRODUCTION ..............................................................................................................................................................................8

OBJECTIVES ...................................................................................................................................................................................10

METHODOLOGY ...........................................................................................................................................................................11 1. TYPE OF SURVEY AND SAMPLE SIZE ............................................................................................................................................11 2. DATA COLLECTION......................................................................................................................................................................11 3. INDICATORS, GUIDELINES AND FORMULAS USED ........................................................................................................................11

3.1. Acute Malnutrition .............................................................................................................................................................11 3.2. Mortality ..............................................................................................................................................................................12

4. FIELD WORK................................................................................................................................................................................13 5. DATA ANALYSIS..........................................................................................................................................................................13

RESULTS ..........................................................................................................................................................................................14 1. DISTRIBUTION BY AGE AND SEX .................................................................................................................................................14 2. ANTHROPOMETRIC ANALYSIS.....................................................................................................................................................15

2.1 Acute malnutrition.........................................................................................................................................................15 2.2 Risk to Mortality: Children’s MUAC .................................................................................................................................17 2.3 Adult Malnutrition: Caretaker’s MUAC............................................................................................................................18

3. MEASLES VACCINATION COVERAGE...........................................................................................................................................18 4. HOUSEHOLD STATUS ..................................................................................................................................................................18 5. COMPOSITION OF THE HOUSEHOLD.............................................................................................................................................19 6. MORTALITY RATE .......................................................................................................................................................................19 7. CAUSES OF MORTALITY ..............................................................................................................................................................19

DISCUSSION ....................................................................................................................................................................................21

APPENDIX........................................................................................................................................................................................24

3

SUMMARY

1. OBJECTIVES • To evaluate the nutritional status of children aged 6-59 months. • To estimate the measles immunization coverage among children aged 9-59 months. • To estimate crude and under-five mortality rates through a retrospective survey. • To evaluate the nutritional status of the sampled children’s caretakers using MUAC. • To assess the extent of household movement. Specific objective is: • To identify groups at higher risk of malnutrition: age group and sex.

2. METHODOLOGY The survey was conducted from January 21st to February 1st 2003 in Panomdit and Chuei Payams, Sobat County, Northern Upper Nile. All villages within four hours walking distance of the airstrip at Payuer in Malek Boma, Panomdit Payam were included in the survey. This includes parts of Panomdit, Malek and Liet Bomas in Panomdit Payam and part of Tiep Boma in Chuei Payam. At the time of the survey, the total population figures (for the area included in the survey) were estimated at 4,2031. Due to the small number of children under five years of age observed in the area during the pilot survey, it was decided to do an exhaustive survey of the area, with 545 children under five being measured. However, due to data collection errors three records were not included in the analysis. Constraints encountered in the field • The walking distances to some of the villages included in the survey made it difficult for the team (ACF-USA

survey team) to supervise all the six teams involved in the survey everyday.

1 Figure obtained through exhaustive retrospective mortality survey conducted in the area at the time of the survey.

4

3. SUMMARY OF RESULTS

Age

Group Indicator RESULT

6-59 N= 542

Z-score Global Acute Malnutrition

23.4% [127]

Severe Acute Malnutrition

4.8% [26]

Acute

% Median Global Acute Malnutrition

13.3% [72]

Malnutrition Severe Acute Malnutrition

2.2% [12]

6-29 N= 230

Z-score Global Acute Malnutrition

32.2% [74]

Severe Acute Malnutrition

8.7% [20]

% Median Global Acute Malnutrition

19.1% [44]

Severe Acute Malnutrition

4.3% [10]

Caretaker’s MUAC

<185mm 185 – 219mm >=220mm

Malnourished ‘At Risk’ ‘Well Nourished’

0.2% 17.8% 82.0%

Under-five retrospective mortality (last 4 months) 25.0/10,000/day Crude retrospective mortality (last 4 months) 10.0/10,000/day Measles vaccination coverage By EPI card

By Caretaker Total

2.3% 17.3% 19.6%

4. DISCUSSION

The rate of Global Acute Malnutrition [GAM] and Severe Acute Malnutrition [SAM] for children aged between 6 to 59 months as reflected in this survey is very alarming. These rates are above the WHO classification criteria for an emergency situation2. Especially alarming is the eight cases of edema found, as this is a very severe form of malnutrition. However, the edema found could also be related to the kalazar present in the area, as in some cases of kalazar “Edema may be part of a syndrome comprising hair and skin changes resembling kwashiorkor.”3 There is also a significant difference between the rates in the different age groups, with the children 6-29 months of age more likely to be malnourished than those aged 30-59 months (relative risk 1.84, p<0.001). Young children are exclusively breastfed for more than six months even though children above six months need complementary food as well as breast milk for proper growth and development. At around one year of age children begin to receive a porridge made of grain (sorghum or maize) and water twice a day. Children do not begin to eat green leafy or other vegetables and family foods until they are at least 18 months of age. To better understand the problem the results concerning the mothers / caretakers are important. The nutritional status of the adults/caretakers as reflected by their MUAC shows that 18.0% are exhibiting the effects of acute food shortage by their energy deficient state. The caretakers are living at a cost of their usual physical and physiological needs and functions. Caretakers are currently feeding their family by collecting and preparing wild foods. This is very time and energy consuming task, especially since the wild foods nearby have already been used

2 Cf. World Health Organization, 1995. Classification of wasting prevalence in under five’s. 3 Manson’s Tropical Diseases, 20th edition, 1996, p. 1233

5

and the population is forced to walk for one to two hours in order to locate the wild food. The adverse effect of collecting wild food (although a very common and good coping mechanism in time of food shortage) is that they have less time to do something else. As well, physical tiredness due to the wild food collection is enhanced by a bad nutritional state. Not only does their bad nutritional status affect their normal physiological functioning but also it determines their ability to undertake physical activities let alone their resistance to diseases. This energy deficient state could be linked to the high rates of malnutrition among the children as it affects the ability of the mothers to ensure household food security and the quality of childcare. Little is known on the quality of breastfeeding in the case of malnutrition of the mother. This also could be a problem for the children. According to the MUAC results, 2.3% of the children are malnourished, with a further 30.7% of the children on the borderline or “at risk” of becoming malnourished. The backbone of household food security in Panomdit and Chuei Payams in general is agriculture. The Dinkas are agro-pastoralists and rely on crops for grains (staple food) and livestock for blood and milk. Crop production depends on climatic fluctuations and the security of the region. During the time of the survey it was mentioned that the harvest this year was way below average. The local community reported that the late and insufficient rains, flooding, and bird attacks the sorghum and maize crops were almost nonexistent, with families harvesting only one or two tins of grain this year. The community is requesting sickles, as they need to cut grass to clear fields in the area where they grow crops. Without sickles this clearing of grass is very time-consuming and labor intensive leaving less time for other productive activities. Fish were being eaten, but families were mainly subsisting on wild foods such as lalop and water lily, which are expected to run out by March or April. Most years the population does not even begin to rely on these wild foods until March or April. Adults were said to be eating only once a day, with small children eating twice a day. Livestock levels appeared very low, with most families having no cows and few or no goats. Some households also had chickens. Non-food items were distributed in the area by MedAir in April 2002, Open Doors in May 2002, and SSOM (South Sudan Operation Mercy) in December 2002. These included mosquito nets, blankets, soap, serving spoons, plates, jerrycans, cooking pots, clothing, and sewing needles. Seeds included maize, sorghum, and beans. Fishing equipment included hooks, nets, and twine, and tools included pangas, axes, and malodas. All three organizations are planning to distribute non-food items in 2003. This area has not previously been served by WFP, though they plan to do a distribution in February of 2003. However, in January 2001 relief food was distributed from the north by barge to the area, and consisted of maize, lentils, oil, and salt. During the May non-food item distribution by Open Doors small amounts of beans, salt, wheat flour, and sorghum were distributed and during the December non-food item distribution by SSOM small amounts of simsim, sorghum, UNIMIX, groundnuts, and salt were distributed. The U5MR (under-five mortality rate) and the CMR (crude mortality rate) are high. The under-five retrospective mortality rate of 25.0/10,000/day is way above emergency level of 4/10,000/day, and the crude retrospective mortality rate of 10.0/10,000/day is way above the emergency level of 2/10,000/day4. These rates are indicative of a very bad situation although mortality data in these area are always difficult to properly collect. The high level of mortality is concurrent with the observed severe acute malnutrition rates. Malnutrition was cited as the leading presumed cause of death for both under-fives and over-fives in the retrospective mortality survey, with diarrhea the second most cited cause of death for those less than five years of age. In community meetings, the community listed hunger as the most common cause of death5 followed by kalazar, diarrhea, fever/malaria, and TB. In general, Upper Nile has always shown high mortality from and a high prevalence of diarrheal diseases6. This could be linked to the poor public health (hygiene and sanitation practices), poor access to safe water and low access to health care. A large proportion of the population is under-served. There are no preventive health measures, such

4 Cf. WHO 5 Subjective and to be interpreted with caution 6 UNICEF reported morbidity figures for southern Sudan-July 2002

6

as routine immunization, nutrition and health education and surveillance activities. Poor management of diseases, as well as the alarming rates of malnutrition and high mortality, suggests additional underlying factors such as the poor child care practices in this community. The health workers in the area list a TB clinic, injections for malaria treatment, and an EPI program as priorities for medical services in the community now that they have a kalazar clinic supported by MedAir. The measles vaccination coverage according to the presence of an EPI card was very low at 2.3% and there is no ongoing EPI (Expanded Program of Immunization). No measles vaccination campaigns have been done in the area. However, according to caretakers 19.6% of children had been vaccinated against measles. The few children who were vaccinated against measles had been taken to Aburoc in Shilluk Kingdom or to GoS towns such as Malakal, Meluth, or Khartoum for vaccination. The population along the Awilwil depends on the river for all their water needs. When the Awilwil dries up towards the end of March/April, the population moves across the river to an island formed by the White Nile and Awilwil Rivers in order to access the water, fish, and wild foods of the Nile. During the rainy season the population grows crops in the desert approximately three to four hours from the Awilwil River in an area called Maloc. There is no water source in this area, forcing people to carry water from the Awilwil River. The community is requesting boreholes to be dug in Maloc, which would make it possible for those without livestock to live in the Maloc area during planting rather than traveling back and forth from the villages along the river. Those with livestock need to be near the river so that water can be provided to their animals. Many people are currently using gourds for water storage and transport. Although some jerrycans have been distributed, buckets with lids would be useful for the population as these are easier to keep clean and can be used for other purposes as well as water storage and transport. The hygiene and sanitation situation is very poor. The population does not use latrines except for those who are patients at the kalazar clinic. The general cleanliness of the population is also an issue. Though some people bathe in the river, many appear to be constantly covered in dirt, especially the children.

5. RECOMMENDATIONS

Health care services including preventive health measures (such as health and hygiene education) to be set up in the area.

Therapeutic and supplementary feeding centers should be opened to address the high levels of severe and

moderate malnutrition in the area.

WFP should sustain a monthly distribution at a ration level of 50% until the situation improves.

Systematic food security monitoring to assess crop performance and other predictors for food insecurity.

Establish continuous EPI activities with specific emphasis on measles.

Establish hygiene promotion activities.

Intervention to provide improved access to safe water.

MedAir, SSOM, and Open Doors to carry out planned distributions, with sickles and buckets with lids to be included as some of the items distributed.

Maintain nutritional surveillance to monitor the situation

7

ACKNOWLEDGEMENTS

ACF-USA acknowledges the invaluable support and assistance of the following: • Sudan Relief and Rehabilitation Agency [SRRA], both at Lokichoggio and field level for facilitating the work in

the field • UNICEF/OFDA for funding the survey. The local survey teams for working tirelessly in the heat • All ACF-USA staff and team members who contributed to the survey. • And most importantly, thank you to the local community, particularly mothers and caretakers, for their

cooperation.

8

INTRODUCTION

Panomdit and Chuei Payams are located in Sobat County, Northern Upper Nile. Panomdit Payam consists of three Bomas: Panomdit, Malek, and Liet. Chuei Payam consists of Tiep, Majak, and Wuntheep Bomas. Majak and Wuntheep Bomas were not included in the survey due to distance (more than four hours walking from Payuer airstrip). The majority of the villages are along the rivers, with a desert to east where the farms of the population are allocated. Panomdit and Chuei Payams are currently under SPLA administration, and have been since 1998. In the past there has been a lot of insecurity in the area due to its nearness to the GoS controlled areas due to the presence of the Adar Oilfields and the oil pipeline running north of the above area, pushing much of the population south and west. At the time of the survey, the security situation was quiet. However, GoS militia attacked Thangrial in April of 2002, leading to large numbers of IDPs in the area covered by the survey. Many of these IDPs were unable to cultivate as they did not have time to clear land in their new location and could not return to their homes in time to plant the land they had previously cultivated. In Kuomthor there were reports of four people being abducted by the GoS in September when they crossed the Nile River during flooding. The inhabitants of Panomdit and Chuei Payams are mainly Nyiel Dinka. As with most Dinka groups, they are agro-pastoralists. Although cattle are a focal point of their social and economic structure, the majority of the cattle in the area of Panomdit and Chuei Payams had previously been taken in cattle raids by GoS militia and Murhaleen and the community is still in the process of restocking their livestock. The area has also experienced raids from the Dongjol area to the south, however at the moment the two communities have agreed not to raid. Most homes now have no livestock, and those that have livestock have few animals, with the majority being shoats. During community meetings, it was determined that a rich man has 3-4 cows, those in the middle having 1-2 cows or only goats, and the poor having no livestock, with the poor making up approximately 88% of the population7 For most of the year, the Dinka diet consists of sorghum (jak, a long-term variety), maize, and fish, though some vegetables and legumes are cultivated and consumed. These include pumpkins, okra, groundnuts, simsim, onion, tomatoes, watermelon and beans. The Dinka routinely collect wild foods during the hunger gap. In the area covered by the survey the main wild foods eaten are lalop (leaves, fruit, and oil from seeds) and agor (water lily), as well as anuer (small green leaves), lang (a berry), anet (leaves of an evergreen bush), apac (root/tuber found in water and eaten throughout the year mainly by children), awer (root/tuber eaten like potatoes), gum (sap from trees) and akolthiep. The majority of the villages included in the survey are located along the Awilwil River, which dries up around March or April. At this time, most of the people from these villages move across the Awilwil River to an island formed by the Awilwil and the White Nile in order to have access to water from the Nile as no other source of water is available at this time of the year. This also allows them access to fish and wild foods available along the banks of the Nile. According to the community, the food security situation is worse this year than last year. The sorghum and maize crops failed due to drought and flooding, as well as bird attacks. Before 1998 it was possible to harvest 15 sacks of grain for food with enough extra for seed for the next year’s planting, but this year people were only able to harvest 1-2 tins of maize. There was also drought last year, but people were able to go to the Shilluk Kingdom to work for food. This year, the Shilluk harvests were also poor, making this not an option this year compared to last year. During the survey it was discovered that approximately one-fourth of the households in the area surveyed had migrated due to hunger. Some have gone to the island earlier than usual, starting in January as opposed to late February, in previous years. Some had gone south to the Dongjol area to exploit kinship ties, some moved to Gumku as the wild foods there have been less utilized, and some have gone to GoS towns further north to work to obtain

7 Determined through proportional piling exercise.

9

food8. Food is available through trade in the GoS town of Maluth, however people are not allowed to bring the food obtained out of the GoS area, it must be eaten there. WFP has never distributed food in this area, but plans to have a distribution in February 2003. However, food aid from Khartoum was received in Payuer by barge in January 2001, and consisted of grain, lentils, oil and salt. SSOM (South Sudan Operation Mercy) distributed some food and non-food items in Payuer in December 2002. The non-food items consisted of: 50 bales of mosquito nets, 55 cartons of soap, 2,366 cooking pots, 8 cartons of fishing twine, 30,000 fishing hooks, 70 cartons of serving spoons, 30 cartons of pangas, 31 cartons of malodas, 1,480 plates, 25 cartons of small jerrycans, and 80 boxes of sewing needles. A small amount of food was also distributed and consisted of 50 bags of salt, 3 ½ bags of simsim, 14 bags of sorghum, 50 bags of UNIMIX, and 20 bags of groundnuts. SSOM plans to do another distribution in March 2003. MedAir is supporting a kalazar clinic in Payuer, which also treats some PHCU Patients. In April 2002, Medair also distributed 2,000 mosquito nets, 2,000 blankets, 1,728 malodas, 1,008 pangas, 80 axes, 25,000 size six fishing hooks, 1,000 size 7 fishing hooks, 16,400 size 8 fishing hooks, 415 rolls of 21-ply fishing twine, 3.8 tons of maize seeds and 3.75 tons of bean seeds. They plan to do another distribution in early 2003, including a canoe to be used by the community for fishing. They are planning to begin hygiene education in Payuer as well. Open Doors distributed food and non-food items in Payuer in May 2002. The food distributed consisted of sorghum, beans, salt, and wheat flour. Other items distributed included sorghum seeds, cooking pots, blankets, mosquito nets, fishing nets, jerrycans, and clothing. Open Doors is planning to work with MedAir to do a similar distribution in early 2003. The following table shows NGO activities in the area.

Table 2

Agency Activities MedAir • Health: support of Kalazar Clinic in Payuer

• Non-food item and seeds distribution ACF-USA • Nutritional Surveillance SSOM • Food and Non-Food Items Distribution Open Doors • Food and Non-Food Items Distribution

8 The above food security information was determined through community meetings as well as data on empty houses collected during the survey.

10

OBJECTIVES

• To evaluate the nutritional status of children aged 6-59 months • To estimate the measles immunization coverage among children aged 9-59 months • To estimate crude and under-five mortality rates through a retrospective survey • To evaluate the nutritional status of the sampled children’s caretakers using MUAC • To assess the extent of household movement Specific objective is: • To identify groups at higher risk to malnutrition: age group and sex

11

METHODOLOGY

1. Type of survey and sample size The target population of the survey was children aged 6 to 59 months. The area covered was restricted to a maximum of 4 hours walking distance from the Payuer airstrip (in Malek Boma, Panomdit Payam). A map showing the area is included in the Appendix. When the team first arrived in Payuer, total population figures were estimated at 9,2229. This therefore gave us a target population estimated at 1,846 children (calculated as 20% of the total population). However, during the pilot survey it was discovered that households were fewer than expected due to households migrating due to hunger. Also, the percentage of children in the population was lower than 20%. Therefore, it was decided to do an exhaustive survey of the area (see appendix for a list of villages included in the survey). 712 households were included in the survey, with a total of 545 children under five years of age measured. However, three records were not used due to data collection errors. 2. Data Collection For each child chosen, aged 6 to 59 months old: Age: recorded with the help of a local calendar of events. Sex: recorded. Weight: [SALTER balance of 25 kg, precision of 100g]. Children were weighed without clothes. Height: [Shorr measuring board, precision of 0.1 cm]. Children less than 85 cm were measured lying down, while those greater than or equal to 85 cm were measured standing up. Mid-Upper Arm Circumference: [MUAC: precision of 1 mm]. MUAC was measured at mid-point of left upper arm for children and the mother of the measured child. Bilateral oedema: assessed by the application of normal thumb pressure for at least 3 seconds to both feet. Measles vaccination: This was assessed by checking for measles vaccination on EPI cards and asking the caretakers of the children when no card was present. Household status: For the surveyed children, households were asked if they were permanent residents, temporarily in the area or displaced. Caretaker information: At each household with children under five years old, teams inquired who the caretaker was, their sex was noted, and their relationship to the children and their MUAC was measured. Retrospective mortality: At all households [with or without under five], teams inquired for the number of household members alive per specified age groups [see mortality questionnaire in appendix]. Additionally, it was inquired how many people had died, if any, [from September, with the beginning of the season Anyoc used as a reference point] and the presumed cause of death. 3. Indicators, guidelines and formulas used

3.1. Acute Malnutrition

Weight-for-Height Index For the children, acute malnutrition rates were estimated from the weight for height [W/H] index values combined with the presence of oedema. The W/H indices are compared with NCHS10 references. W/H indices were expressed both in Z-scores and in percentage of the median. The expression in Z score has true statistical meaning and allows inter-study comparison. The percentage of the median, on the other hand, is commonly used to identify eligible children for feeding programs and both will be reported. 9 Based on household numbers estimated for villages within four hours walk. These were determined through a meeting with the SRRA Secretary and surveyors. 10 NCHS: National Center for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics. 165, 11-74.

12

Guidelines for the results expressed in Z Score: • Severe malnutrition is defined by WFH < -3 SD and/or existing bilateral oedema on the lower limbs of the child • Moderate malnutrition is defined by WFH < -2 SD and >= -3 SD and no oedema. Guidelines for the results expressed in percentage according to the median of reference: • Severe malnutrition is defined by WFH < 70 % and/or existing bilateral oedema on the lower limbs • Moderate malnutrition is defined by WFH < 80 % and >= 70 % and no oedema. Global acute malnutrition is therefore defined as the proportion of children presenting with a weight for height index less than –2 z scores [or less than 80% in the percentage of median] with/without oedema.

Mid-Upper Arm Circumference [MUAC] Children’s MUAC The weight for height index is the most appropriate index to quantify wasting in a population in emergency situations where acute forms of malnutrition are the predominant pattern. However the mid-upper arm circumference [MUAC] is a useful tool for rapid screening of children at a higher risk of mortality. The MUAC is only taken for children with a height of 75 cm and more. The guidelines are as follows: MUAC <110 mm severe malnutrition and high risk of mortality MUAC>=110 mm and <120 mm moderate malnutrition and moderate risk of mortality MUAC>=120 mm and <125 mm high risk of malnutrition MUAC>=125 mm and <135 mm moderate risk of malnutrition MUAC>=135 mm ‘adequate’ nutritional status Caretaker’s MUAC Common cut-offs for the two sexes have also been suggested at 185mm to define global acute malnutrition and 160mm to define severe acute malnutrition [Collins, 1996] and these cut-offs have been accepted by the agencies working in South Sudan during a task force meeting.11 Additionally, a cut-off of 220mm for women and 230mm for men has been proposed as delineating energy deficiency [James et al, 1994].

3.2. Mortality The mortality rate [MR] is determined for both the whole population [CMR] and children under five years [U-5MR] old. The defined limits are as follows12: U-5MR Alert level: 2/10,000 people/day Emergency level: 4/10,000 people/day CMR Alert level: 1/10,000 people/day Emergency level: 2/10,000 people/day 11 April 13th 1998, Lokichoggio 12 Health and nutrition information systems among refugees and displaced persons, Workshop report on refugees nutrition, ACC / SCN, Nov 95.

13

The death rate [DR], for U-5s or the whole population, is calculated as follows: If: n = the number of deaths (in the last 4 months) And: N = the number alive the day of the survey Then: DR = n/ [((n+N) + N) /2] The RMR = [DR x 10,000] /number of days in the period. The period corresponds to the 4 months (120 days) preceding the survey. Therefore, RMR = [DR x 10,000]/120. It is expressed per 10,000 people/day. 4. Field Work Five teams of three people each and one team of four people executed the fieldwork. All participants underwent a three-day training and a one-day pilot survey, with a one-day review after the pilot. The survey lasted for a period of four working days. 5. Data Analysis Data processing and analysis were carried out using EPI-INFO 5.0 program and EPINUT 2.2 computer software.

14

RESULTS

1. Distribution by age and sex

Table 4 DISTRIBUTION BY AGE AND SEX

AGE

(In months) BOYS GIRLS TOTAL Sex

Ratio N % N % N %

06 – 17 53 51.0% 51 49.0% 104 19.2% 1.04 18 – 29 68 54.0% 58 46.0% 126 23.2% 1.17 30 – 41 62 52.1% 57 47.9% 119 22.0% 1.09 42 – 53 56 57.1% 42 42.9% 98 18.1% 1.33 54 – 59 50 52.6% 45 47.4% 95 17.5% 1.11

Total 289 53.3% 253 46.7% 542 100% 1.14

54-59

42-53

30-41

18-29

06-17

Figure 1D ist r ibut io n by A ge and Sex

Payuer January 2 0 0 3

BoysGirls

The distribution by sex at 1.14 does not show a significant imbalance.

0% 5% 10% 15% 20% 25% 30%

54-59

42-53

30-41

18-29

06-17

Figure 2A ge D ist r ib ut ion

Payuer January 2 0 0 3

The age distribution shows an imbalance, with the age groups 6-17 months and 42-53 months being slightly underrepresented and the 18-29 months, 30-41 months, and 54-59 months age groups over-represented. While this could be a fact in the population, it should also be noted that in most cases during the survey, ages given by the caretakers were rather approximate. A local calendar was used to estimate the ages, as the exact birth dates were not known. To a large extent, inclusion of children in the sample was based on the satisfaction of

15

the height criteria of 65-115 cm. An overestimation of age could have resulted in the inclusion of some younger children in the 54-59 month age group. This could explain some of the imbalance.

2. Anthropometric analysis

2.1 Acute malnutrition

Distribution of malnutrition in Z-score

Table 5

WEIGHT FOR HEIGHT: DISTRIBUTION BY AGE IN Z-SCORE

AGE

(In months) < -3 SD ≥ -3 SD & < - 2 SD ≥ -2 SD Oedema

N N % N % N % N % 06-17 104 7 6.7% 29 27.9% 64 61.5% 4 3.8% 18-29 126 5 4.0% 25 19.8% 92 73.0% 4 3.2% 30-41 119 3 2.5% 13 10.9% 103 86.6% 0 0.0% 42-53 98 3 3.1% 14 14.3% 81 82.7% 0 0.0% 54-59 95 0 0.0% 20 21.1% 75 78.9% 0 0.0%

TOTAL 542 17 3.3% 95 18.6% 415 76.6% 8 1.5%

Figure 3Z score distribution - Weight-for-Height

Payuer January 2003

0

5

10

15

20

25

30

-5 -4 -3 -2 -1 0 1 2 3 4 5

Reference

SexCombined

There is a significant displacement of the sample curve to the left of the reference, indicating a poor nutritional situation in this population. The mean Z score of the sample is –1.39 (SD: 0.87).

Table 6 WEIGHT/HEIGHT vs. OEDEMA

< -2 SD ≥ -2 SD Marasmus/Kwashiorkor Kwashiorkor YES 1 0.2% 7 1.3% Oedema Marasmus Normal NO 119 22.0% 415 76.6%

16

Table 7 GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP

In Z-score

6-59 months (n = 535) 6-29 months (n = 228) Global acute malnutrition 23.4% [127] 32.2% [74] Severe acute malnutrition 4.8% [26] 8.7% [20]

There is a statistically significant difference between the prevalence of malnutrition in children aged 6-29 months and those aged 30-59 months [p<0.001], with the children 6-29 months of age more likely to be malnourished than those aged 30-59 months (relative risk 1.89, p<0.001). There might be a problem of access and availability of adapted weaning food for the small children in the area, however the worsening of the situation seems to be leveling this gap between age groups.

Table 8 NUTRITIONAL STATUS BY SEX

In Z-Score

Nutritional status Definition Boys Girls N % N %

Severe malnutrition Weight for Height < -3 or oedema

17 5.9% 9 3.6%

Moderate malnutrition -3 ≤ Weight for Height < -2 and no oedema

57 19.7% 44 17.4%

Normal -2 ≤ Weight for Height and no oedema

215 74.4% 200 79.1%

TOTAL 289 253 Statistically, there is no difference between the malnutrition rates for the boys and girls [p>0.05].

Distribution of malnutrition in percentage of the median

Cut-offs for acute malnutrition expressed in percentage of the median are commonly used in determining admission criteria in feeding centers.

Table 9 WEIGHT/HEIGHT: DISTRIBUTION BY AGE

In percentage of the median

AGE (In months)

< 70% ≥ 70% & < 80% ≥ 80% Oedema

N N % N % N % N % 06-17 104 1 1.0% 22 21.2% 77 74.0% 4 3.8% 18-29 126 1 0.8% 12 9.5% 109 86.5% 4 3.2% 30-41 119 1 0.8% 10 8.4% 108 90.8% 0 0.0% 42-53 98 1 1.0% 9 9.2% 88 89.8% 0 0.0% 54-59 95 0 0.0% 7 7.4% 88 92.6% 0 0.0%

TOTAL 542 4 0.7% 60 11.1% 470 86.7% 8 1.5%

17

Table 10 WEIGHT/HEIGHT vs. OEDEMA

In percentage of the median

< 80% ≥ 80% Marasmus/Kwashiorkor Kwashiorkor YES 0 0.0% 8 1.5% Oedema Marasmus Normal NO 64 11.8% 470 86.7%

Table 11

GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP In percentage of the median

6-59 months (n = 535) 6-29 months (n = 228) Global acute malnutrition 13.3% [72] 19.1% [44] Severe acute malnutrition 2.2% [12] 4.3% [10]

Table 12 NUTRITIONAL STATUS BY SEX

In percentage of the median

Nutritional status Definition Boys Girls N % N %

Severe malnutrition Weight for Height < 70% or oedema

9 3.1% 3 1.2%

Moderate malnutrition 70% ≤ Weight for Height < 80% and no oedema

32 11.1% 28 11.1%

Normal 80% ≤ Weight for Height and no oedema

248 85.8% 222 87.7%

TOTAL 289 253

2.2 Risk to Mortality: Children’s MUAC As MUAC overestimates the level of under nutrition in children under 1 year old, the analysis refers only to children having height equal to or greater than 75cm.

Table 13 MUAC DISTRIBUTION ACCORDING TO NUTRITIONAL STATUS

For children of height greater or equal to 75cm

Criteria Nutritional status N %

<110 mm Severe malnutrition 2 0.4% 110 mm >=MUAC<120mm Moderate malnutrition 9 1.9% 120 mm >=MUAC<135 mm Mild malnutrition 149 30.7% MUAC>=135 mm Normal 326 67.1%

TOTAL 486

18

According to the MUAC measurement, 2.3% of the children are severely or moderately malnourished and therefore at high risk to mortality. However, a further 30.7%, which is a very high proportion, are mildly malnourished and therefore have an increased risk of mortality. With the poor food security situation and the lack of adequate health services, it is very possible that the nutritional situation of these children will worsen, with some of those moderately malnourished becoming severely malnourished and some of the mildly malnourished becoming moderately malnourished.

2.3 Adult Malnutrition: Caretaker’s MUAC

Table 14 MUAC DISTRIBUTION ACCORDING TO NUTRITIONAL STATUS

Criteria Nutritional status N %

<185 mm Malnourished 1 0.2% 185 mm >=MUAC<220 mm At risk to malnutrition 72 17.8% MUAC>= 220 mm ‘Well Nourished’ 332 82.0%

TOTAL 405

Although only one of the caretakers was wasted, the proportion of those that are energy deficient is high [18.0%]. Considering that 84.1% of the caretakers were mothers, this poor nutritional status is likely to have a negative impact on their collective roles such as child care and ensure household food security. 3. Measles vaccination coverage Measles vaccination is administered from the age of 9 months. Children 9-59 months were included in the analysis. A total of 532 children were included in the analysis. Measles vaccination coverage was very low at only 2.3% according to the presence of an EPI card. However, according to caretakers 19.6% of children, which is still a low rate, are vaccinated against measles. 4. Household Status

Table 15

Status N % Resident 224 54.1 Temporary residents 24 5.8 Internally displaced 166 40.1 TOTAL 414

40.1% of the families surveyed were IDP households. During community meetings it was determined through a proportional piling exercise that the IDP and resident populations in the area surveyed are approximately equal, which supports the findings of the survey. Some villages visited, such as Kuomthor, Nyayok 2, Wunbarco 1-3, and Bailual, were inhabited mainly by IDP households.

19

5. Composition of the household

Table 16: Household composition

Age group N % 0 to 5 years 707 16.4 Above 5 years 3,614 83.6

Total 4,321

414 caretakers were interviewed for the survey. The mean number of children under five per household is 0.98 (SD 0.86) and the mean number of those over five per household is 5.01 (SD 3.26). 6. Mortality rate - Under Five There were 707 children under five years old alive on the day of the survey and 250 children under five had died within the preceding four months. Mortality Rate [MR] = [0.30 x 10,000] /120 = 25.0/10,000 persons/day According to the above formula, the under-five mortality rate is 25.0/10,000/day.

- Crude mortality rate [CMR]

There were 4,321 people alive during the survey period and 545 people had died within the preceding four months. MR= [0.12 x 10,000] /120 = 10/10,000 persons/day According to the above formula, the CMR is 10/10,000/day. 7. Causes of mortality

- Under five

Table 17 CAUSE OF DEATH

Cause of Death N %

Malnutrition 72 28.8 Simple Diarrhea 35 14.0 Other 33 13.2 Respiratory Infections 30 12.0 Fever 27 10.8 Measles 24 9.6 Bloody Diarrhea 22 8.8 Accidents 7 2.8 TOTAL 250 100

According to caretakers the main cause was classified as ‘malnutrition’. ‘Other’ deaths were mainly due to kalazar (61.0%) and TB (21.2%).

20

- Above five Table 18

CAUSE OF DEATH

Cause of Death N %

Malnutrition 95 32.2 Other 87 29.5 Bloody Diarrhea 26 8.8 Respiratory Infections 24 8.1 Fever 23 7.8 Simple Diarrhea 20 6.8 Accident 14 4.8 Measles 6 2.0 TOTAL 295 100

‘Other causes’ were primarily due to kalazar (34.5%), TB (31.0%) and gunshot wounds (14.9%).

21

DISCUSSION

The rate of Global Acute Malnutrition [GAM] and Severe Acute Malnutrition [SAM] for children aged between 6 to 59 months as reflected in this survey is very alarming. These rates are above the WHO classification criteria for an emergency situation13. Especially alarming is the eight cases of edema found, as this is a very severe form of malnutrition. However, the edema found could also be related to the kalazar present in the area, as in some cases of kalazar “Edema may be part of a syndrome comprising hair and skin changes resembling kwashiorkor.”14 There is also a significant difference between the rates in the different age groups, with the children 6-29 months of age more likely to be malnourished than those aged 30-59 months (relative risk 1.84, p<0.001). Young children are exclusively breastfed for more than six months even though children above six months need complementary food as well as breast milk for proper growth and development. At around one year of age children begin to receive a porridge made of grain (sorghum or maize) and water twice a day. Children do not begin to eat green leafy or other vegetables and family foods until they are at least 18 months of age. To better understand the problem the results concerning the mothers / caretakers are important. The nutritional status of the adults/caretakers as reflected by their MUAC shows that 18.0% are exhibiting the effects of acute food shortage by their energy deficient state. The caretakers are living at a cost of their usual physical and physiological needs and functions. Caretakers are currently feeding their family by collecting and preparing wild foods. This is very time and energy consuming task, especially since the wild foods nearby have already been used and the population is forced to walk for one to two hours in order to locate the wild food. The adverse effect of collecting wild food (although a very common and good coping mechanism in time of food shortage) is that they have less time to do something else. As well, physical tiredness due to the wild food collection is enhanced by a bad nutritional state. Not only does their bad nutritional status affect their normal physiological functioning but also it determines their ability to undertake physical activities let alone their resistance to diseases. This energy deficient state could be linked to the high rates of malnutrition among the children as it affects the ability of the mothers to ensure household food security and the quality of childcare. Little is known on the quality of breastfeeding in the case of malnutrition of the mother. This also could be a problem for the children. According to the MUAC results, 2.3% of the children are malnourished, with a further 30.7% of the children on the borderline or “at risk” of becoming malnourished. The backbone of household food security in Panomdit and Chuei Payams in general is agriculture. The Dinkas are agro-pastoralists and rely on crops for grains (staple food) and livestock for blood and milk. Crop production depends on climatic fluctuations and the security of the region. During the time of the survey it was mentioned that the harvest this year was way below average. The local community reported that the late and insufficient rains, flooding, and bird attacks the sorghum and maize crops were almost nonexistent, with families harvesting only one or two tins of grain this year. The community is requesting sickles, as they need to cut grass to clear fields in the area where they grow crops. Without sickles this clearing of grass is very time-consuming and labor intensive leaving less time for other productive activities. Fish were being eaten, but families were mainly subsisting on wild foods such as lalop and water lily, which are expected to run out by March or April. Most years the population does not even begin to rely on these wild foods until March or April. Adults were said to be eating only once a day, with small children eating twice a day. Livestock levels appeared very low, with most families having no cows and few or no goats. Some households also had chickens. Non-food items were distributed in the area by MedAir in April 2002, Open Doors in May 2002, and SSOM (South Sudan Operation Mercy) in December 2002. These included mosquito nets, blankets, soap, serving spoons, plates, jerrycans, cooking pots, clothing, and sewing needles. Seeds included maize, sorghum, and beans. Fishing equipment included hooks, nets, and twine, and tools included pangas, axes, and malodas. All three organizations are planning to distribute non-food items in 2003. 13 Cf. World Health Organization, 1995. Classification of wasting prevalence in under five’s. 14 Manson’s Tropical Diseases, 20th edition, 1996, p. 1233

22

This area has not previously been served by WFP, though they plan to do a distribution in February of 2003. However, in January 2001 relief food was distributed from the north by barge to the area, and consisted of maize, lentils, oil, and salt. During the May non-food item distribution by Open Doors small amounts of beans, salt, wheat flour, and sorghum were distributed and during the December non-food item distribution by SSOM small amounts of simsim, sorghum, UNIMIX, groundnuts, and salt were distributed. The U5MR (under-five mortality rate) and the CMR (crude mortality rate) are high. The under-five retrospective mortality rate of 25.0/10,000/day is way above emergency level of 4/10,000/day, and the crude retrospective mortality rate of 10.0/10,000/day is way above the emergency level of 2/10,000/day15. These rates are indicative of a very bad situation although mortality data in these area are always difficult to properly collect. The high level of mortality is concurrent with the observed severe acute malnutrition rates. Malnutrition was cited as the leading presumed cause of death for both under-fives and over-fives in the retrospective mortality survey, with diarrhea the second most cited cause of death for those less than five years of age. In community meetings, the community listed hunger as the most common cause of death16 followed by kalazar, diarrhea, fever/malaria, and TB. In general, Upper Nile has always shown high mortality from and a high prevalence of diarrheal diseases17. This could be linked to the poor public health (hygiene and sanitation practices), poor access to safe water and low access to health care. A large proportion of the population is under-served. There are no preventive health measures, such as routine immunization, nutrition and health education and surveillance activities. Poor management of diseases, as well as the alarming rates of malnutrition and high mortality, suggests additional underlying factors such as the poor child care practices in this community. The health workers in the area list a TB clinic, injections for malaria treatment, and an EPI program as priorities for medical services in the community now that they have a kalazar clinic supported by MedAir. The measles vaccination coverage according to the presence of an EPI card was very low at 2.3% and there is no ongoing EPI (Expanded Program of Immunization). No measles vaccination campaigns have been done in the area. However, according to caretakers 19.6% of children had been vaccinated against measles. The few children who were vaccinated against measles had been taken to Aburoc in Shilluk Kingdom or to GoS towns such as Malakal, Meluth, or Khartoum for vaccination. The population along the Awilwil depends on the river for all their water needs. When the Awilwil dries up towards the end of March/April, the population moves across the river to an island formed by the White Nile and Awilwil Rivers in order to access the water, fish, and wild foods of the Nile. During the rainy season the population grows crops in the desert approximately three to four hours from the Awilwil River in an area called Maloc. There is no water source in this area, forcing people to carry water from the Awilwil River. The community is requesting boreholes to be dug in Maloc, which would make it possible for those without livestock to live in the Maloc area during planting rather than traveling back and forth from the villages along the river. Those with livestock need to be near the river so that water can be provided to their animals. Many people are currently using gourds for water storage and transport. Although some jerrycans have been distributed, buckets with lids would be useful for the population as these are easier to keep clean and can be used for other purposes as well as water storage and transport. The hygiene and sanitation situation is very poor. The population does not use latrines except for those who are patients at the kalazar clinic. The general cleanliness of the population is also an issue. Though some people bathe in the river, many appear to be constantly covered in dirt, especially the children. 15 Cf. WHO 16 Subjective and to be interpreted with caution 17 UNICEF reported morbidity figures for southern Sudan-July 2002

23

6. RECOMMENDATIONS

Health care services including preventive health measures (such as health and hygiene education) to be set up in the area.

Therapeutic and supplementary feeding centers should be opened to address the high levels of severe and

moderate malnutrition in the area.

WFP should sustain a monthly distribution at a ration level of 50% until the situation improves.

Systematic food security monitoring to assess crop performance and other predictors for food insecurity.

Establish continuous EPI activities with specific emphasis on measles.

Establish hygiene promotion activities.

Intervention to provide improved access to safe water.

MedAir, SSOM, and Open Doors to carry out planned distributions, with sickles and buckets with lids to be included as some of the items distributed.

Maintain nutritional surveillance to monitor the situation

24

APPENDIX

Appendix 1

Exhaustive Nutritional Survey Payuer January 2003 Village Payam Boma Walking

Distance from Payuer

# Households with people

# Households empty due to hunger migration

# 6-59 months

% IDPs

Liet 1 Panomdit Liet 2 ½ hours 3 13 Panomthii Panomdit Panomdit 1 ½ hours

63 3 51

23.6%

Panomdit Panomdit Panomdit 1 hour 131 31 74 12.2% Mading Panomdit Panomdit 35 minutes 37 5 30 45.0% Payuer 1 Panomdit Malek ------------- 93 9 64 18.5% Bailual Panomdit Malek 20 minutes 5 0 4 75.0% Baijak Panomdit Malek 35 minutes 25 5 13 0.0% Belgo Panomdit Malek 1 hour 50 21 48 2.9% Wunbarco 1 Panomdit Malek 1 hour 20 min 4 Wunbarco 2 Panomdit Malek 1 hour 30 min 2 Wunbarco 3 Panomdit Malek 1 hour 35 min

20

6

12 88.9%

Wunbarco 4 Panomdit Malek 1 hour 40 min 2 Nyayok 1 Panomdit Malek 1 hour 45 min

9 4

6 40.0%

Nyayok 2 Panomdit Malek 1 hour 47 min 20 0 25 82.4% Nyayok 3 Panomdit Malek 1 hour 49 min Nyayok 4 Panomdit Malek 1 hour 51 min

20 29 26 35.0%

Kuomthor Chuei Tiep 3 ½ hours 42 47 44 100% Chuei Chuei Tiep 3 ¾ hours 71 6 53 50.0% Thangrial 1 Chuei Tiep 4 hours 30 Thangrial 2 Chuei Tiep 4 hours

138 34

80 29.0%

Total 724 241 543 40.2%

25

Appendix 2

Population figures for SPLA area by Chief Head Chief Population Area 1 Awer Yac Loi 3,982 Panomdit Payam 2 Anyang Wal Ador 3,939 Chuei Payam 3 Dhieu Joh Palier 2,319 Abayath IDPs 4 Deng Akol Abuol 2,482 Maluth IDPs 5 Ayiik Akok Lueth 2,136 Paloc IDPs 6 Kieu Koc 1,948 Thak IDPs 7 Juac Ngor Gieng 1,725 Sobat IDPs (Abelong) 8 Thon Anyoul 2,432 Akoka IDPs (Dongjol) 9 Majiek Lam 2,901 Baliet IDPs (Ngok) Total 23,864

26

Appendix 3

DATE: TEAM N°.: VILLAGE: CLUSTER N°.:

CHILDREN (from 65 to 115 cm) CARETAKER

N°. Family N°.

Age mths

Sex M/F

Weight kg

Height cm

Oedema Y/N

MUAC mm

EPI Card Y/N

Measles M/C/N*** Status *

Parental Link

With The Child **

Sex M/F

MUAC mm

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Status*: 1=resident, 2=displaced, 3=family temporarily resident in the village (cattle camp, water point..) Parental link**: 1=mother, 2=other person Measles***: M=vaccination according to Mother, C= vaccination according to EPI Card, N=No

ANTHROPOMETRIC SURVEY QUESTIONNAIRE

27

Appendix 4

DATE: TEAM LEADER: VILLAGE: TEAM NUMBER:

< 5 YEARS > = 5 YEARS

N° Number of < 5

Years alive today

Number of dead in last 3

months CAUSE**

Number >/= 5 Years alive

today

Number of dead>/=5 years

in the last 3 months

CAUSE**

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

**1= Diarrhea (simple), 2=Diarrhoea (bloody), 3=Measles, 4=Fever, 5=Lower Respiratory Infection, 6=Malnutrition, 7=Accident, 8=Other (write presumed cause of death)

MORTALITY SURVEY QUESTIONNAIRE

28

Appendix 5

Community Priorities

1) Food 2) Fishing items 3) Mosquito nets 4) Cooking pots 5) Blankets 6) Sickles 7) Seeds 8) Drugs 9) Boreholes in area of cultivation 10) Water jerrycans 11) Education material 12) Tools, inc. axes 13) Plastic sheeting 14) Children’s drugs (in syrup form) 15) TBA training 16) Feeding center