Nutritional survey Dadaab, North Eastern Province, Kenya August 2000

Nutritional survey Dadaab, North Eastern Province, Kenya August 2000 Médecins Sans Frontières With the participation of UNHCR, WFP, CARE and MOH. Carine Daenens Joke Van Peteghem Gunter Boussery

Summary of the Results Date of the survey: 29 th to 31 st of August 2000 Design: Two stage random cluster sampling (30 clusters of 30 children). Population figures (September 2000) Total population: 123.138 Under five: 25.570 Family survey Dadaab camps Number of families 602 Total number of persons 3908 Families without ration card* 23 (3,8 %) [2,1 5,5] Average person per family* 6,5 Note* : The families included in the survey were families including children from 6 to 59 months. Results on ration card information do not give a picture of the general population. Nutritional survey Number of children 911 Proportion of female 49,8 % [46,8 52,8] Malnutrition in z-score Global 20 % [16,6 23,9] Moderate 13,9 % [10,7 17,1] Severe* 6 % [3,8 8,2] Malnutrition in % of the median Global 14,8 % [11,6 18,0] Moderate 9,8 % [7,1 12,5] severe* 5 % [3,2 6,9] Coverage of the nutritional program 37,8 % [28,9 46,7] Severe* malnutrition in z-score = Weight/height < - 3 z-score or edema. Severe* malnutrition in % of median = Weight/height < 70 % or edema. Moderate malnutrition in z-score = Weight/height > or = - 3 z-score and < - 2 z-score. Moderate malnutrition in % of the median = Weight/height > or = 70 % and < 80 % Measles vaccine (9 to 59 months = 850 children) Vaccinated with card 433 50,9 % [45,1 56,8] Vaccinated on history 357 42 % [36,3 47,7] Non vaccinated 60 7,1 % [5,0 9,1] Note: For 10 children (6 to 59 months), the result on measles vaccination was unknown, they have been excluded of analyze.

Main Conclusions There is about 3,8 % of the families (with under five children) which have no ration card. The food distribution monitoring showed that the average food ration decreased from 2.184 Kcal (11,7 % proteins) before January 2000 to an actual ration in August 00 of 1.820 Kcal (12,5 % proteins). The ration has been decreased from 2.100 Kcal to 1.900 Kcal because of shortage in the pipeline and for budgetary reasons. Shortfalls of non-cereal items are expected in the coming months. In the past shortfalls of commodities were compensated by increasing the quantity of other items. As from the first October 2000 this strategy (to compensate shortfalls with other commodities) will be abandoned until the end of the year for the same reasons of shortage in the pipeline and budgetary reasons. This means that the ration of 1900 Kcal, which is already insufficient, will be lowered every time a commodity is out of stock. 3,8 % of the families (with children from 6 to 59 months) have no ration card. There is a sensible degradation of nutritional status particularly marked by an increase of edema forms (Kwashiorkor type). The coverage of the nutritional program is low. The measles coverage is low. Recommendations 1. To provide an adequate ration through the general food distribution and this in quantity and in quality to reach a caloric value of 2.100 Kcal/per/day including at least 10 % of proteins/per/day and 20 % of fats and micronutrients. 2. To improve registration of new arrivals. 3. To increase the coverage of the nutritional programs by active malnutrition case finding at all level (CHW, HP, OPD). 4. To continue the nutritional rehabilitation programs (SFP and TFC). 5. To increase the measles vaccination coverage. 6. To repeat nutritional survey in 3 to 6 months.

Table of content A/ INTRODUCTION A.1. Reasons for the survey A.2. Objectives of the survey A.3. Background Population A.4. Nutritional context General Food Distribution (GFD) Nutritional rehabilitation programs Morbidity and Mortality B/ METHODOLOGY B.1. Study sites B.2.Survey design C/ RESULTS C.1. Family survey C.2. Nutritional survey Description of the sample Proportion of malnourished children, in z-score Proportion of malnourished children, in percentage of median MUAC categories Coverage of the malnutrition programs Edema repartition according to age Edema linked to MUAC C.3. Measles vaccine assessment D/ DISCUSSION General Food Distribution Nutritional Status Coverage of the nutritional programs Measles vaccine coverage E/ CONCLUSIONS AND RECOMMENDATIONS List of annexes Annex 1: Map of Dagahaley camp Annex 2: Map of Hagadera camp Annex 3: Map of Ifo camp Annex 4: Population and list of clusters Annex 5: Children questionnaire

A/ INTRODUCTION Médecins Sans Frontières, with the participation of UNHCR, WFP and Care conducted a nutritional survey in the three camps of Dadaab from the 29 th of August to the 31 st of august. A.1. Reasons for the survey Regular nutritional surveys are included in the monitoring of the situation in the three Dadaab camps. It s part of the surveillance system. In January 2000 there has been an increase in number of admissions in the feeding centers. The survey can confirm the degradation of the nutritional status among the under five population. A.2. Objectives of the survey Main objective To estimate the proportion of severely and moderately malnourished children. Secondary objectives To estimate the nutritional status amongst different age groups, identify high-risk groups. To assess trends in nutritional status based on repeated surveys. To evaluate the coverage of the rehabilitation program. To estimate the coverage of measles. To estimate the coverage of the general food distribution. A.3. Background The refugee camps were established in September 1991 (Ifo), March 1992 (Dagahaley) and June 1992 (Hagadera) following the conflict in Somalia. A medical and nutritional assistance program started in 1992 upon an agreement with UNHCR by MSF Belgium and MSF France. By June 1995, MSF France withdrew from this area and MSF B took over the camps (Ifo and Dagahaley) being already involved in Hagadera. Between 1993 and 1996, the health situation was quite good. However, a deterioration of the refugee s health installed gradually from July 1996, as a consequence to the reduction in the general food ration, the switch to maize as a staple which was considered unpalatable by the Somali, and the withdrawal of vitamin enriched CSB supplements. The August 1996 nutritional survey showed an increase in the malnutrition especially in the severe malnutrition rates, as several children with Kwashiorkor were observed, a new phenomenon in this camp. Concomitantly, an outbreak of scurvy occurred. It took several months to correct the situation. From 1997, the ration was maintained at 2.100 Kcal/per/day, and nutritional status improved again to acceptable level. In January 97, MSF carried out a nutritional survey in the three camps as the mortality rates were increasing and this was thought to be due to a deterioration of the medical and nutritional status of refugees. This survey showed a high prevalence of global malnutrition. Based on these results, MSF implemented a Blanket Feeding Program for all under 5 years, pregnant and lactating mothers from March to August 97. Blended Corn Soya was reintroduced in the ration starting mid August 97. The August 97 nutritional assessment showed a significant improvement of the situation in global malnutrition.

The floods caused by heavy rains seriously affected life in the camps from November 97 to mid January 98. Livestock mortality was very high due to a conjunction of diseases, among which the Rift Valley Fever and over 8000 animals died in the camps. The floods created an environment for RVF and malaria outbreaks. The floods had an adverse effect on refugee s health. The impact of the floods and the ensuring various epidemics was assessed in a survey carried out by MSF B in February 98. There was no significant difference in the global malnutrition rate from the August survey. Until December 99 food rations distributed were quite stable, the situation seemed again under control. Rations norms and monitored were about 2.100 Kcal and 12 % protein. Recently the ration has been reduced due to budgetary reasons and also a shortage in the pipeline, to 1.900 Kcal. At the same time a continual increase of admission in nutritional program was observed, including Kwashiorkor. Cases of Kala Azar have been detected. In this context, the detection of Kala Azar cases is worrying. Kala Azar cases have been diagnosed sporadically in the camps since 1992. The first case linked to the current outbreak was traced back to August 1999. From there to end of August 00, 36 cases has been recorded. Population At the time of the survey, the population of the three Dadaab camps has been estimated (CHW) at 123.138 inhabitants and 25.570 under 5 years. Dagahaley: Hagadera: Ifo: 35.267, including 7.553 under 5 years 45.577, including 8.836 under 5 years 42.294, including 9.181 under 5 years A.4. Nutritional context A.4.1. General Food Distribution (GFD) Food is supplied by WFP and distributed by CARE; the GFD is carried out twice a month simultaneously in the three camps. Until December 99, WFP was using a reference value of 2.100 Kcal/per/day with 68 gr proteins (12,9 %). From February 2000 to beginning September 2000, the reference value decreased to 1.900 kcal/per/day and 60 gr proteins (12,6 %). WFP has decreased the ration for budgetary reasons and shortage in the pipeline. This ration is lower than the standard ration of 2.100 Kcal, recommended and by MSF and by WFP. Shortfalls of especially non-cereal items are expected in the coming months. In the past shortfalls of commodities were compensated by increasing the quantity of other items, in order to maintain the1.900 Kcal. As from the first of October this strategy will be abandoned, shortfalls of a commodity will no longer be compensated. This strategy will be abandoned because of budgetary reasons and shortage in the pipeline as said before. That means that the 1.900 Kcal ration will be lowered every time a commodity is out of stock. In the actual situation with the increase of global malnutrition and especially severe malnutrition, this ration will be insufficient. Food monitoring is carried out during every food distribution by the MSF outreach team.

Average food ration distributed by WFP through CARE, food distribution monitored by MSFB Dadaab camps 2500 Kcal/per/day 2000 1500 1000 500 0 Jan-99 Apr-99 Jul-99 Oct-99 Jan-00 Apr-00 Jul-00 evolution in time A.4.2. Nutritional rehabilitation programs Nutritional rehabilitation centers (in each camp) TFC linked to Hospital SFC linked to Health Posts

New admissions in nutritional programs Total beneficiaries in TFC and SFC at the end of the month, Dadaab camps 3000 number of children 2500 2000 1500 1000 500 0 Jan-99 Apr-99 Jul-99 Oct-99 Jan-00 Apr-00 Jul-00 evolution in time The number of beneficiaries in nutritional programs has been stable around 1000 till November 99, from December there as been a sensible increase up to more than 2000 children in January 00. After a small decrease, we are again over 2.000 children at the end of August 00. new admissions in TFC and SFP Dadaab camps MSF B Aug 99 - Aug 00 1600 1400 number of children 1200 1000 800 600 400 SFP TFC 200 0 Aug-99 Oct-99 Dec-99 Feb-00 Apr-00 Jun-00 Aug-00 evolution in time The increase of malnutrition cases in January 00 could be explained wit the increase of morbidity. The morbidity decreased in February, March 00 at the level before the rainy season. The malnutrition doesn t. At the same time, the food ration decreased to remain low. As from July 00 and especially August 00 the malnutrition raised.

Proportion edema on total admissions in TFC percentage oedema / total admissions in TFC Dadaab camps 40.00% percentage oedema 30.00% 20.00% 10.00% 0.00% Jan-99 Mar-99 May-99 Jul-99 Sep-99 Nov-99 Jan-00 Mar-00 May-00 Jul-00 evolution in time From August 99 to April 00, the average admission with edema was about 8,2 %, from May 00 a serious increase has been monitored to reach in August 00, 32,4 %, which is quite high and unusual for Dadaab. Further investigation on edema should be done to try to explain this major increase in edema.

A.4.3. Morbidity and mortality Crude mortality rate and under five mortality rate (/10.000/day) Crude mortality and under five mortality rates Dadaab camps Deaths/10.000/day 1.4 1.2 1 0.8 0.6 0.4 0.2 0 CMR <5MR Jan-99 Apr-99 Jul-99 Oct-99 Jan-00 Apr-00 Jul-00 evolution in time The last five months, although the rates are still acceptable (< 1/10.000/day for both Crude Mortality Rate and under 5 MR), the mortality has increased, especially the under five mortality. Malaria remains the main cause of death but also malnutrition became a major cause of death with the under fives (MSF B monthly report). total cases end of the month 45000 40000 35000 30000 25000 20000 15000 10000 5000 0 Morbidity Dadaab (total cases in cosultation end of the month) Jan-99 Mar-99 May-99 Jul-99 Sep-99 Nov-99 Jan-00 evolution in time Mar-00 May-00 Jul-00 In April 99 and December 99, there has been two peaks of increase of the morbidity, this corresponds with the rainy seasons. At the same time an increase of admissions in the nutritional programs has been observed. Except these two peaks in April and December 99, the morbidity has been stable.

Concerning Kala Azar, from April 00 to end August 00, 36 cases has been recorded and 35 confirmed or by DAT* test or by splenic aspiration or by both; 1 suspected case is recorded on the 1 st of September, awaiting the DAT test result. Concerning mortality, 12 on the 36 confirmed cases died, 7 of them died before treatment. 13 of them achieved initial cure, 11 are under treatment and 1 is waiting for the result. *DAT = Direct Agglutination Test. B/ METHODOLOGY B.1. Study sites The survey included the three Dadaab camps of Dagahaley, Hagadera and Ifo. See annex 1, 2, 3. B.2. Survey design One survey has been conducted for the three camps, with a two-stage random cluster sampling method. The sample size was estimated at 900, and 30 clusters of 30 children were selected. Cluster selection was proportional to the size of the population in the three camps. All children from 6 months to 59 months living in the selected houses were included in the nutritional survey. The age was the first criteria to select the children. If age was unknown, height from 65 cm to < 110 cm was chosen as second criteria to select the children. Anthropometrical measurements (Weight, Height, Middle Upper Arm Circumference (MUAC)) and edema were taken from all children selected. Bilateral edema was a criteria on its own for severe malnutrition. The proportion of malnourished children attending SFP and TFC was computed in order to estimate the coverage of these programs. See annex 5. Vaccination against measles was estimated by checking the vaccination card of all selected children. Information on the vaccination status was also obtained from interview with the mother or the father when the card could not be found and was recorded as history. Access to general food distribution was estimated by asking for the WFP registration card. A comparison between family size (people sleeping in the house) and ration card family size has been estimated. The survey was conducted from 29 th to 31 st of August by 5 teams of 5 persons and 1 person from Care, WFP, UNHCR and MOH. Team members were trained before the survey and supervised by MSF. Data ^^was analyzed by EPI-INFO 6.04c software. Proportions are presented in percentages with 95 % confidence intervals in brackets.

C/ RESULTS C.1. Family survey Total number of persons included in the survey 3908 100 % Mean number of persons per family 6,5 Number of families* 602 Number of families* with ration card 579 96,2 % [94,5 97,9] Arrival date: Before 98 558 92,7 % [90,1 95,3] After 98 44 7,3 % [4,7 9,9] *The families included in the survey were families including children from 6 to 59 months. Results are only applicable to these families, not on the general population. The risk to not have a ration card is 60,2 [24,1 150,9] times higher for people arrived after 1998. Before 1998: 4 families on 558 do not have ration card = 0,7 % [0,1 1,4] After 1998: 19 families on 44 do not have ration card = 43,2 % [27,5 58,9] C.2. Nutritional survey Description of the sample Dadaab Camps Number of children 911 Proportion of female 454 / 911 49,8 % [46,8 52,8] Age distribution (n = 911) < 18 months 192 21,1 % 18 29 months 243 26,7 % 30 41 months 178 19,5 % 42 53 months 201 22,1 % 54 59 months 97 10,6 % < 29 months (2,5 y) 435 47,7 % sex ratio = 1.06 30 59 months (5 y) 476 52,3 % sex ratio = 0.96 Proportion of malnourished children, in z-score Definitions: Moderate malnutrition = weight / height > or = - 3 z-score and < - 2 z-score Severe malnutrition = weight/height < - 3 z-score or presence of bilateral edema Z score Dadaab Camps Moderate malnutrition 127 (13,9 %) [10,7 17,1] Severe malnutrition 55 (6 %) [3,8 8,2] Global malnutrition 182 (20 %) [16,6 23,9] Edema* 41 (4,5 %) [2,6 6,4] *Edema are included in severe malnutrition.

Proportion of malnourished children, in percentage of median Definitions: Moderate malnutrition = weight / height > or = 70 % and < 80 % Severe malnutrition = weight / height < 70 % or presence of bilateral edema % of median Dadaab Camps Moderate malnutrition 89 (9,8 %) [7,1 12,5] Severe malnutrition 46 (5 %) [3,2 6,9] Global malnutrition 135 (14,8 %) [11,6 18,0] Edema 41 (4,5 %) [2,6 6,4] MUAC MUAC Dadaab Camps MUAC < 125 mm 75 (8,2 %) [6,3 10,2] MUAC < 110 mm 7 (0,8 %) [0,2 1,4] Coverage of the nutritional rehabilitation programs The coverage of the program has been estimated according to the criteria of admission into the supplementary feeding program (SFP) and the therapeutic feeding center (TFC) SFP: moderate malnutrition = weight/ height > or = 70 % and < 80 % TFC: severe malnutrition = weight / height < 70 % or bilateral edema Note: MUAC <110 mm is until now not been considered as an admission criteria. Survey s children Dadaab Camps Moderate malnourished childr. attending the SFP 39 / 89 (43,8 %) [34,0 53,6] Severe malnourished childr. attending the TFC 1 / 46 (2,2 %) [0,0 6,3] Children responding to one criteria of malnutrition 51 / 135 (37,8 %) Attending the SFP or TFC [28,9 46,7] Edema age repartition Definition: Edema = shallow print or pit that remains when the thumb is lifted after 3 seconds pressure. Nutritional edema = bilateral. Edema Age < 29 months 34 / 435 (7,8 %) [4,3 11,3] Age >= 29 months 7 / 476 (1,5 %) [0,5 2,4] Total 41 / 911 (4,5 %) [] The relative risk to suffer from edema is 5,3 [2,6 10,8] times higher for the < 29 months than for the > or = 29 months.

Edema linked to MUAC Below MUAC 125 mm: 16,0 % [7,8 24,2] Below MUAC 110 mm: 84,0 ù [75,8 92,2] The relative risk to suffer from edema is also 4,6 times higher for children with a MUAC below 125 mm than for children with a MUAC over 125 mm. C.3. Measles vaccine assessment The variable has been analyzed for children from 9 to 59 months, to correspond to the target group of the national EPI program. Dadaab Camps Vaccinated with card 433 (50,9 %) [45,1 56,8] Vaccinated on history 357 (42,0 %) [36,3 47,7] Not vaccinated 60 (7,1 %) [5,0 9,1] Total 850 (100 %) Vaccination coverage linked to ration card: The risk not to be vaccinated is 4,5 [2,7 7,6] times higher for the ones who do not have ration card then for the ones who have one. Vaccination coverage linked to arrival date: The risk not to be vaccinated is 7,7 [4,5 13,1] times higher for people arrived after 1998 then for people arrived before. D/ DISCUSSION General Food Distribution The survey indicated that 96,2 % of the families included in the survey (with children from 6 to 59 months) had a ration card. The survey indicated also that the risk to not have a ration card, for the people arrived after 1998 in the camps, is 60 times higher than the ones arrived before 1998. This can be explained by the fact that systematic registration by UNHCR stopped in 1998. Actually the procedure to be registered takes more time and is more complicated. The actual ration is lower than the standard 2.100 Kcal/per/day. The actual average ration monitored by food monitoring is 1.820 Kcal in August and 1.864 first cycle of September, proteins percentage is around 12 %. Maize has been used to replace or compensate a shortage of wheat flower. Refugees have complained about it several times, they are not eating maize and maize has a bad value on the market, so they can t really use it to diversify the WFP ration buying other things on the market. In the coming months no amelioration of the ration can be expected, nether in the quantity, nether in the commodities to be distributed. In the actual situation of increase of malnutrition rates and

particularly increase in severe malnutrition and edema form and the current outbreak of Kala Azar, this is insufficient. Nutritional status In July 1999, three nutritional surveys occurred in the three Dadaab camps. The results have been regrouped in one by meta-analyze, so that a comparison can be made with the August 2000 survey. Nutritional survey July 99 (n = 2.371 children) Malnutrition in z-score Severe 2,8 % [2,0 3,7] Global 15,0 % [12,9 17,1] Malnutrition in % of median Severe 1,9 % [1,2 2,5] Global 9,0 % [7,5 10,5] Nutritional survey in August 00 (n = 911 children) Malnutrition in z-score Severe 6,0 % [3,8 8,2] Global 20,0 % [16,6 23,9] Malnutrition in % of median Severe 5,0 % [3,2 _ 6,9] Global 14,8 % [11,6 18,0] Conclusions: There is statistically a significative increase between July 1999 and August 2000 for Edema Severe malnutrition in z-score and % of the median Global malnutrition in % of median There is a sensible degradation of the nutritional status particularly marked by an increase of edema forms. A further investigation should be done on edema to find out the causes of this high increase of edema forms. Coverage of the nutritional program and screening strategy The coverage of the nutritional rehabilitation program is quite low, 37,8 %. Investigation on the reasons of this low coverage should be done and action should be taken at all level (CHW, HP, OPD). Measles vaccine coverage If vaccination is considered on card if using the UNICEF definition, the coverage is very low (50,9 %). The risk to not be vaccinated is higher for refugees arrived after 1998 and for the ones who do not have ration card. Action should be taken to register all new arrivals and checked refugees arrived after 1998. Action should be taken at the level of CHW to inform and refer not vaccinated children to EPI program. This is important in order to decrease the risk of measles outbreak in camps situation.

E/ CONCLUSIONS and RECOMMENDATIONS The actual ration distributed is 1.900 Kcal, which is insufficient. A full ration of 2.100 Kcal/per/day should be provided. The quality and the variety of the ration have to be respected and accepted by the refugees. The ration has to include at least 10 % proteins, 20 % fats and micronutrients. Improvement in the registration of new arrivals should be done Ration card should be given to all families registered after 1998 and still do not have ration card. There is a degradation in the nutritional status of the under five population with a deterioration particularly in severe malnutrition with an increase of edema forms. The nutritional rehabilitation programs should continue and be closely followed. The high increase of edemas has to be investigated deeper. The actual coverage of the nutritional programs is very low. Active screening of malnutrition cases at different levels (CHW, health posts, OPD) should be organized or improved. Measles coverage is also very low. We have also seen that people without ration card and arrived after 1998 have a lower coverage in measles vaccination. The coverage should be improved through health programs and CHW. In conclusion, the nutritional status has sensibly deteriorated and risk factors for a further deterioration are present. Dadaab should stay under nutritional surveillance and capacity of reaction should be maintained. A future nutritional survey should be carried in three to six months.