Nutrition Sentinel Site Surveillance Report South Sudan – June 2008

Malakal Southern Zone, Upper Nile State

With the support and collaboration of

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.I. INTRODUCTION

This bulletin presents findings of the sixth round of data collection undertaken in Southern Zone, Malakal county of Upper Nile state in June 2008. This was the second round of data collection undertaken utilizing LQAS methodology. 33 clusters of 6 children were assessed. The qualitative questionnaire was administered in every sampled household with children aged 6-59 months.

.II. DATA PRESENTATION – ANTHROPOMETRY AND MORBIDITY

Anthropometric data was analyzed using ENA for SMART and LQAS decision rule. Various indicators were used to elucidate the prevailing situation; GAM

1 and SAM

2 being the main ones. These findings

were then expressed in WHZ at 95% confidence intervals due to it’s statistical significance. Morbidity is an underlying cause of malnutrition more so amongst the under five years of age due to the vulnerability to infections. As such, BCG vaccination status and availability of a vaccination card were used as proxy indicators of; risk of prevalence of immunizable childhood illnesses and child health care practices amongst caretakers. Additional qualitative data was gathered during the period. This entailed issues pertaining to household health care seeking practices, water and sanitation, child care as well as household dietary diversity.

1. ANTHROPOMETRIC RESULTS Figure I: Malnutrition rates, Nutrition sentinel site, Malakal Southern Zone

1 GAM: encompasses both the proportion of children who are severely and moderately malnourished

(WHZ <-2 plus any cases of bilateral oedema) 2 SAM is derived from the proportion of children who are severely wasted (WHZ <-3) plus the

proportion of children with or without bilateral oedema

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Table 1: Acute malnutrition rates, nutrition sentinel site; Southern Zone, Malakal County

INDICATOR RESULTS Sept. 07 (n =122)

RESULTS Oct. 07 (n =122)

RESULTS Nov. 07 (n =120)

RESULTS Dec. 07 (n =121)

RESULTS March 08 (n =210)

RESULTS June 08 (n =210)

18.0% 21.3% 26.7% 27.3% 26.7% 21.90% GAM

[14.9% - 21.2%] [11.1% - 31.5%] [13.6% - 39.7%] [18.8%-35.8%] [20.3%-33.0%] [15.8%-28.0%]

4.9% 1.6% 2.5% 4.1% 1.9% 2.90% Z-score

SAM [0.0%-9.9%] [0.1%-3.4%] [0.0%-7.4%] [0.2%-8.1%] [0.2%- 3.6%] [0.4%- 5.3%]

8.2% 9.0% 17.5% 14.0% 14.3% 10.50% GAM

[5.0%-11.4%] [1.1%-16.9%] [7.10%-27.9%] [5.5%-22.6%] [9.3%-19.3%] [5.8% - 15.1%]

0.8% 0.8% 0.8% 0.8% 0.0% 0.50%

% Median

SAM [0.0%-2.4%] [0.0%-2.2%] [0.0%-2.5%] [0.0%-2.4%] [0.0%-0.0%] [0.0% - 1.5%]

Taking a look at the z-score findings, even though the trends tabulated above indicate a 4.8% decline in GAM rates, the situation still remains above WHO emergency cut offs of 15.0%. The SAM on the other hand has risen from 1.9% to 2.9%. This could be attributed to lack of targeted feeding and care of the moderately malnourished children who slipped into severe malnutrition amongst other factors such as disease prevalence and not up to date water and sanitation practices. 198 out of the 210 children measured were randomly selected and their nutritional status analyzed. 43 children had a WHZ less than -2. For a threshold of GAM ≥ 20%, the decision rule is 33 in LQAS methodology. If the alpha error is 10%, it is considered with 90% confidence that the global acute malnutrition rates are equal to or greater than 20%. This is in tandem with the results in table 1 above.

2. MORBIDITY: Figure II: Morbidity results, Nutrition sentinel site- Malakal Southern Zone

During this round of data collection, Malaria, diarrhea and RTI were the predominant causes of morbidity in that order. There were increased cases of malaria compared to March results.

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3. HEALTH SEEKING PATTERN

(a) Immunization

Figure III: Immunization status, Nutrition sentinel site, Malakal Southern zone

The figure to the left shows consistency in trends. Even though most children had BCG scars, maintenance of vaccination cards was poor

(b) Health seeking patterns

Most of the sampled households sought medication either from the public hospital or the PHCC/U within Malakal town.

Figure IV: Health seeking behaviour, Nutrition Sentinel site, Malakal Southern Zone

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4. HOUSEHOLD STRUCTURE Figure V: Household structure, Nutrition sentinel site, Malakal Southern zone

Generally, most households were headed by adult males.

5. WATER AND SANITATION

Figure VI: Water sources, Nutrition sentinel site; Malakal Southern Zone

No major changes were noted in water sources. Tap water still remained to be the predominant water source. However the water consumed was not clean as observed. This predisposed household members to water borne infections such as diarrhea.

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Figure VII: Distance to and from water sources, Nutrition sentinel site; Malakal Southern Zone

6. HYGIENE PRACTICES Figure VIII: Soap availability and its uses at household level, nutrition sentinel site; Malakal Southern Zone

Soap was a commodity owned by most households with main function as reported by most households being washing clothes. There is need to enhance use of soap in cleaning utensils and personal hygiene.

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7. CHILD FEEDING PRACTICES Figure IX: Feeding practices for children less than five years. Nutrition sentinel site, Malakal Southern Zone

Most children were fed to two meals per day unlike March 2008 when most children were fed to three meals per day. 8. ACCESS TO FOOD.

Figure X: Diet diversity score. Nutrition Sentinel site, Malakal Southern Zone

Household dietary diversity score (HDDS) is used as an economic measure to food access. A 24 hour recall period was used to gather the HDDS on a scale of 12. Most households (80%) had HDDS that ranged between 6 and 8. This indicated that of the 12 major food groups, most households virtually consumed more than half of them with the main ones being cereals, oil, spices, sugar, vegetables and meat. Milk and fish were consumed by around half of the households. The least consumed food groups were eggs, fruits, legumes, tubers and roots. 11.3% of the households consumed no more than 5 food groups. The mean household dietary diversity score was 7.

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Figure XI: Sources of livelihood. Nutrition Sentinel site, Malakal Southern zone

Malakal being a town set up, employment (permanent and casual) and petty business still formed important sources of livelihood to the community. The market was relocated from the town to the outskirts near Dengershufu. Traders were putting up structures in the new location while others had acquired new premises within the town. Table 2: Average food prices Malakal County

Item March 2008 June 2008

Bag of sorghum 83.75 96.60

Bag of sugar 126.25 125

Oil (500ml) 3.12 3

Bull (largest) 1100 1200

There was a 15% increase in the price of sorghum between March and June 2008.

I..III. CONCLUSION

The June 2008 round of data collection was faced by a number of challenges ranging from insecurity related demonstrations, intermittent rains and unforeseen holidays. Nevertheless, collection of good quality data using LQAS methodology was accomplished as ascertained by standard deviation of 0.84 and design effect of 1.12. Similarly, a 24 hour recall period was adopted so as to minimise recall bias with 12 food groups used in the calculation of household dietary diversity score. The total cost of training, refreshments, remuneration of enumerators, transport and communication in this round of data collection was estimated at 1,063 USD. Transport cost in locations requiring long journeys with boats is most likely to push up the total cost in other locations. The use of WFP vehicle provided to MOH for nutrition surveillance activities will come in handy in locations that can be accessed by road. Bearing in mind that data is collected on quarterly basis; the next round will be undertaken in September 2008. There is also need for agencies in collaboration with MOH and other ministries to address treatment of malnutrition, provision of safe drinking water and sanitation facilities.