International Notes Nutritional and Health Status of Displaced Persons -- Sudan, 1988-1989

Since 1987, more than 1.3 million persons have fled civil strife in southern Sudan and settled in urban areas (e.g., the capital city of Khartoum) or in camps in the northern regions of the country (Figure 1). In August 1988, after extensive flooding destroyed the dwellings of 750,000 displaced persons (DP) living in outlying areas around Khartoum, 23% of children less than 5 years of age were moderately or severely undernourished (1). In response to recommendations for continued health-status monitoring, from September 1988 through February 1989, 71 surveys (each with 30 randomly chosen clusters of 10 children) were conducted in 27 different sites in Khartoum. A total of 17,639 children less than 5 years of age (or less than 110 cm in height if age was unknown) were weighed and measured. Children less than 80% of the median weight-forheight (Wt/Ht) for children less than 5 years of age (2) were classified as acutely undernourished (children 70%-79% of the median Wt/Ht were classified as moderately undernourished and children less than 70% of the median Wt/Ht as severely undernourished).

In September and October 1988, the mean prevalence of acute undernutrition among displaced children in surveyed communities in Khartoum was 19.9%. By February 1989, the mean prevalence in those communities resurveyed at least once had declined to 10.9%.

In southern Darfur, approximately 500 km southwest of Khartoum, greater than 80,000 additional DP live in temporary camps. Cluster surveys were conducted in seven camps where food rations were distributed biweekly. The surveys showed a decline in the prevalence of acute undernutrition in children less than 5 years of age from May 1988 (mean: 35.9%; range: 25.0%-43.0%) through February-March 1989 (mean: 6.4%; range: 4.6%-9.4%). The mean monthly crude mortality rate (CMR) for all ages in these camps also declined from April 1988 (11.8 deaths per 1000 population; range: 4.9-18.3) to January 1989 (0.4 per 1000; range 0-0.7) (Figure 2). In April 1988, the mean monthly CMR for children less than 5 years of age was 19.0 deaths per 1000 children; diarrhea and meningitis were the leading reported causes of childhood death. By January 1989, this rate had declined to 6.0 deaths per 1000 children, and the leading causes of death were diarrhea and acute respiratory infections.

To reduce the risk of measles, mass immunization campaigns were conducted in the seven camps targeting all children 6 months to 5 years of age. By March-April 1989, measles vaccination coverage levels were 80%-95% in children aged 12-23 months in these camps. Reported by: A El Amin, P Nestel, IA Mageed, KA Mohamed, Nutrition Dept; MA Ali, MD, F El Magzoub, Diarrheal Diseases Control Programme; Ministry of Health, Sudan. M Philips, MD, Medecins Sans Frontieres-Belgium. I Kabintang, MD, M Kabintang, MD, Inter Aid International. A Mackie, PhD, RB Hawkins, MPH, P Curtis, US Agency for International Development, Sudan. Technical Support Div, International Health Program Office, CDC.

Editorial Note

Editorial Note: In refugee and displaced populations, mortality rates in children less than 5 years of age increase in relation to the prevalence of acute undernutrition (3,4). For the southern Darfur camps, the monthly CMR in April 1988 (11.8 per 1000) is more than five times that expected in the poorest developing nations in Africa ( less than 2 deaths per 1000 per month) (5). In a DP camp located in southern Kordofan (Figure 1), the monthly CMR in July 1988 (120 per 1000) was among the highest reported for any famine-affected population since 1969 (CDC, unpublished data). Mortality data collected under adverse conditions such as those in southern Darfur must be interpreted with caution. However, the observed decline in mortality is consistent with the reported decline in undernutrition prevalence.

Most undernutrition-related childhood deaths can be prevented by provision of food of adequate caloric content (minimum of 1900 kilocalories per person per day (all ages)) and quality (appropriate amounts of carbohydrates, proteins, fats, and essential micronutrients (e.g., vitamins A, B complex, and C)) (6,7). The prevalence of undernutrition has declined in most areas surveyed while the number of children in the camps in southern Darfur has reportedly increased; however, the deaths of the most severely undernourished children could account, at least in part, for the lower prevalence of undernutrition reported (8).

In urban areas, general food rations were not distributed, although some communities have had supplementary and/or therapeutic feeding programs for acutely undernourished children. The administration of (and access of DP to) these feeding programs, as well as the local availability of food and employment, may have influenced levels of childhood undernutrition. In the camps in southern Darfur, food rations were routinely distributed to displaced families, although rations were sometimes inadequate because of local shortages of foodstocks and difficulties in transporting supplies through the affected areas.

Measles has been a leading cause of childhood death in some refugee and displaced populations (4). The high measles vaccination coverage in displaced children living in the seven camps in southern Darfur may have prevented many measles-related deaths in those locations. CDC has recommended that measles vaccination of children be an early priority in the care of refugees and DP (9).

References

1. Sudan Ministry of Health. Relief and Rehabilitation Committee report. Khartoum, Sudan: Ministry of Health, April 1989.

2. World Health Organization. Measuring changes in nutritional status: guidelines for assessing the nutritional impact of supplementary feeding programmes for vulnerable groups. Geneva: World Health Organization, 1983.

3. Person-Karell B. The relationship between child malnutrition and crude mortality among 42 refugee populations. Presented at the International Symposium on Health Care for Displaced Persons and Refugees, Washington, DC, December 4-7, 1988.

4. Toole MJ, Waldman RJ. An analysis of mortality trends among refugee populations in Somalia, Sudan, and Thailand. Bull WHO 1988;66:237-47.

5. United Nations Children's Fund. The state of the world's children, 1988. New York: Oxford University Press, 1988.

6. Anonymous. Nutrition in times of disaster: report of an international conference. Geneva: United Nations Administrative Committee for Coordination, Subcommittee on Nutrition/ International Nutrition Planner's Forum, 1988.

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

8. Nieburg P, Berry A, Steketee R, Binkin N, Dondero T, Aziz N. Limitations of anthropometry during acute food shortages: high mortality can mask refugees' deteriorating nutritional status. Disasters 1988;12:253-8.

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

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