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

Health and Nutrition organizations Eastern Chad July August 2008

Lucas Machibya, UNHCR Nutritionist, on mission.

Table of contents
LIST OF ACRONYMS .............................................................................................................................................4 ACKNOWLEDGEMENT ............................................................................................................................................5 The map of Eastern Chad UNHCR refugee operation.. 6 Executive summary .. 7 1. INTRODUCTION .......................................................................................................................................8 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2. Background... 8 Food aid and coping strategies. .. 8 Joint Assessment mission .. 8 Selective feeding programme.. 9 Expanded programme for immunization (EPI)... 9 Reproductive health ... 9 Morbidity and mortality rates.... 9 Iron deficiency anaemia 10 Access to clean water and sanitation .. 10

GENERAL OBJECTIVE OF THE SURVEY ........................................................................................11 2.1 Specific Objectives: ...................................................................................................................................11

3.

SUBJECTS AND METHODOLOGY .....................................................................................................11 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Study population ................................................................................................................................11 Sample size.........................................................................................................................................11 Sampling method ... 11 Data collection methods .....................................................................................................................12 Data analysis ......................................................................................................................................12 Anthropometric indices among under 5 years children 13 Limitation of the survey. 13

4.

T ABLE OF RESULTS AND SUMMARY DISCUSSION....................................................................14 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Anthropometric results: (based on NCHS reference 1997)....14 Prevalence of Wasting........................................................................................................................14 Prevalence of Stunting .......................................................................................................................16 Prevalence of Underweight ................................................................................................................18 Sex prevalence of malnutrition among children aged 6.0 - 59.0 months ......20 Comparing NCHS 1997 and WHO 2005 base reference results 21 Comparison of GAM from previous surveys .,.. 21

5.

CONTRIBUTING FACTORS TO THE INCREASE OF MALNUTRITION22 5.1 New refugee influxes 22 5.2 The inception of IDP camps .. 22 5.3 Security related factors .. 23 5.4 Food aid and household food security 23 5.5 Health and nutrition 24 5.6 Water and sanitation .. 24 5.7 Protection issues .24 5.8 Distribution of non food items .. 24 RETROSPECTIVE MORTALITY.........................................................................................................24

6.

7.

IRON DEFICIENCY ANAEMIA............................................................................................................25 7.1 7.2 7.3 Anaemia among children below the age of five years ..................................................................25 Anaemia prevalence among women 28 Programs to prevent anaemia ... 29

8. 9. 10. 11. 12.

MEASLES IMMUNIZATION: ...............................................................................................................30 SELECTIVE FEEDING PROGRAMME...............................................................................................30 CONCLUSION..........................................................................................................................................33 RECOMMENDATIONS ..........................................................................................................................33 REFERENCES ..........................................................................................................................................34

List of tables Table 1: Table 2: Table 3: Table 4: Table 5: Table 6: Table 7: Table 8: Table 9: Table 10: Table 11: Table 12: Table 13: Table 14: Table 15: Table 16: Table 17: Table 18: Table 19: Table 20: Table 21: Table 22: List of figures Figure 1: Figure 2: Figure 3: Figure 4: Figure 5: Figure 6:

WHO (1995) cut off points to describe survey results for anthropometric indices .....13 Age and sex distribution ratio..14 Prevalence of wasting among 6.0 59.0 months based on NCHS 1997..15 Distribution of wasting by age groups based on NCHS 1997......................................15 Prevalence of wasting (%median) among 6.0 59.0 months children ...................................16 Prevalence of stunting among 6.0 59.0 months children ......17 Distribution of stunting by age groups among 6.0 59.0 months children .....17 Prevalence of underweight among 6.0 59.0 months children by NCHS 1997 reference values ...............19 Distribution of stunting by age groups among 6.0 59.0 months children .....19 Comparison of anthropometric findings based on NCHS 1997 and WHO 2005 reference values ...21 Comparing GAM and SAM from previous surveys, 2006 2008 .22 Crude and < 5 years mortality rates, deaths per 10,000 per day.25 Mean Haemoglobin levels and prevalence of anaemia among 6.0 59.0...26 Mean Haemoglobin levels and prevalence of anaemia by age groups .......26 Protein Energy Malnutrition, mean haemoglobin and prevalence of anaemia among children 6.0 59.0 months ....27 Mean Haemoglobin levels and prevalence of anaemia among refugee women ..28 Mean Haemoglobin, % severity of anaemia and physiology status among women28 Comparing prevalence of anaemia with WHO standards ...29 Percentage coverage of measles vaccination for =>9.0 - 59.0 months ...30 Percentage coverage of selective feeding programme by refugee camps ...31 Trend of SFP performance indicators .....32 Trend of TFP performance indicators .32 Distribution of wasting compared to NCHS 1997 reference values ..16 Distribution of stunting compared to NCHS 1997 reference values .18 Distribution of underweight compared to NCHS 1997 reference values ..20 Prevalence of wasting among children aged 6.0 59.0 months by sex 20 Distribution of anaemia levels among wasted, underweight and stunted children aged 6.0 59.0 months ..27 Showing trend of haemoglobin levels among women by physiology status 29

LIST OF ACRONYMS ACTED CBR CDC C.I CMR COOPI CRT CSB CTC EPI EPI INFO FAO GAM Hb HFA HIS IDPs IEC IMC IRC JAM LBW MDGs MoH MOU MSF Luxembourg MSF Holland NFIs NGOs NSC OCHA OPEC PEM SD SFP SLM/A SMART TBAs TFP WFH WHM WHO UNHCR UNICEF Crude Birth Rate Centre for Disease Control Confidence Intervals Crude Mortality Rate Cooperazione Iinternationale Croix-Rouge Tchadienne Corn Soy Blend Community Therapeutic Care Expanded Program for Immunization Epidemiology Word Processing Data base Food and Agricultural Organisation of United Nations Global Acute Malnutrition Haemoglobin Height for Age Health Information System Internally Displaced Persons Information Education and Communication International Medical Corps International Rescue Committee Joint Assessment Mission of UNHCR and WFP Low Birth Weight Millenium Development Goals Ministry of Health Memorundum of Understanding Medisan Sans Frontiere - Luxembourg Medisans Sans Frontiere - Holland Non Food Items Non Government Organizations Nutrition Steering Committee Office of the Coordination of Humanitarian Affairs Organization of Petroleum Exporting Countries Protein Energy Malnutrition Standard Deviation Supplementary Feeding Programme Sudan Liberation Movement / Army Standardized Monitoring and Assessment of Relief and Transitional protocols Traditional Birth Attendants Therapeutic Feeding Programme Weight for Height percent for median Weight for Height percent for median World Health Organization United Nations High Commissioner for Refugees United Nations Children and education Funds

ACKNOWLEDGEMENT I am grateful for the valuable assistance and support provided by many colleagues for this work to be a successful. The UNHCR staff from Ndjamena Branch Office played a key role, special thanks goes to UNHCR Sub Office Abeche for an excellent coordination and patronage provided in terms of logistics, administration, funding processing and provision of security assistance during the period this work was undertaken in the 12 Sudanese refugee camps along the Eastern Chad boarder. Special thanks go to UNICEF and WFP Abeche Sub Offices for the strong commitment they had on this work. Further more, thanks go to Health and Nutrition implementing partners of UNHCR, refugees especially the children under 5 years, women and refugee leaders who supported the exercise. I further accord abundant appreciation to the following government institution and non government organizations 1. 2. 3. 4. 5. 6. 7. 8. Abeche School of Nursing Agency for Technical Cooperation and Development (ACTED) International Medical Corps (IMC) International Rescue Committee (IRC) Cooperazione Iinternationale (COOPI) Croix-Rouge Tchadienne (CRT) Medecines Sans Frontieres (MSF) Holland Medecines Sans Frontieres (MSF) Luxembourg 2. Haoua Ahmat Mahamat 4. Houda Mahamat Abdelaziz 6. Mahamat Bani 8. Mahamat Youssouf Ibetine 10. Ousmane Cheikhdine 12. Yaya Barka Arabi

Survey team members 1. Amine Ndolassoum 3. Helou Abdalah 5. Liliane Ngaradouel 7. Mahamat Nour Zacharia 9. Mahamat Cherif Bakhari 11. Tantee Nabaringar

Survey supervision and coordination 1. Jean Paul Habamungu, Food and Nutrition Officer, UNHCR Abeche 2. Lucas Machibya, UNHCR Nutritionist, Tanzania, on mission 3. Bonaventura Muhimfura, UNHCR Nutritionist, Abeche 4. Djimandoumour Doumbaye, WFP Nutritionist, Abeche 5. Diongoto Domaya Esaie, UNICEF Nutritionist, Abeche Operation coordination 1. Catherine Huck, Assistant Representative Operation, UNHCR Chad 2. Carolyn Wand, Senior Reintegration Officer, UNHCR Abeche 3. Jean Paul Habamungu, Food and Nutrition Officer, UNHCR Abeche 4. Lucas Machibya, UNHCR Nutritionist, Tanzania, on mission 5. Bonaventura Muhimfura, UNHCR Nutritionist, Abeche Technical support 1. Paul Spigel, Chief of Section, Public Health and HIV Section, UNHCR Geneva 2. Le Guillouzic, Herv, Senior Public Health Officer, UNHCR Geneva 3. Fathia Abdala, Senior Nutritionist, UNHCR Geneva 4. Hering Heiko, Public Health Information Officer, UNHCR Geneva 5. Allison Omer, Senior Food and Nutrition Coordinator, UNHCR Nairobi Data entry, analysis and report compilation 1. Lucas Machibya, UNHCR Nutritionist, Kasulu, Tanzania, on mission 2. Bonaventura Muhimfura, UNHCR Nutritionist, Abeche, Chad 3. Djimandoumour Doumbaye, WFP Nutritionist, Abeche, Chad 4. Diongoto Domaya Esaie, UNICEF Nutritionist, Abeche, Chad Funding support 1. High Commissioners special fund on nutrition project, UNHCR Geneva

Figure 1: The map of Eastern Chad UNHCR refugee operation

Executive summary An Anthropometric, hemoglobin measurements and retrospective mortality survey was conducted in 12 Sudanese refugee camps in Eastern Chad. A two stage cluster sampling technique was used. The survey took place from 30th June to 11th August 2008. The prime aim of the survey was to determine the prevalence of protein energy malnutrition, estimate the prevalence of anemia, determine the crude death rate and under 5 years death rate in the camps. UNHCR funded this survey under the special funds of the High Commissioners project on nutrition. UNICEF, WFP and NGOs participated fully in the planning and executions of the survey exercise. Three categories of sampled populations were surveyed, children aged 6.0 59.0 months and 65 110 cm was assessed for anthropometric, measles and feeding programme coverage, sub sample of adult women in the reproductive age and children under 5 years had their hemoglobin levels estimated using Haemocue machines. Retrospective crude and under 5 years mortality rate were surveyed covering the entire family members. The anthropometric findings in this report are presented using NCHS 1997 in Z-scores and percent for median. The global acute malnutrition rate (weight for height <- 2 Z-score and or oedema) was 12.3% (95% C.I. 11.5 13.2). The prevalence of underweight and stunting as expressed by z-scores were 40.5% (95% C.I 39.1 41.8) and 34.6% (95% C.I 32.8 36.3) respectively. The global acute malnutrition as expressed in percents for median was 5.8% (95% C.I 5.3 6.4). The severe acute malnutrition as expressed in percents for median was 0.2% (95% C.I 0.1 0.3). No oedema was recorded during data collection, so its prevalence was zero percent in all camps. The retrospective crude mortality rate was 0.40 (95% C.I 0.30 0.90) and the under 5 years mortality rate was 0.80 (95% C.I. 0.16 1.40). The prevalence of anemia among children was 30.9%, pregnant women were 36.7% and lactating women was 27.6%. Measles vaccination coverage of children aged => 9.0 59.0 months was 94.6% across the camps. Mile camp had the highest supplementary feeding programme coverage with 73% followed by Djabal 66% and Goz Amer had 62%. The therapeutic feeding programme Djabal camp had the highest coverage of 63% followed by Goz Amer which had 55% coverage. All coverage levels were below the recommended target of 90%, it is imperative for the health and nutrition partners to increase the uptake of malnourished children in the feeding programme. Programs to prevent iron deficiency anaemia are present in the camps; however these need close monitoring for both children and women. UNICEF and UNHCR are working closely to ensure that the measles coverage increases to above 95% in all camps. Coordination on health and nutrition activities in the camps was emphasized during the field movements and security concerns were mentioned to be a serious obstacle to achieve their objectives by humanitarian agencies.

INTRODUCTION 1.1 Background The East Chad refugee operation provides protection and humanitarian assistance to 243,000 Sudanese refugees in 12 camps along the border with Sudan. Refugee influxes in Eastern Chad from Sudan, Darfur region started in April 2003 as a result of the resumption of the fighting between government army troops supported by Janjaweed Arab militias and Sudan Liberation Movement / Army (SLM/A). By the end of October 2003 about 60,000 refugees had arrived in Eastern Chad border from Darfur region of Sudan. The refugees ethnicities include Ouaddaian, Massalite, Arabs, Fur, Dadjo and Zagawa. The on going internal civil conflict in Chad has led to around 170,000 Chadian national to be internally displaced (IDPs), they are currently settled in camps in Dar Sila, Ouaddai, Assoungha and Salamat. Since 2006, groups possessing weapons including Chadian Janjaweed, Sudanese Janjaweed, Chadian rebels bandits have primary destabilized the civilian characters of the communities along the Eastern Chad border with Sudan. The refugee influxes continued to arrive in Gaga since the end of 2006 (12,402). At the end of July 2008 this camp had 19,781 registered refugees and the camp is still open for new arrivals. At the end of 2006 Kounoungou camp, had 13,315 refugees while by the end of July 2008 the camp population has increased to 18,167 registered refugees. The increase of refugee influxes is a result of the continuous crisis in Darfur. 1.2 Food aid and coping strategies The Sudanese refugee camps in Eastern Chad operation depend on food aid support from WFP. The agreed food ration for this operation is 425 grams cereal, 50 grams pulses, 50 grams of corn soy blend, 25 grams of vegetable cooking oil, 15 grams of sugar and 5 grams of salt, this ration provides approximately 2,100 kilocalories. By the end of 2007, WFP provided an average of 1,995 kilocalories in the general food distribution. At the beginning of 2008, a reduced food ration started to be implemented during general food distribution in Sudanese refugee camps. The food commodities which are in reduced ration include cereals, pulses, CSB and salt whereas vegetable cooking oil and sugar have been kept at 100% provisions. Until the last general food distribution in the fourth week of August 2008, in average 1,734 kilocalories per person per day had been provided in the Sudanese camps Eastern Chad, equivalent to 90% of the 2,100 recommended kilocalories. The food distribution in use is the scooping system; until June 2008 food basket monitoring has not been conducted during food distributions. 1.3 Joint assessment mission UNHCR and WFP annually organize joint assessments that observe critically the overall assistances of the care and maintenance programme for UNHCR and emergency operation programme for WFP. The JAM determines the level of assistance required in terms of food and non food items provisions. UNICEF, OCHA, FAO, Government of Chad CNAR, donors and cooperate partners of UNHCR and WFP are invited. The last JAM took place in 2006; the next JAM in Chad refugee operation is planned to take place in September 2008.

1.4 Selective feeding programme The nutrition programme provides nutritional rehabilitation services to severely and moderately malnourished identified children; the community health workers are responsible for identifying and referring children to the feeding centers for registration in the camps. A feeding programme protocol is available and in use in all camps. As part of the strategies to fight against malnutrition, partners implementing nutrition programme in the camps conduct monthly general screening of under 5 years children in order to identify malnourished children and admit them in the feeding programme. All children who are < 80% median weight for height are admitted in the supplementary feeding programme where they receive a food ration to rehabilitate their nutritional status. Severely malnourished who are < 70% median weight for height with medical complications, without good appetite are admitted in the stabilization centre this is normally outside the camps where health facilities with admission capacity exist, with an exception of Djabal and Goz Amer camps. Children, who are severely malnourished but pass the appetite test is admitted in the out patient therapeutic programme they collect food based support and eat at home. At the beginning of 2007, Community based management (CTC) of malnourished children was rolled out in 9 camps (Iridimi, Touloum, Amnabak, Mile, Oure Cassoni, Kounongou, Gaga, Farchana and Bredjing. The camps of Djabal and Goz Amer started CTC at the beginning of 2008. 1.5 Expanded programme for immunization (EPI) In close coordination with UNICEF, EPI is implemented in all camps. The programme provides measles vaccination to children from 6.0 months to 15 years during emergency. The target for measles coverage in 2007 for children aged 6 -59.0 months was => 90.0%. The camps which attained and exceeded this target were Treguine, Iridimi, Touloum, Oure Cassoni, Kounongou and Bredjing whereas Amnabak registered the lowest coverage, 28.0%. The measles mean coverage was 85.2% across the camps in Eastern Chad. There has been different interventions implemented to raise measles coverage including measles immunization campaigns led by the MoH across the country which included refugee camps. The EPI unit in Abeche is working hard to raise the Polio coverage as one confirmed case was registered in Bredjing camp recently. UNHCR and its cooperatives are part of these MoH efforts of which refugee camps are included. 1.6 Reproductive health The programme advocates that all deliveries should take place in the health facilities where skilled personnel are present to attend. In 2007, this indicator was attained better in Goz Amer and Djabal camps where by above 90.0% of all deliveries where reported to have taken place in the health facilities henceforth assisted by skilled personnel. Bredjing and Farchana camps had the highest percents of deliveries assisted by traditional birth attendants (TBAs), 97.7% and 92.8% respectively. The target for crude birth rate (CBR) for the programme in 2007 was 10 40 per 1,000 population per year. The highest figures for CBR were found in Goz Amer and Treguine where by these camps had 56 and 52 per 1,000 per year respectively. The CBR for Sub Saharan Africa is 44 per population per year1. It is important to underscore the fact that these camps had the lowest percent of low birth weight (2,500 grams) weighed within 72.00 hours of births. The percent of LBW was 2.9% in Goz Amer and 4.3% in Treguine while it was 3.1% in Bredjing camp. 1.7 Morbidity and mortality rates UNHCR provide health services in the refugee camps in collaboration with UNICEF, WHO and the health and nutrition partners, the services are coordinated jointly with the Ministry of Health at provincial level in locations where refugee camps are established. National treatment guidelines and standards in terms of staffing and provision of care and treatments are adhered.

UNHCR Handbook in Emergencies, February 2007

The leading causes of morbidity at the time of the survey were acute respiratory infections, with 41% overall camps, acute respiratory infection was very high in Oure Cassoni with 59% of all morbidities among children2 By the end of 2007 Djabal camp had the highest crude mortality rate (CMR) that stood at 0.32 per 1,000 per month; the lowest recorded crude mortality rate was 0.02 per 1,000 per month in Amnabak camp. Djabal camp had the highest under 5 years mortality rate (<5MR), 0.85 per 1,000 per month, whereas Amnabak camp recorded the lowest under 5 years mortality rate, 0.04 per 1,000 per month. All rates were within the acceptable UNHCR standards and indicators limits3. Despite these achievements the health and nutrition sector encounters some challenges which include frequent changes of expatriate qualified staff among health partners, changes of health and nutrition agencies, different levels of coordination within MoH hierarchies, frequent out breaks, i.e. Hepatitis E and Polio and different agencies implementing health and nutrition programs in one camp. 1.8 Iron deficiency anaemia Nutritional iron deficiency implies that the diet can not supply enough iron to cover the bodys physiological needs, this is the most common cause of iron deficiency world wide4. The diet in most cases contains less quantity of the required iron. Highest prevalence figures for iron deficiency are found in infants, children, adolescents, and women of child bearing age. Fortified foods have been reported to significantly reduce iron deficiency and iron deficiency anemia. In this operation preventive programme against anaemia are implemented, this includes; malaria prevention, diagnostics and treatment according to national protocols, fortified and blended foods is provided in the general and targeted food assistance with particular focus to pregnant and lactating women, children under 5 years. A systematic de-worming program is implemented in the camps twice a year. 1.9 Access to clean water and sanitation The standard and indicators for UNHCR refugee operation is to provide water at least 15 20 liters of water per person per day; by the end of 2007 the maximum amount of water provided was 17 liters per person per day in 4 camps (Gaga, Bredjing, Treguine and Djabal). The lowest amount of water provided was in Touloum camp where by 7.0 liters per person per day were provided. In the camps of Iriba zone a minimum of about 5 liters per day was provided in months. In average 12 liters per person per day of water were provided across the Sudanese refugee operation in Eastern Chad, equivalent to approximately 60% of the year target. In Amnabak and Oure Cassoni water is provided through trucking where as in the rest of camps water is provided through pumping schemes. The programme aimed at ensuring 100% coverage of family / private latrines in all camps, by the end of 2007, the mean value for family latrines was only 8%, however, the number of persons per drop hole in communal latrines which was initially planned to be <=20 people increased to 78 persons per drop hole in average across the camps. The vulnerability to under nutrition is aggravated by limited access to adequate, clean and safe water, sanitation and lack of adequate health care often given rooms for potential out breaks5. Sanitation challenges currently are experienced in the camps of Farchana, Bredjing, Gaga and Treguine.

2
3

Health Information System monthly report June 2008

Note that UNHCR standard and indicators for crude mortality rate is <1.5 / 1,000 / month and for children under 5 years is <3.0 / 1,000 / month. 4 WHO (2000): The Management of Nutrition in Major Emergencies. WHO Geneva. 5 WHO: Health Action in Crises Sahel Region, October 2006 (Burkina Faso, Niger, Mali, Chad and Senegal)

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2.

GENERAL OBJECTIVE OF THE SURVEY

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

1. To estimate the prevalence of both severe and global acute malnutrition including oedema in children aged 6-59 months old and/or 65-110 cm height in the refugee camps 2. To estimate the overall crude death rate and under 5 years mortality rate among the refugee population 3. To estimate the prevalence of anaemia and measles coverage among children below the age of five years in the refugee camp 4. To estimate the coverage of the nutrition feeding programme among refugee children attending the selective feeding programme in the operation area 3.0 SUBJECTS AND METHODOLOGY
3.1 STUDY POPULATION

Study subjects were children below the age of five years ranging between 6.0-59.0 months, were subjected to anthropometric measurements, measles and feeding programme assessment. For haemoglobin measurements a sub sample of children under 5 years and adult women was drawn whereas for retrospective mortality heads of families and other family members were included. 3.2 SAMPLE SIZE A total of 11,406 children aged 6.0-59.0 months from all 12 camps were finally included in the analysis after exclusion of 2% flags in this study. Of these 3,625 children were sampled for Haemoglobin (Hb) testing to establish their haemoglobin levels, henceforth, determination of their iron deficiency anaemia status. Also sampled for the survey were 3346 adult women of which 16% of them were pregnant, 49% were lactating and the rest were neither pregnant nor lactating these participated in the survey for haemoglobin levels determination. For mortality study a total of 37,1086 population was involved in the assessment. The average family size used was 5 members per family

3.3

Sampling method

The cluster sampling method as recommended in the WHO guidelines was used (WHO, 2001). A total of 30 clusters, each including 30 children were applied. At least 30 children aged 6.0 59.0 months with 65.0 110.0 cm height were sampled in each cluster. Upon arrival at the centre of the cluster, the survey team spinned a pen to decide the direction where to start and then all houses in that direction were counted. For example, if there are 20 houses, numbers 1-20 were written down on 20 small papers and folded. These folded papers were mixed up in a cup and any young child was requested to pick one, the number picked was the first house to start the measurements. The second house sampled was the house on his / her right hand side. The same was repeated for the subsequent houses. Children who were found not at home were not revisited as time could not permit due to security reasons and yet were not replaced. All sampled children for anthropometric measurement were as well assessed to establish measles and feeding programme coverage. The sample size for haemoglobin measurements for the children aged 6.0 59.0 months was calculated from the following parameters, 40% estimated prevalence of anaemia, and 7% desired precision and 2 design effect. The same sample size for adult women reproductive age was used. The sample size for retrospective mortality survey was calculated on the following assumptions; average camp population 20,250, estimated prevalence rate 2 per 10,000 populations per day, 1%
6

Table 5 crude and under 5 years mortality rate

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desired precision, design effect of 2 and 90 days recall period (supported with a locally developed calendar of events, annex II) therefore, a minimum population of 1,610 was expected to be sampled. In order to estimate the number of households to be covered for mortality it was assumed that in each family there were 1.5 children aged 6.0 59.0 months. Therefore, 900 children divided by 1.5 provided an average of 600 households to be covered in each camp. This implied that a minimum of 20 households were to be covered in each cluster. It was agreed that if anthropometric measurements is completed in the cluster, the mortality survey should continue until the 20 households were covered. This helped to cover a bigger population in all camps than the estimated 1,610 sample population. 3.4 DATA COLLECTION METHODS Anthropometric measurements which entail height, weight and age were collected for each child and oedema was assessed. Weight was measured using UNICEF - Salter scales which were recorded to the nearest 0.1kg decimal point, the weighing scales were calibrated prior to commencement of the survey and every morning. The exercise started by checking the weighing scales using the standard weight of 1 kilogram. Height was measured using Shorr portable infant / child height/length measuring board7. The age of the sampled children was recorded from the child health card of the children, where the road to health cards were not available locally developed calendar of events was used to help mothers / guardians to estimate the age of the children which then was recorded in months to nearest 0.1 month. Oedema was assessed bilaterally from the feet of the children. All teams were given a VHF radio hand set for communication. It was agreed that a team which sees an oedema case should call for the supervisors to confirm this prior to recording. The team leaders ensured quality data were collected, verified and recorded in the data collection sheets. Nutrition and Medical Officers from UNICEF, WFP, UNHCR and Health and nutrition NGOs were supervisors during the survey. Haemoglobin levels were measured using a haemoglobinometer (HeamoCue haemoglobinometer, Angelholm, AB, Sweden) and recorded to the nearest 0.1g/dl decimal point for both children and women. Measles vaccination status information was extracted from the child health card of each sampled child. Where cards were not available maternal or guardians confirmation was sought through a recall process. Data on feeding programme coverage were collected based on the response if the children were admitted in the programs. Retrospective mortality information was collected from the entire family members of the surveyed households.

3.5 DATA ANALYSIS Data were entered and managed in EPI-INFO 6.04B version whereas analysis for protein energy malnutrition was done using Nutri-survey programme and the reference value used were NCHS 1997. All three anthropometric indices were used to describe the nutritional status of the children. Malnutrition low weight-for-height (wasting), low height-for-age (stunting) and low weight-for-age (underweight) were defined based on WHO cut off points for global, moderate and severe categories (WHO, 1995). Oedema was also included in the analysis for severe and global acute malnutrition prevalence.
Anaemia for both children and women were defined based on the recommended WHO cut off points (WHO, 2001)8. Haemoglobin levels for both children and women were computed and the mean values were established. The data were as well analyzed based on percent for median for weight-for-height since it is an indicator used to admit children in the selective feeding program.

7 How to Weigh and Measure Children written by Irwin J. Shorr for the UN Department of Technical Cooperation for Development and Statistical Office, New York, 1986.

WHO Guidelines on the management of severe malnourished children

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Measles coverage was determined from the data recorded on the road to health cards of the children and by recall responses from the mothers or responsible guardians found taking care of the children at family level. Estimation of crude and under 5 mortality rates was done based on the SMART programme method and 90 days recall period was used for each camp. Counting of the recall period was done starting the previous day of the survey date for each camp. This meant that each camp had its own specific recall period since the camps were surveyed on different days. 3.6 ANTHROPOMETRIC INDICES AMONG UNDER 5 YEARS CHILDREN The traditional anthropometric indices used to assess the nutritional status of children were used to classify the nutritional status based on the findings. The results were presented only in Z-scores, quoted, this is a deviation of the individual anthropometric measurement from the median value of the WHO reference for that childs height of age divided by the standard deviation for the reference population (WHO 1995):
a) Weight-for-Height (wasting or thinness): Reflects body weight relative to height. Low weight for height or wasting / thinness usually indicates a recent and severe process of weight loss due to acute starvation, severe disease or chronic unfavorable conditions. Two categories of low weight for height were used in presenting the results in the tables; severe and moderate wasting if Z-scores <-2; and severe wasting if Z-score <-3. Therefore by definition, global acute malnutrition is defined as <-2 z scores

weight-for-height and/or edema and severe acute malnutrition is defined as <-3z scores weight-for-height and/or oedema.
b) Height-for-Age (stunting or chronic malnutrition). Stunting reflects a process of failure to reach linear growth as a result of sub optimal nutritional and / or health conditions which are in turn rooted in poor socio-economic conditions and poverty. Three categories of low height for age were used in presenting the results in the tables; severe and moderate stunting if Z-scores <-2; and severe stunting if Z-score <-3. c) Weight-for-Age (underweight). Weight for age on the other hand reflects body mass in relation to chronological age. Low weight for age indicates insufficient weight gain in relation to age sometime known as weight loss.

Nb: Oedema was assessed and analyzed separately, however no oedema case was recorded.
Table 1 Presents the prevalence groups used to describe the survey results for anthropometric indicators (WHO 1995)
Prevalence ranges (% of children <-2 Z scores) Low weight for height Low height for age <5 < 20 5-9 20 - 29 10 - 14 30 - 39 > 15 > 40 Low weight for age < 10 10 - 19 20 - 29 > 30

Prevalence group Acceptable Poor Serious Critical

3.7 Limitation of the survey 1. Organizing convoy movements for the survey team took much of time due to high level of insecurity in the operation area. Logistical plans and coordination took much of time. 2. The survey was conducted during the rainy season therefore, movements of the survey team from some of the locations were delayed to allow good weather conditions for traveling 3. Security movements in all camps were the concern as the operation area is on phase 4

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4. T ABLE OF RESULTS AND SUMMARY DISCUSSION 4.1 ANTHROPOMETRIC RESULTS (NCHS 1997 reference values) In this survey the global acute malnutrition is defined as <-2 z scores weight-for-height and/or oedema whereas severe acute malnutrition is defined as <-3z scores weight-for-height and/or oedema. The sex ratio between boys and girls was 5827(51.1%) boys and 5579 (48.9%) girls. Of the sampled boys 54.0 percent of them were aged 6.0 17.0 months whereas majority of girls that were sampled were aged 30 41 months. Children aged 18.0 29.0 months were the majority, representing 25.7%, Table 2, illustrate the age and sex distribution ratio. Table 2 Age groups no. 6-17 months 18-29 months 30-41 months 42-53 months 54-59 months Total 1379 1482 1327 1018 621 5827 Age and sex distribution ratio Boys % 54.0 50.5 49.7 49.9 51.5 51.1 no. 1177 1450 1344 1024 584 5579 Girls % 46.0 49.5 50.3 50.1 48.5 48.9 no. 2556 2932 2671 2042 1205 11406 Total % 22.4 25.7 23.4 17.9 10.6 100.0 Ratio Boy : girl 1.2 1.0 1.0 1.0 1.1 1.0

4.2 PREVALENCE OF WASTING

The combined global acute malnutrition (<-2 z-score and /or oedema) weight for height was 12.3% (95% C.I. 11.5 13.2). The prevalence of moderate malnutrition (<-2 z-score and >=-3 z-score) was 11.6% (C.I 95% 10.8 12.4). The prevalence of severe malnutrition (<-3 z-score and / or oedema) was 0.8% (C.I 95% 0.6 0.9). Prevalence of oedema was 0.0%. The highest global acute malnutrition was found in Oure Cassoni camp, 13.8% (95% C.I. 10.4 17.3) weight for height whereas the lowest was recorded in Goz Amer camp with 8.6% (95% C.I. 6.0 11.1). There was no significant difference for both severe and global acute malnutrition rate among surveyed refugee camps. However a numerical difference is vivid particularly between Oure Cassoni and Goz Amer camps, where a GAM difference of 5.2% is seen. Table 2.0 summarizes severe, moderate and global acute malnutrition for all camps. Data were also analyzed based on the WHO 2005 reference values the combined results indicated that acute severe malnutrition was 2.2% (95% C.I 1.8 2.5). The prevalence of moderate malnutrition was 10.9% (95% C.I 10.3 11.6) and the global acute malnutrition rate was 13.1% (95% C.I 12.3 13.9). See annex I. Comparing the NCHS 1997 and WHO 2005 findings, it was found that a significant difference was vivid on severe acute malnutrition, the highest results were the once presented using the WHO 2005 reference values. There was no significant different for global acute and moderate malnutrition results for both reference values. Oure Cassoni camp which had the highest global acute prevalence rate of 13.8% (10.4 17.3) based on NCHS 1997, which is in the serious classification according to WHO standards. Based on the WHO 2005 reference values the results increased to 15.2% (95% C.I 12.0 18.3), this value is classified as critical according to WHO classification of malnutrition.

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Table 3 Camp N

Prevalence of wasting (weight-for-height Z score) among 6.0 59.0 months (based on NCHS reference 1997) Severe (<-3SD and or odema) 0.7% (0.2-1.1) 0.9% (0.1 1.0) 0.8% (0.2 1.5) 0.9% (0.1 1.7) 0.8% (0.2 1.5) 0.7% (0.1-1.4) 0.7% (0.2 1.2) Wasting (% with 95% C.I Moderate Global (-3 - <-2SD) (<-2SD and or odema) 7.9% (5.5 10.3) 8.6% (6.0 11.1) 9.9% (7.4 12.4) 10.4% (7.8 - 131) 12.2% (9.9 14.5) 13.1% (10.8 15.4) 12.0% (10.1 13.9) 12.9% (11.0 14.9) 11.1% (8.8 13.3) 11.9% (9.6 14.3) 10.6% (8.0 13.3) 11.4% (8.7 14.0) 13.1% (9.7 16.6) 13.8% (10.4 17.3) 8.6% (6.8 10.3) 9.1% (7.2 11.0) 9.0% (6.5 11.4) 9.5% (6.8 12.2) 10.1% (7.8 12.4) 10.6% (8.2 13.0) 9.3% (6.7 12.0) 9.8% (6.8 12.7) 11.7% (9.1 14.3) 12.1% (9.4 14.8) 11.6% (10.8 12.4) 12.3% (11.5 13.2) Normal (-2SD) 91.4% (89.4 - 93.4) 89.6% (86.6 -92.7 ) 86.9% (84.8 89.0) 87.1% (84.9 89.2) 88.1% (84.8 - 91.3) 88.6% (83.3 - 93.9) 86.2% (81.2 - 91.2) 90.9% (88.8 - 93.0) 90.5% (88.5 -92.5 ) 89.4% (87.2 - 92.0) 90.2% ( 88.2 -92.1) 87.9% (83.6 92.2) 87.7% (87.2 88.4)

Goz Amer 912 Djabal 919 Gaga 964 Farchana 973 Bredjing 948 Treguine 960 Oure 968 Cassoni Amnabak 978 0.5% (0.1 0.9) Touloum 905 0.6% (0.1 1.0) Iridimi 989 0.5% (0.0 1.0) Mile 923 0.4% (0.0 0.8) Kounongou 967 0.4% (0.0 0.8) Combined 11406 0.8% (0.6 0.9) The prevalence of oedema is 0.0%

Overall the children aged 6.0 29.0 were most vulnerable to malnutrition compared to other age groups. They are more than 3 times nutritionally vulnerable than children aged 30-41 months and 2.8 times than children aged 42-53 months. Children aged 30-41 months (9.4%) were less much affected by wasting; a general trend suggests that there is a decrease of wasting as age increases. Wasting increased from age 6.0 17.0 months (13.1%) to 18.0 29.0 months (15.6%), these are 2 years old children. This could be attributed to the introduction of complementary feeding and possibly the decreased child care attention. Overall children start to be affected by protein energy malnutrition before 2 years and from the findings wasting, underweight and stunting started to decline immediately after 2 years. Table 3, 6 and 8 Table 4 Distribution of wasting by age groups of children (combined camp data) (NCHS 1997base reference) N % of Severity of PEM Severe Moderate (<-3SD and or (-3 - <-2SD) odema) 12.4 14.2 8.8 9.7 12.4 11.6 Global (<-2SD odema) Normal or (<-2SD) 86.9 84.4 90.9 90.0 87.4 87.9

Age group (months)

and

wasting 6.0 - 17.0 2552 0.9 18.0 - 29.0 2935 1.5 30.0 41.0 2670 0.3 42.0 53.0 2040 0.4 54.0 - 59.0 1209 0.2 Combined 11406 0.8 The prevalence of oedema is 0.0%

13.3 15.7 9.4 10.4 12.6 12.3

Data were analyzed as well by percent for median as it is an important indicator used in the admission and discharging criteria of beneficiaries in the selective feeding programme protocols. Overall the prevalence of malnutrition as expressed by percent for median stood at 5.8%. Camps with the highest weight for height percent for median < 80% were Treguine (6.5%), Gaga (6.2%) and Oure Cassoni camps (6.0%) weight WFH <80%.

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Figure 1

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

Table 5

Prevalence of wasting (% median) among children aged 6.0 59.0 months (based on NCHS reference 1997) N Wasting (median % with 95% CI) Severe (<70% Moderate Global (<80% median and or (>=70% - <80%) median and or odema) odema) 0.0% (0.0 0.0) 5.0% (3.3 6.8) 5.0% (3.3 6.8) 0.0% (0.0 0.0) 3.4% (2.1 4.6) 3.4% (2.1 4.6) 0.4% (0.1 0.9) 5.8% (4.2 7.5) 6.2% (4.6 7.9) 0.1% (0.0 0.3) 4.8% (3.4 6.3) 4.9% (3.5 6.4) 0.0% (0.0 0.0) 4.4% (3.0 5.8) 4.4% (3.0 5.8) 0.2% (0.2 0.6) 6.3% (4.3 8.2) 6.5% (4.5 8.4) 0.1% (0.0 0.3) 5.9% (3.7 8.1) 6.0% (3.8 8.2) 5.8% (4.3 7.3) 4.1% (2.6 5.5) 3.6% (2.1 5.7) 3.9% (2.1 5.7) 4.8% (3.3 6.4) 5.7% (5.2 6.2) 5.8% (4.3 7.3) 4.3% (2.7 5.9) 3.6% (2.1 5.7) 3.9% (2.1 5.7) 4.9% (3.4 6.4) 5.8% (5.3 6.4) Normal (>=80% median 95.0% (93.6 - 96.6) 96.6% (93.9 99.7) 93.8% (92.0 95.5) 95.1% (93.4 - 96.7) 95.6% (94.0 - 97.2) 93.5% (89.0 - 98.0) 94.0% (90.9 - 97.1) 94.2% (92.5 97.4) 95.7% (93.5 96.4) 96.4% (94.4 - 98.4 ) 96.1% ( 94.8 - 97.3) 95.1% (93.6 - 96.6) 94.2% (93.3 - 95.1)

Camp

Gozamir 912 Djabal 919 Gaga 964 Farchana 973 Bredjing 948 Treguine 960 Oure 968 Cassoni Amnabak 978 0.0% (0.0 - 0.0) Touloum 905 0.2% (0.1 0.5) Iridimi 989 0.0% (0.0 0.0) Mile 923 0.0% (0.0 0.0) Kounoungou 967 0.1% (0.0 0.3) Combined 11406 0.2% (0.1 0.3) The prevalence of oedema is 0.0%

4.3 PREVALENCE OF STUNTING Height for age is a malnutrition measure that defines chronic malnutrition; it is an indicator that measures linear growth. When prevalence are higher than the WHO defined thresholds that serves to explain that the affected community / person has been for a long period on deprived food security, coupled with other forms of aggravating factors like hidden forms of malnutrition (micronutrient deficiencies) and frequently attacked with illness. In this survey, stunting (HAZ<-2D) for each camp was calculated and the overall prevalence of stunting was 34.6% (95% C.I 32.8 36.3). The highest prevalence was recorded in Djabal camp of 42.4%, followed by Farchana camp with 41.5%. Stunting was relatively lower in Iridimi and Mile camps with the prevalence of approximately 30.0%.

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Table 6

Prevalence of stunting (Height-for-age Z score) among children aged 6.0 59.0 months (based on NCHS reference 1997) Stunting (% with 95% CI) N Severe (<-3SD and or oedema) 8.4% (6.2 10.7) 8.3% (5.7 10.8) 8.2% (5.3 11.1) 9.3% (6.7 11.8) 7.2% (3.6 10.7) 10.8% (8.5 13.2) 7.9% (5.7 10.0) Moderate (-3 - <-2SD) 22.9% (19.9 26.0) 34.2% (30.6 37.7) 22.7% (18.8 25.6) 32.2% (28.5 36.0) 29.5% (26.7 32.4) 24.4% (22.3 26.5) 23.7% (20.3 27.0) 23.4% (20.0 26.8) 20.8% (17.0 24.6) 24.1% (19.3 28.8) 22.3% (18.0 26.6) 22.1% (19.1 25.1) 23.8% (22.6 25.0) Global (<-2SD and or oedema) 31.4% (27.1 35.7) 42.4% (38.1 46.8) 30.9% (27.5 - 34.4) 41.5% (38.3 44.7) 36.7% (32.4 41.0) 35.2% (32.1 38.4) 31.5% (27.1 36.0) 30.9% (26.7 35.0) 28.8% (24.5 33.2) 29.9% (24.4 35.5) 29.4% (23.3 35.4) 32.4% (28.4 36.5) 34.6% (32.8 36.3) Normal (-2SD)

Camp

Gozamir 912 Djabal 919 Gaga 964 Farchana 973 Bredjing 948 Treguine 960 Oure 968 Cassoni Amnabak 978 7.5% (5.1 9.8) Touloum 905 8.1% (6.1 10.0) Iridimi 989 5.9% (4.0 7.7) Mile 923 7.0% (4.6 9.4) Kounongou 967 10.3% (7.8 12.8) Combined 11,406 10.7% (9.9 11.5) The prevalence of oedema is 0.0%

68.6% (65.5 71.6) 57.6% (51.6 74.6) 69.1% (66.1 - 72.1) 58.5% (55.4 61.6) 63.3% (60.0 - 66.5) 64.8% (61.9 68.0) 68.5% (65.8 71.7 ) 69.1% (66.3 - 71.9) 71.8% (68.4 74.4) 70.1% (67.1 73.0) 70.6% ( 67.7 73.5) 67.6% (64.5 70.4) 65.4% (64.7 66.4)

There is a significant difference between Djabal and the other 8 camps on stunting. The prevalence of stunting in Djabal and Farchana is on the very high category according to WHO classification of malnutrition. Looking at the confidence intervals the maximum limit for Bredjing is above 40%, this is on the very high category, this illustrates that growth faltering is a nutritional problem in the camps, the global prevalence of stunting in Africa according to WHO9 is around 38.6%. Table 5.0 When stunting results based on NCHS 1977 were compared with stunting results based on the WHO 2005, it was found that a significant different existed between the severe chronic malnutrition of the two reference values. As it was the case for wasting the WHO 2005 results was higher than NCHS 1977 results. Table 7 Distribution of stunting by age groups of children (combined camp data) based on NCHS reference 1997 N % of Severity of PEM Severe Moderate (<-3SD and or (-3 - <-2SD) odema) 21.5 31.0 26.8 21.4 17.7 23.8 Global (<-2SD odema) Normal or (<-2SD) 68.7 51.1 62.7 64.6 75.6 65.4

Age group (months)

and 31.3 47.0 37.3 27.1 19.1 34.6

Stunting 6.0 - 17.0 2552 9.8 18.0 - 29.0 2935 17.9 30.0 41.0 2670 10.5 42.0 53.0 2040 8.5 54.0 - 59.0 1209 6.7 Combined 11406 10.7 The prevalence of oedema is 0.0%

The world wide magnitude of protein energy malnutrition: an overview from the WHO Global Database on Child Growth. M. de Onis, C. Monteiro, J.Akre and G. Clugston

17

Children in the age range 18.0 29.0 months (47.0%) were mostly affected by stunting than other age groups, followed by 30.0 41.0 age groups with 37.3% prevalence. Stunting decreased as the age increases, age groups 42.0 53.0 and 54.0 59.0 had 21.4 and 17.7 percents respectively. Table 6.0 Figure 2.0 shows the graphical presentation of stunting when compared with NCHS reference values by sex

Figure 2

Distribution of stunting by sex compared to NCHS reference1997 values

4.4 PREVALENCE OF UNDERWEIGHT: Underweight is responsible for several deaths, majority of children suffer from this form of malnutrition, mild and moderate state, it is a result of inadequate diets, compromised immune systems, frequent episodes of diseases including mild diarrhea which go on un-noticed for days. Mildly under weight children are at an increased risk of dying due to diseases as does a child of normal body weight who suffers the hidden hunger of micronutrient deficiency10. Underweight (WAZ< -2SD) was analyzed, the overall prevalence was 40.5% (95% C.I 39.1 41.8). The findings indicate that the lowest value for underweight was recorded in Oure Cassoni camp (30.9%) whereas the highest was recorded in Farchana camp, (43.9%). The prevalence of underweight for all camps is in the very high category according to WHO classification levels11 as all camps have > 30.0 percents global underweight prevalence. Table 7.0 Comparing underweight results analyzed based on the NCHS 1997 and underweight results analyzed based on the WHO 2005 reference values it was found WHO 2005 based results both moderate underweight 24.4% (95% C.I 23.5 25.4) and global underweight 31.7% (95% C.I 30.4 32.9) were lower than the results of the same indices presented based on NCHS 1977 reference values, moderate underweight 32.5% (95% C.I 31.6 33.5) and global underweight 40.5% (95% C.I 39.1 41.8). There was significant difference to both moderate and global underweight with the NCHS 1977 based results being higher than the WHO 2005 based results. Table 7 and Annex I.
SUSTAIN: Malnutrition over view, technology for better nutrition http://www.sustaintech.org/world.htm WHO cut off points for underweight, less than 10% low, 10 19% moderate, 20 29% High and equal and above 30% very high ; Bulletin of WHO, 71(6):703-712 (1993)
11

10

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Table 8

Prevalence of underweight among children aged 6.0 59.0 months based on NCHS reference 1997 N Global (<-2SD and or oedema) 34.0% (28.8 39.2) 37.4% (32.5 42.3) 36.8% (33.7 39.9) 43.9% (40.0 47.7) 38.8% (34.0 43.7) 38.5% (35.4 41.7) 30.9% (26.7 35.1) 34.0% (29.4 38.7) 41.3% (35.8 46.9) 35.6% (29.7 41.5) 35.3% (30.1 40.5) 39.6% (34.7 44.6) 40.5% (39.1 41.8) Normal (-2SD) 66.0% (62.9 69.2) 62.6% (56.5 - 68.7) 63.2% (60.1 - 66.3) 56.1% (50.7- 61.5 ) 61.2% (57.9 - 64.5) 61.5% (58.5 64.7) 69.1% (66.2 - 72.0) 66.0% (62.9 68.8) 58.7% (55.5 62.0) 64.4% (61.2 - 67.6) 64.7% (61.6 67.8) 60.4% (54.4 - 66.4) 59.5% (58.9 60.7)

underweight (% with 95% CI) Severe Moderate (<-3SD and or (-3 - <-2SD) oedema) Gozamir 912 5.8% (4.2 7.4) 28.2% (23.5 32.9) Djabal 919 5.7% (3.5 7.8) 31.8% (28.0 35.5) Gaga 964 7.5% (5.3 9.7) 29.4% (27.1 31.6) Farchana 973 7.1% (4.9 9.3) 36.8% (33.0 40.6) Bredjing 948 7.2% (4.2 10.2) 31.6% (27.8 35.5) Treguine 960 8.0% (6.3 9.8) 30.5% (27.5 33.5) Oure Cassoni 968 5.5% (4.2 6.7) 25.4% (21.5 29.3) Amnabak 978 5.2% (3.8 6.7) 28.8% (24.9 32.8) Touloum 905 5.6% (3.9 7.4) 35.7% (30.5 40.9) Iridimi 989 3.4% (1.5 5.3) 32.2% (27.1 37.2) Mile 923 4.0% (2.6 5.5) 31.3% (26.7 35.9) Kounongou 967 6.4% (4.7 8.2) 33.2% (29.1 37.2) Combined 11406 7.9% (7.3 8.5) 32.5% (31.6 33.5) The prevalence of oedema is 0.0% Camp

These findings on under weight auger well with the nutritional status of children under 5 years in Sahel countries; WHO reports that prevalence of weight for age in Chad is 36.7%, Niger 40% and Mali 33.2%12 among under 5 years children, these prevalence are on the very high category.

Table 9

Distribution of underweight by age groups of 6.0 59.0 children (combined camp data) N % of Severity of PEM Severe Moderate (<-3SD and or (-3 - <-2SD) oedema) 34.8 38.9 30.9 26.8 25.1 32.3 Global (<-2SD and or oedema) 44.4 53.1 36.7 29.1 26.4 37.9 Normal (<-2SD) 53.1 44.6 62.1 68.3 70.1 59.5

Age group (months)

Underweight 6.0 - 17.0 2552 10.2 18.0 - 29.0 2935 14.2 30.0 41.0 2670 5.8 42.0 53.0 2040 2.3 54.0 - 59.0 1209 1.3 Combined 11406 7.9 The prevalence of oedema is 0.0%

Observing critically the lower PEM prevalence on this study on wasting (8.6%), stunting (29.4%) and under weight (30.9%), the nutritional situation of under 5 years children remains an important public health issue, this translates the need for multi-sectoral approach and efforts in setting priorities in line with programs working towards achieving the millennium development goals (MDGs).

12

WHO: Health Action in Crises Sahel Region, October 2006

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

4.5 Sex prevalence of malnutrition among children aged 6.0-59.0 months The sex difference on the prevalence of malnutrition was clear among children at the age of 6.0 29.0 months. Boys were more susceptible to malnutrition (wasting, underweight and stunting) than girls. As illustrated in figure 5.0 below boys were 2.4 percents more wasted than girls. Figure 4.0: Sex differences in prevalence of wasting among children aged 6.0 59.0 months
20 18 % Wasting (WFH) 16 14 12 10 8 6 4 2 0 6-17 18-29 30-41 42-53 54-59 Total Age groups - months Girls Boys Combined

Prevalence of wasting, underweight and stunting increased from age 6.0 24.0 months across the camps and immediately started to decrease when the age of children exceeded 2 years, figure 5.0. The above figure shows how wasting differed between girls and boys in the camps. The above graph shows that malnutrition start developing among refugee children before attaining 1 year. This explains inadequate child care, infant and young child feeding practices prior to 2 years, a critical period for child growth and development. Much of this can be attributed to poor knowledge, collapsed social family ties and infrastructures due to war13. Focus group discussions indicated that families lack knowledge on exclusive breastfeeding, do not know the value of colostrums, introduce complementary foods in most cases at below 3 months, and give tea and water as breast milk is
13

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

20

believed not sufficient. A project on infant and young child feeding in Goz Amer camp is making a positive change as lactating women who are members of the programme are exclusively breastfeeding their babies. 8 women interviewed by the reporters who their babies were 3, 4 and 5 months said that were exclusively breastfeeding their babies14, among them was a mother with twins. They were registered in the supplementary feeding programme, benefit from the SFP food ration until 6 months post delivery. Sudanese camps in which exclusive breastfeeding and infant and young child feeding program have been initiated are Goz Amer, Gaga and Oure Cassoni from the OPEC funding support.

4.6 Comparison of NCHS 1997 and WHO 2005 base reference analyzed results
When compared using NCHS 1997 and WHO 2005 reference values, results indicate that the global acute malnutrition (Global (<-2SD and or oedema) WFH) for both reference values is within the serious category. Further observation indicate that there is also significant difference between the two prevalence values and that numerically the NHCS 1997 prevalence value is lower than the WHO 2005 GAM result. The overall underweight prevalence indicates that significant differences exist between the NCHS 1977 and WHO 2005 based reference results. Here the NCHS 1997 result is higher than the WHO 2005 results. The numerical difference between the two values of 8.8 is very high. Although both values falls within the critical category as per WHO classification of severity, the NCHS 1997 is on the very high side compared to the WHO 2005 based reference results. The global prevalence of stunting for both NCHS 1997, 34.6% (32.8 36.3) and WHO 2005, 41.1% (39.4 42.8) based reference results falls in the serious and critical classifications of the severity of malnutrition. Significant differences exist between the two results and the result in the NCHS 1997 is lower than the WHO 2005 based reference results. The numerical difference between the two stunting findings of 6.5 is seen on the very high side. Table 10 Table 10 Comparison of combined anthropometric findings based on NCHS 1997 and WHO 2005 reference values Reference value Wasting Underweight Stunting Global (<-2SD) 95% C.I Global (<-2SD) 95% C.I Global (<-2SD) 95% C.I NCHS 1997 12.3% (11.5 13.2) 40.5% (39.1 41.8) 34.6% (32.8 36.3) WHO 2005 13.1% (12.3 13.9) 31.7% (30.4 32.9) 41.1% (39.4 42.8)

4.7 Comparison of GAM from previous survey results In May 2004, during the emergency the Center for Diseases Control and Prevention (CDC) under the request of UNHCR conducted nutrition surveys in all Sudanese refugees camps in Eastern Chad. The findings at that time according to WHO classifications, GAM (weight for height Z- scores) for all camps were CRITICAL. Surveys conducted in June - July 2006, found lower prevalence of GAM to all camps when compared to 2004 and 2005 results. When comparing the 2006 findings and this survey results there is a significant difference in 3 camps which are Farchana, Bredjing and Kounoungou, while to the rest of the camps a notable numerical difference is observed. Table 11

14

Result of focus group discussions on infant and young child feeding in Goz Amer camp organized by COOPI.

21

Table 11 Camp

Comparing GAM and SAM from previous surveys 2006 2008 by camps Severe (<-3SD and or odema) WFH 2006 2008 0.3% (0.0-3.5) 0.7% (0.2-1.1) 0.3% (0.0-1.5) 0.9% (0.1 1.0) 0.8% (0.2 2.3) 0.8% (0.2 1.5) 0.4% (0.0 0.7) 0.9% (0.1 1.7) 0.4% (0.0 0.7) 0.8% (0.2 1.5) 0.2% (-0.0 1.3) 0.7% (0.1-1.4) 0.7% (0.2 2.1) 0.7% (0.2 1.2) 0.4 % (0.0 1.7) 0.5% (0.1 0.9) 0.1% (0.0- 1.2) 0.6% (0.1 1.0) 0.1% (0.0- 1.2) 0.5% (0.0 1.0) 0.8% (0.2 2.3) 0.4% (0.0 0.8) 0.3% (-0.1 3.4) 0.4% (0.0 0.8)

Global (<-2SD and or odema) WFH 2006 2008 Gozamir 7.2% (5.0 10.0) 8.6% (6.0 11.1) Djabal 8.3% (6.1 11.3) 10.4% (7.8 131) Gaga 12.0% (9.3 15.4) 13.1% (10.8 15.4) Farchana 5.79% (4.5 7.3) 12.9% (11.0 14.9) Bredjing 5.79% (4.5 7.3) 11.9% (9.6 14.3) Treguine 8.4% (6.1 11.5) 11.4% (8.7 14.0) Oure Cassoni 8.8% (6.5 11.9) 13.8% (10.4 17.3) Amnabak 11.2% (8.5 14.5) 9.1% (7.2 11.0) Touloum 6.3% (4.4 9.0) 9.5% (6.8 12.2) Iridimi 6.3% (4.4 9.0) 10.6% (8.2 13.0) Mile 8.7% (6.4 11.7) 9.8% (6.8 12.7) Kounongou 4.7% (3.0 7.1) 12.1% (9.4 14.8)

During the period of 2005 2006 a Nutrition Steering Committee (NSC) was formed composed of humanitarian nutritionists drew a common strategy to reduce GAM. The strategy included sensitization of the refugee populations on health and nutrition, family and personal hygiene, kitchen gardening activities and income generating activities, monthly screening of all under 5 years with the aim of capturing all malnourished children and enroll them in the feeding programme, infant and young child feeding activities. NSC intensified monitoring of food and nutrition activities in the camps. This self programme initiative helped much to reduce the critical prevalence of global acute malnutrition to the 2006 levels.

5. CONTRIBUTING FACTORS TO THE INCREASE OF MALNUTRITION 5.1 New refugee influxes Gaga camp has continuously been receiving new arrivals since its opening until to date. Services have not been increasing along with the increase of the population from 12,402 at the end of 2006 to 19,781 registered refugees as of July 2008. As for Kounoungou camp, the change of population was also significant; by the end of 2006 the camp had 13,315 refugees while by the end of July 2008 the camp population has increased to 18,167 registered refugees as a result of the continuous crisis in Darfur. The increase of resources did not go along with the camp population growth. This impacted achievement of some services; like the sanitation, health structures and number of staff in the health and nutrition services. 5.2 The inception of IDP camps Since the nutrition survey in 2006 influxes of about 170,000 internally displaced persons have been settled in various locations around the refugee camps. The same agencies are working in both refugee and IDP camps. The number of staffs and resources has not increased substantially to meet the increased population demanding assistance and support. To mention some examples COOPI has 1 Expatriate Nutrition Officer who is responsible for 2 refugee camps and 5 IDP camps; IMC has 1 Expatriate Nutrition Officer who is responsible for 4 refugee camps and at the same time he works in the IDP projects. ACTED has 1 national nutrition officer for Oure Cassoni camp; other agencies lack expatriate or national nutrition officers.

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5.3 Security related factors Humanitarian workers can not move freely in the camps due to increased insecurity levels necessary to move to move military escort is required; this hinders NGOs staff free executions of their responsibilities. In most cases there is 1 military escort in each camp with several agencies. The convoy movements posses a logistical and coordination challenge among humanitarian workers to go to the camps in convoys, depart from their base stations latest 8.30 a.m. and arrive around 9.30 a.m. in the camps, going to the camps requires military escort by 14.30 pm all workers start departing from the camps in convoys escorted by military. Continuity of programme implementation, monitoring and close follow up is always interrupted due to high insecurity incidences. In the last 2 years consecutively humanitarian workers have been evacuated 3 times due to serious security incidences. Due to high degree of insecurity in the camps humanitarian workers sometime are forced to stay in their compounds without going to the camps to perform their duties. Since 2006, when insecurity increased in the region, particularly to the border zones refugee freedom of movements outside the camps for coping activities have been limited especially in the 6 South Eastern camps. 5.4 Food aid and household food security In 2007 WFP provided an average of 1995 kilocalories equivalent to 90% of the agreed and recommended minimum 2,100 kilocalories and by end August 2008 had provided in average 1743 kilocalories. Since the beginning of 2008, refugees have been on reduced food ration. The reduced ration if is subjected to other of food losses (30% of the food ration is sold to meet milling costs, losses due to scooping during food distribution) the net food ration that is consumed by the refugees is significantly reduced from the intended or planned kilocalories. 5.5 Health and nutrition The health seeking behavior of refugees requires consistent awareness which have been not conducted adequately for 2 years now due to insecurity. Culturally accepted IEC materials have been lacking in the camps, these are important in helping to transform and motivate refugees to increase use of conversional treatments especially to children and women who are at risk. Some health and nutrition NGOs implement different health policies, guidelines and treatment protocols this has made impossible to standardize treatment protocols. Use of Zinc in treating diarrhea cases among under five years children and systematic de-worming is not done in some camps. There exist different reporting formats, different Health Information Systems (HIS) hence different surveillance systems. Harmonization of such monitoring and reporting tools and approaches is necessary in order to allow common assessment and evaluation of the health and nutrition status of the refugees. In one of the camp, one agency implement health / curative and preventive health program and another implements nutrition programme. Holistically health and nutrition projects should be managed and implemented by one agency in one camp. In Oure Cassoni, approximately 60% of under 5 years reported morbidities has been acute respiratory infections (ARI). ARI is known as one of the potential disease contributing to high prevalence of malnutrition. Out break of Hepatitis E occurred in the operation area and 1 case of confirmed Polio was isolated from Bredjing refugee camp.

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5.6 Water and sanitation Access to safe, clean and adequate water in some of the camps is below 20.0 liters per person per day. In 2007, the highest amount provided was 17.0 liters per person per day equivalent to 85% of the recommended target; this was in Gaga, Bredjing, Treguine and Djabal. Camps of Oure Cassoni, Iridimi, Touloum, Amnabak, Mile and Kounongou received below 55% of the 20 liters, recommended amount of water. Low water supply in some of refugee camps is known to cause communicable water born diseases. Program discussions on water supply in the camps are ongoing between UNHCR and the Ministry of water on new approach of rationalization of the limited water resources in the Eastern Chad region to allow both refugees and Chadian nationals rationalize the use. 5.7 Protection issues From end of 2006 freedom of movements to refugees out of the camps has been gravely affected due to continuously degradation of security in the border line, so access to copping mechanism including livestock keeping that could allow refugees to supplement food aid has been severely limited. 5.8 Distribution of non food items General distributions of domestic non food items (NFI) are currently targeted to refugees with specific needs. Fuel wood and other sources of energy are provided in all camps. The last general distribution of NFI took place during refugee influxes, 2004 2005. It is important to consider another general distribution of water containers jerry cans, cooking utensils, mats and sanitary materials as they are related to the health and nutritional status of the population at large. The program aims to provide a monthly general distribution of soap (250gm/p/month); however soap distribution has not been systematically done. This affects the personal hygiene status of the refugee population.

6.

RETROSPECTIVE MORTALITY

This survey also included a mortality survey which was retrospectively assessed. As the priority for the health surveillance system is to produce reliable information of mortality rates. Two mortality indicators were studied namely, crude mortality rate (CMR) and <5 years mortality rate (<5 MR) The formula used to calculate the mortality rates was as follows: Mortality Rate= n / [((n +N) +N) / 2] Where: n = number of deaths N = number of people alive on the day of the survey 90 days = recall period 10,000 = used to express mortality rate per 10,000 people per day.

37,108 population was involved in the retrospective mortality survey across the 12 Sudanese refugee camps in Eastern Chad. The highest crude mortality rate (CMR) was 0.57 / 10,000 population / day recorded from Goz Amer camp. Farchana camp depicted the highest under 5 years mortality rate, 1.04 / 10,000 population / day. The lowest CMR was recorded from Amnabak camp, 0.22 / 10,000 population / day whereas the same camp also had the lowest under 5 years mortality rate, 0.35 / 10,000 population / day. There was no significant difference for the crude death rate among the camps, suggesting that all camps are fairing in the same levels on CMR. The upper limit of the < 5 MR confidence interval was equal and above 1.0 for most of the camps, this gives an alarm to the health program and it further indicates that children are more vulnerable to deaths. A slight increase or change of the aggravating factors the <5 MR is likely to increase.

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Table 12 Camp Gozamir Djabal Gaga Farchana Bredjing Treguine Oure Cassoni Amnabak Touloum Iridimi Mile Kounongou Combined

Crude and < 5 years mortality rates as expressed by 10,000 people per day Population 2,753 2,710 3,993 3,140 2,559 3,007 2,997 4,035 3,235 3,139 2,781 2,759 37,108 Death rates calculated at 10,000 / day CMR survey CMR HIS 0 5 Year death rate results report 0.57 (0.25 0.89) 0.6 0.86 (0.05 1.77) 0.41 (0.12 0.70) 0.8 0.95 (0.15 1.74) 0.36 (01.9 0.54) 0.6 0.65 (0.25 1.06) 0.35 (0.11 0.60) 0.23 1.04 (0.25 1.83) 0.44 (0.18 - 0.69) N/A 0.98 (0.34 1.62) 0.37 (0.15 0.59) 0.8 0.81 (0.17 1.45) 0.52 (0.13 0.91) 0.3 0.86 (0.18 - 1.55) 0.22 (0.05 0.40) 0 0.35 (0.02 0.69) 0.42 (0.17 0.66) N/A 0.87 (0.13 1.60) 0.46 (0.23 0.70) N/A 0.69 (0.17 1.22) 0.28 (0.09 04.6) 0.6 0.56 (0.15 0.97) 0.36 (0.10 0.63) 0.6 0.56 (0.01 1.11) 0.40 (0.30 0.90) 0.6 0.80 (0.16 1.40) <5 yrs HIS report 2.7 3.6 1.8 0.29 N/A 2.4 1.0 0 N/A N/A 1.0 1.2 2.7

Reports from HIS indicate that the under 5years mortality rates are slightly higher than the results from the survey. The under 5 years mortality rate as reported in the HIS for the camps of Djabal, Goz Amer and Treguine were slightly higher than 2/10,000 population/day. This suggests that the Surveillance system in place is able to capture and record most of the deaths happening particularly neonatal deaths which may have not been reported by the community during the survey. Generally the findings indicate that crude mortality rate for all camps are under control and compare well with the monthly HIS reports. Table 12 For relief programme when CMR is below 1.0 deaths / 10,000 / day, then relief programme is under control15 and also the baseline reference mortality data by region indicate that for Sub Saharan Africa; if CMR is 0.44 deaths / 10,000 / day then situation is under control and when CMR is 0.9 deaths / 10,000 /day indicates an emergency state16. 7. IRON DEFICIENCY ANAEMIA

Iron deficiency and iron deficiency anaemia although different are responsible for low haemoglobin levels in the affected community. Their main signs include pallor of palms, fatigue, weakness and short breath, increase hemorrhage risks, for pregnant women risks associated with child births, low birth weight babies and are responsible for low cognitive development among infants and children17. This survey studied haemoglobin levels to both under 5 years and adult women.
7.1 ANAEMIA AMONG CHILDREN BELOW THE AGE OF FIVE YEARS

Overall 30.9% of the under 5 years children were found anaemic across all camps. Oure Cassoni camp had the highest prevalence of anemia among children under 5 years, 37.0% of the sampled children were anemic. Goz Amer camp had the lowest anaemia prevalence, 25.6% when compared to other camps. Majority of the children were moderate and mild anaemic. Across the camps severe anaemia was rarely seen, all camps had less than 2% of severe anaemia cases.

15

UNHCR Hand book for Emergencies: Crude Mortality Rates; Benchmarks: <1.0 deaths / 10,000 / day Relief programme under control, >1.0 deaths / 10,000 / day Relief programme: very serious situation, 345 pg UNHCR Hand book on emergencies, Third edition 2007 17 WHO: Management of severe acute malnutrition, 2001
16

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Table 13 Camps

Mean haemoglobin levels and prevalence of anaemia among children aged 6.0 59.0 months N Mean Hb 11.6 11.4 11.3 11.3 11.6 11.4 11.4 11.7 11.6 11.7 11.3 11.2 11.5 Severity of anaemia - % Severe Moderate 0.2 1.1 0.7 0.9 1.0 0.6 1.8 0.8 0.9 0.5 1.6 1.1 0.9 6.6 9.9 11.2 14.0 11.3 11.0 10.6 8.3 12.0 9.0 17.5 14.6 11.3 mild 18.8 17.2 18.1 17.2 21.9 22.3 25.5 18.7 13.4 15.2 15.0 19.9 18.6 Total anaemic 25.6 28.2 30.1 32.0 34.3 33.8 37.8 27.8 26.4 24.8 34.1 35.6 30.9

Goz Amer Djabal Gaga Farchana Bredjing Treguine Oure Cassoni Amnabak Touloum Iridimi Mile Kounongou Combined

457 273 276 344 388 355 341 252 216 210 246 267 3625

The mean haemoglobin levels for all camps were within the acceptable WHO cut off points for anaemia levels; it ranged from 11.2 for Kounongou camp and 11.7 for Iridimi and Amnabak camps. According to WHO, overall the prevalence of anaemia found in this study is within the moderate category (20-39.9%). Table 13 Table 14 Age group N 6.0 17.0 18.0 29.0 30.0 41.0 42.0 53.0 54.0 59.0 Combined 828 948 854 620 374 3,624 Mean Hb 11.5 11.4 11.5 11.7 11.5 11.5 Mean haemoglobin levels and prevalence of anemia among children aged 6.0 59.0 months Severity of anaemia - % severe moderate Mild 1.1 0.8 1.1 0.5 1.1 0.9 12.8 12.9 11.2 10.7 10.1 11.3 16.4 18.5 18.9 20.6 19.3 18.6 Total anemic 30.3 33.0 31.1 29.8 29.5 30.9

Normal 69.7 66.8 68.9 70.2 70.6 68.9

Majority of the under 5 years children are mildly anaemic across the age groups. The prevalence of mild anaemic cases is almost two folds of moderately anaemic cases. The mostly affected age groups were the first three age groups, 06 17, 18.0 29.0 and 30.0 41.0 months, children aged 18.0 29.0 months were highly affected by Iron deficiency anaemia. Table 14

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Table 15

Protein energy malnutrition, mean haemoglobin and prevalence of anaemia among children aged 6.0 59.0 months N Mean Hb 11.7 11.6 11.5 11.6 11.5 11.5 11.6 11.5 11.5 11.4 11.6 11.5 severe 0.0 0.5 1.0 0.9 0.7 1.0 0.9 0.9 1.2 1.8 0.6 0.9 Severity of anaemia - % moderate mild Total anemic 3.6 32.1 35.7 13.0 20.4 33.9 10.9 18.8 30.7 11.3 18.6 30.9 12.1 12.5 10.1 11.3 11.1 13.1 11.0 11.3 21.1 17.1 18.2 18.6 13.3 17.4 18.7 18.6 35.1 32.5 28.1 30.9 25.6 32.4 29.7 30.9

Wasting Severe Moderate Global Combined Underweight Severe Moderate Global Combined Stunting Severe Moderate Global Combined

305 1126 2194 3625 305 1126 2194 3625 305 1126 2194 3625

Normal 64.3 66.1 69.3 69.2 64.9 66.4 70.7 67.3 74.4 67.6 70.3 69.1

Further analysis indicated that 35.7 and 35.1 percent of severely wasted and underweight children were anemic respectively. Consequences of anemia to protein energy malnourished children includes, decreased physical activity like playing, impaired cognitive development of infants and children, decreased body immunity and hence makes children more susceptible to diseases like malaria, acute respiratory infections, diarrhea and measles which are the main causes of mortality in emergencies18. Table 15

Figure 5

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

31 30.5 30 % Total anemia 29.5 29 28.5 28 27.5 27 26.5 Wasting Underweight PEM Stunting

18

UNHCR Handbook for Emergencies, Third Edition, 2007

27

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

7.2 Anaemia prevalence among women

3,350 women had there haemoglobin levels assessed, of them 530 were pregnant, 1,651 were lactating and the rest were neither pregnant nor lactating. Overall Farchana camp had the highest prevalence of anaemia, 39.6% among women. The lowest value was found in Goz Amer camp, 18.4%. As it was for children the most prevalent form of anaemia among women were moderate and mild, Table 16.0 Table 16 Camps N Gozamir Djabal Gaga Farchana Bredjing Treguine Oure Cassoni Amnabak Touloum Iridimi Mile Kounongou Combined 304 237 275 338 351 355 347 229 205 207 238 262 3348 Mean Hb 12.3 11.9 11.7 11.4 11.5 11.9 11.6 11.8 11.7 11.4 11.9 11.8 11.7 Mean haemoglobin levels and prevalence of anaemia among refugee women Severity of anaemia by % Severe moderate mild 0.3 1.7 1.1 0.3 2.8 1.4 1.2 0.9 0.5 1.0 0.4 1.1 1.2 9.5 11.0 10.2 16.6 15.4 11.3 11.2 6.6 16.1 12.1 6.3 13.7 12.7 8.6 10.1 16.0 22.8 19.9 18.0 19.6 18.3 15.7 18.0 19.8 17.6 17.1 Total anaemic 18.4 22.8 27.4 39.6 36.5 30.7 32.5 25.8 31.2 28.3 25.5 32.4 30.9

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

Table 17 Physiology Status Pregnant Lactating Normal Combined

Mean haemoglobin, % severity of anaemia and physiology status among women N 530 1651 1169 3350 Mean Hb 11.3 11.9 11.8 11.7 Severity of anaemia - % severe moderate mild 1.5 1.0 1.2 1.2 16.0 11.0 11.0 12.7 19.2 15.6 16.4 17.1 Total anemic 36.7 27.6 28.6 30.9

Normal 73.4 72.4 71.4 72.4

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Table 18 Indicator Normal Mild Moderate Severe

Comparing prevalence of anaemia with WHO standards Standards <= 4.9 5.0 19.9 20.0 39.9 => 40.0 Pregnant women Lactating women Children results results results 36.7 27.6 30.9

The prevalence of anaemia to both categories of women surveyed and under 5 years children falls with the moderate category of WHO classifications. Table 18 Figure 6 Showing trend of haemoglobin levels among women by physiological status

40 35 % Total anaemia 30 25 20 15 10 5 0 pregnant lactating normal combined Women - by category

7.3 Program to prevent iron deficiency anaemia

The operation implements different programs to preventive and control iron deficiency anaemia, these programs includes; Treatment of malaria using MoH treatment protocols, malaria is known to causes anaemia Systematic de-worming of children using mebendazole as per MoH policy on deworming, twice in a year de-worming campaigns are organized Pregnant women receive Iron supplementation tablets and fansidar during antenatal period The food ration given comprises of CSB that is fortified with iron, CSB is the only major source of micronutrients given systematically to the general population Kitchen gardening programs exist to some camps Livestock keeping, some refugee populations keep goats, sheeps and camels, meat is good source of iron Pregnant women receive SFP food package (comprised of CSB) immediately from the time they book in the antenatal program to 6 months post delivery Distribution of impregnated long lasting mosquito nets to prevent and reduce malaria prevalence

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8.

MEASLES IMMUNIZATION:

A total of 10,900 children whose age was equal and above 9.0 months were involved in the analysis for establishing measles coverage. Their road to health cards were studied and verified if had got measles vaccination, henceforth recorded. Where it was found not recorded mothers / guardians were asked if the child had got measles shot previously. Results indicated that 94.6% of the children had received measles vaccination (77.2% had their cards recorded and 17.4% their mother confirmed to have received measles vaccination) at the time of the survey. Overall children who did not receive measles vaccination were 5.4% across the camps. The programme target coverage for measles for 2007 and 2008 was to achieve 95.0%. From the findings, 94.6% coverage is very close to 95.0% it can be concluded that in general the program achieved this target, however, efforts needs to be directed to 5 camps which have not attained this target. Table 19 Table 19 Camp Goz Amer Djabal Gaga Farchana Bredjing Treguine Oure Cassoni Amnabak Touloum Iridimi Mile Kounongou All camps Percentage coverage of measles vaccination for children aged =>9.0 59.0 months N 912 918 920 918 900 910 919 917 855 942 870 919 10,900 % of measles coverage; children aged =>9.0 months By card By recall =>9 months Not vaccinated 68.5 27.6 96.1 3.9 48.8 39.2 90.9 12.0 84.5 7.5 92.0 8.0 67.5 21.4 88.9 11.1 72.8 19.6 92.4 7.7 83.1 82.7 85.2 86.8 81.5 83.4 80.6 77.12 12.1 14.8 12.3 10.1 15.1 14.3 13.9 17.3 95.2 97.5 97.5 96.9 96.6 97.7 94.5 94.6 4.8 2.5 2.5 3.2 3.4 2.3 5.4 5.4

UNHCR advocates that measles vaccination coverage should be as close as 100% (and must be greater than 90% to be effective)19, in this case, UNHCR and UNICEF as per the joint plan of action have been working jointly with the partners to raise measles vaccination coverage in Farchana (88.9%), Gaga 90.7%), Bredjing (92.4%) and Kounongou (94.5%) camps. Table 19 9. SELECTIVE FEEDING PROGRAMME

The selective feeding programme is implemented in all camps by health and nutrition agencies. The purposes of this programme is to rehabilitate severely and moderately malnourished children, reduce mortality and morbidity and provide medical treatment where required. This study assessed the participation of both severely and moderately malnourished children in the feeding programme, findings indicate that Mile camp had the highest coverage on SFP, 73.0%; followed by Djabal (66.0%), Goz Amer (62%) and Treguine (62%). The highest coverage for TFP was recorded in Djabal camp with 63% coverage. This level is below the programme target of 90%. In Bahai refugee leaders expressed concerns on the SC as it is outside the camp, this requires mothers to go and stay with one malnourished child for some days in Bahai leaving other children and other
19

UNHCR Handbook for Emergencies; measles page 351

30

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

Table 20 Camp Gozamir Djabal Gaga Farchana Bredjing Treguine Oure Cassoni Amnabak Touloum Iridimi Mile Kounongou

Percentage coverage of selective feeding programme by refugee camps N 912 919 964 973 948 960 968 978 905 989 923 967 SFP 62% 66% 51% 35% Nil 62% 47% 43% Nil Nil 73% 54% TFP 55% 63% 50% Nil No TFP 30% No TFP No TFP No TFP No TFP No TFP

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

Table 21 Year Total admission Recovery rate Death rate Defaulter rate Transfer rate

Trend of SFP performance indicators 2005 13822 63.7% 0.2% 25.4% 5.3% 2006 9137 81% 0% 10% 4% 2007 10040 83% 1% 6% 6% Mid year 2008 3561 89.4% 0.2% 5.7% 3.9%

The feeding programs performance indicators show there has been an increasing trend on the recovery rate since 2005 to date in both SFP and TFP. As of mid June 2008 the entire selective feeding programme had above 89 percent recovery rates across the camp. Table 21 Table 22 Year Total admission Recovery rate Death rate Defaulter rate Transfer rate Trend of TFC performance indicators 2005 2910 75.3% 4.6% 13.2% 5.7% 2006 1528 83% 3% 6% 6% 2007 1803 78% 5% 10% 7% Mid year 2008 428 89.7% 2.4% 3.4% 4.5%

The recovery, death and defaulter rates remained within the Sphere acceptable standards and indicators. The SPHERE standards performance indicators for SFP are as follows; coverage >90%, recovered >75%, deaths <3%, defaulter <15%. The standards for Therapeutic feeding programme as

31

recommended by SPHERE are as follows; coverage >90%, recovered >75%, deaths <10% and defaulter <15%. Insecurity makes impossible for the selective feeding programme and particularly the stabilization centre to operate efficiently in most of the Sudanese refugee camps in Eastern Chad. Initiatives like reviving the Nutrition Steering Committee could make a difference in terms of reducing the high levels of the global acute malnutrition in the camps. Review and thorough implementation of the feeding protocol is another element that could be looked into.

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10. CONCLUSION As compared to 2006 the nutritional status of the refugees has relatively deteriorated through 2007 to 2008. The prevalence of GAM falls in the serious category as per WHO. It calls for serious concerted efforts in order to maximize the utilization of the allocated available resources for the programme hence forth the program achieves its objectives.

It has been noted that security concerns could be the leading cause of the deteriorated nutritional status of Sudanese refugees in the Eastern Chad.
11. RECOMMENDATIONS These recommendations are made in line with the findings related to the actual camp based situation: 1. Considering the number of malnourished children not registered in the feeding programs in the camps, it is strongly recommended that the monthly exhaustive screening of under 5 years in all camps is adequately supervised by qualified staff (nutritionist, nurses) in order to ensure that all malnourished children are registered in the appropriate feeding programs. It is recommended that the NSC in Abeche which current is not active be immediately revived with an action plan to reduce the current level of malnutrition; The agreed general food ration be reinstated to a 100% of which will reduce the losses due to milling cost and scooping effects during food distribution; The prevalence of anaemia to children under 5years, pregnant and lactating women falls within the moderate category as per WHO standards. As this value includes a huge population across the camps, it is important to closely monitor and improve programs geared to prevent and control prevalence of anaemia. The coverage of measles vaccination in some of the camps is below the recommended standards, UNHCR and UNICEF should intervene jointly as per global MOU. The aim should be to raise measles coverage to above 95% and where possible closer to 100%. As malnutrition start to attack children at the age of below 2 years, programs on infant and young child feeding should be continued with emphasis on exclusive breastfeeding and child care up to 2 years. The community services sector is in the process of identifying the vulnerable individuals, a common strategy drawn by the sectors can help to reduce the current level of GAM. It is therefore recommended that this process be prioritized jointly with the community services, health and nutrition. Increase assistance and support on WATSAN sector and provision of fire wood to identified vulnerable refugee households. Jointly with WFP conduct a household food economy assessment to determine the existence and contributions of the coping mechanisms available in the Sudanese population in Eastern Chad. Capacity building to national staff in the food and nutrition sector with a view to increase presence and coverage of service providers as this will increase direct implementation, monitoring and reporting of activities undertaken in the camps.

2. 3. 4.

5. 6. 7.

8. 9. 10.

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12. REFERENCES 1. Emergency Nutrition Assessment Guidelines for field workers, SCF UK, 2004 2. Field Exchange; June 2008: Somali KAP Study on Infant and Young Child Feeding and Health Seeking Practices. 3. Health Information System monthly report June 2008 Note that 4. How to Weigh and Measure Children written by Irwin J. Shorr for the UN Department of Technical Cooperation for Development and Statistical Office, New York, 1986 5. The world wide magnitude of protein energy malnutrition: an overview from the WHO Global Database on Child Growth. M. de Onis, C. Monteiro, J.Akre and G. Clugston 6. SUSTAIN: Malnutrition over view, technology for better nutrition http://www.sustaintech.org/world.htm 7. UNHCR Hand book for Emergencies: Crude Mortality Rates; Benchmarks: <1.0 deaths / 10,000 / day Relief programme under control, >1.0 deaths / 10,000 / day Relief programme: very serious situation, 345 pg 8. UNHCR Handbook for Emergencies; measles page 351 9. UNHCR Handbook in Emergencies, February 2007 10. UNHCR standard and indicators for crude mortality rate is <1.5 / 1,000 / month and for children under 5 years is <3.0 / 1,000 / month. 11. WHO (2000): The Management of Nutrition in Major Emergencies. WHO Geneva. 12. WHO: Health Action in Crises Sahel Region, October 2006 (Burkina Faso, Niger, Mali, Chad and Senegal) 13. WHO cut off points for underweight, less than 10% low, 10 19% moderate, 20 29% High and equal and above 30% very high ; Bulletin of WHO, 71(6):703-712 (1993) 14. WHO: Health Action in Crises Sahel Region, October 2006

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ANNEX I

RESULTS PRESENTED BASED ON WHO 2005 REFERENCE VALUES

PREVALENCE OF WASTING: Table 2.0: Prevalence of wasting (weight-for-height Z score) among 6.0 59.0 months (based on WH0 2005 reference) Camp N Normal (<-2 Z-score) Wasting (% with 95% C.I Moderate Global Severe
(<-3SD and or odema)

(-3 - <-2SD)

(<-2SD and or odema)

Goz Amer 912 2.2% (1.2 3.2) Djabal 919 1.0% (0.4 1.6) Gaga 964 2.7% (1.7 3.7) Farchana 973 2.1% (0.8 3.3) Bredjing 948 1.2% (0.4 1.9) Treguine 960 1.7% (0.8 2.5) Oure 968 2.1% (1.1 3.0) Cassoni Amnabak 978 3.0% (1.6 4.4) Touloum 905 1.2% (0.5 1.9) Iridimi 989 1.2% (0.5 1.9) Mile 923 1.4% (0.4 2.4) Kounongou 967 1.4% (0.6 2.3) Combined 11406 2.2% (1.8 2.5) The prevalence of oedema is 0.0%

9.0% (6.2 11.8) 11.2% (8.3 14.0) 8.3% (5.9 10.7) 9.2% (6.7 11.8) 10.7% (8.5 12.8) 13.4% (10.8 16.0) 10.6% (8.5 12.7) 12.6% (10.0 15.2) 9.3% (6.9 11.7) 10.4% (7.7 13.2) 10.0% (8.1 11.9) 11.7% (9.5 13.8) 13.1% (10.3 15.9) 15.2% (12.0 18.3) 8.5% (7.2 9.8) 11.5% (9.5 13.4) 9.6% (6.8 12.4) 10.8% (7.7 13.9) 9.9% (7.9 11.9) 11.1% (8.7 13.6) 9.2% (6.6 11.8) 10.6% (7.3 13.9) 11.4% (9.1 13.7) 12.8% (10.5 15.2) 10.9% (10.3 11.6) 13.1% (12.3 13.9)

88.8% (85.9 91.7) 90.8% (88.3 - 93.3) 86.6% (84.0 89.2) 87.4% (84.8 90.1) 89.6% (86.9 - 92.3) 88.3% (86.1 90.6) 84.8% (81.6 88.0) 88.5% (86.5 90.5) 89.2% (86.1 - 92.3) 88.9% (85.8 - 91.3) 89.4% (86.1 92.7) 87.2% (84.8 89.6) 87.6% (85.6 90.9)

Table 4.0: Prevalence of wasting (% median) among children aged 6.0 59.0 months in refugee camps,(based on WHO 2005 reference)
Name Camp of

N
Severe (<70% median and or odema) Moderate (>=70% - <80%) Global (<80% median and or odema)

Normal (>=80% median) 97.0% (95.8 98.2) 95.4% (94.0 - 96.8) 95.7% (94.5 96.9) 97.1% (95.8 98.4) 97.4% (95.8 - 99.0) 97.4% (96.3 - 98.5) 96.5% (95.4 97.6) 96.2% (94.7 97.7) 97.6% (96.5 - 98.7) 97.8% (96.7 98.9) 97.5% (96.1 - 98.9) 97.5% (96.3 - 98.7) 96.7% (96.2 - 97.2)

Gozamir Djabal Gaga Farchana Bredjing Treguine Oure Cassoni Amnabak Touloum Iridimi Mile Kounoungou Combined

912 919 964 973 948 960 968

0.0% (0.0 0.0) 0.1%(-0.1 0.3) 0.2%(-0.1 0.5) 0.0% (0.0 0.0) 0.0% (0.0 0.0) 01.%(-0.1 0.3) 0.1%(-0.1 0.3)

3.0% (1.7 4.2) 4.5%(3.1 5.9) 4.0%(3.0 5.1) 2.9% (1.6 4.2) 2.6 % (1.4 - 3.9) 2.5% (1.4 3.6) 3.4%(2.3 4.5) 3.8%(2.2 5.3) 2.3%(1.2 3.4) 2.2% (1.1 3.3) 2.5 % (1.1 - 3.9) 2.5% (1.3 3.7) 3.2% (2.8 3.6)

3.0% (1.7 4.2) 4.6% (3.2 6.0) 4.3%(3.1 5.4) 2.9% (1.6 4.2) 2.6 % (1.4 - 3.9) 2.6% (1.5 3.7) 3.5% (2.4 4.6) 3.8%(2.2 5.3) 2.4%(1.3 3.5) 2.2% (1.1 3.3) 2.5 % (1.1 - 3.9) 2.5% (1.3 3.7) 3.3% (2.8 3.7)

978 0.0 %(0.0 - 0.0) 905 0.1%(-0.1 0.3) 989 0.0% (0.0 0.0) 923 0.0% (0.0 0.0) 967 0.0% (0.0 0.0) 11406 0.1% (0.0 - 0.1) The prevalence of oedema is 0.0%

35

PREVALENCE OF STUNTING: Table 5.0 Prevalence of stunting (Height-for-age Z score) among children aged 6.0 59.0 months (based on WH0 2005 reference) Stunting (% with 95% CI) Camp N Severe
(<-3SD and or odema)

Normal (<-2 SD) Global

(<-2SD and or odema)

Moderate
(-3 - <-2SD)

Gozamir 912 12.1% (9.0 15.1) Djabal 919 15.7% (12.5 18.8) Gaga 964 17.5% (14.8 20.3) Farchana 973 20.1% (17.2 23.1) Bredjing 948 16.7% (12.8 20.5) Treguine 960 14.5% (12.2 16.7) Oure 968 11.7% (8.8 15.1) Cassoni Amnabak 978 12.0% (8.8 15.1) Touloum 905 10.5% (7.9 13.1) Iridimi 989 11.1% (8.3 13.9) Mile 923 10.2% (7.5 12.9) Kounongou 967 15.1% (12.2 18.0) Combined 11,406 15.2% (14.2 16.3) The prevalence of oedema is 0.0% PREVALENCE OF UNDERWEIGHT:

27.0% (23.6 30.3) 33.5% (30.3 36.7) 22.5% (19.7 25.3) 28.0% (25.1 30.8) 36.0% (32.2 39.7) 28.4% (25.6 31.3) 26.1% (22.8 29.4) 24.8% (22.0 27.7) 24.4% (20.1 28.7) 26.3% (22.9 29.7) 24.7% (21.0 28.4) 25.0% (22.0 28.1) 25.9% (24.8 27.0)

39.0% (35.0 43.0) 49.2% (45.1 53.3) 40.0% (36.4 43.7) 48.1% (44.9 51.3) 52.6% (49.0 56.3) 42.9% (39.3 46.5) 37.8% (33.2 42.5) 36.8% (32.8 40.8) 34.9% (29.3 40.5) 37.4% (32.6 42.2) 34.9% (29.2 40.6) 40.1% (35.5 44.8) 41.1% (39.4 42.8)

61.0% (57.1 64.7) 50.8% (46.7 - 55.7) 60.0% (56.4 63.5) 51.9% (49.3 53.2) 47.4% (44.7 50.7) 57.1% (53.5 60.7) 62.2% (57.5 66.4) 63.2% (36.8 44.8) 65.1% (61.3 68.7) 62.6% (57.8 67.4) 65.1% (59.4 70.8) 59.9% (55.3 - 64.5) 58.9% (52.9 60.9)

Table 7.0 Prevalence of underweight among children aged 6.0 59.0 months in refugee camps (based on WH0 2005 reference) Camp N Severe underweight (% with 95% CI) Moderate
(-3 - <-2SD)

Normal (<-2 SD) Global

(<-2SD and or odema)

(<-3SD and or odema)

Gozamir 912 5.8% (4.2 7.4) Djabal 919 6.0% (3.8 8.2) Gaga 964 9.1% (7.2 11.0) Farchana 973 9.7% (6.5 12.8) Bredjing 948 5.2% (2.6 7.8) Treguine 960 7.6% (6.0 9.2) Oure 968 5.6% (4.1 7.1) Cassoni Amnabak 978 4.9% (3.6 6.3) Touloum 905 4.5% (3.0 6.1) Iridimi 989 3.0% (1.5 4.6) Mile 923 2.5% (1.3 3.7) Kounongou 967 6.5% (4.8 8.2) Combined 11406 7.2% (6.6 7.8% The prevalence of oedema is 0.0%

20.1% (16.4 23.8) 21.5% (18.2 24.8) 22.5% (20.0 25.0) 26.2% (23.1 29.3) 26.1% (23.2 28.9) 22.6% (20.3 24.9) 18.4% (15.2 21.6) 20.6% (17.5 23.6) 24.8% (19.9 29.6) 24.3% (19.8 28.7) 24.3% (20.1 28.4) 25.0% (21.2 28.9) 24.4% (23.5 25.4)

25.9% (21.7 30.0) 27.5% (23.2 31.9) 31.6% (28.1 35.2) 35.9% (32.3 39.4) 31.2% (27.2 35.3) 30.2% (27.4 33.0) 24.0% (20.2 27.7) 25.5% (21.7 29.2) 29.3% (24.3 34.3) 27.3% (22.0 32.6) 26.8% (22.1 31.4) 31.5% (26.8 36.3) 31.7% (30.4 32.9)

74.1% (70.0 - 78.2) 72.5% (68.2 - 76.8) 68.4% (64.8 72.0) 64.1% (60.6 - 67.6) 68.8% (64.7 - 72.9) 69.8% (64.2 - 75.4) 76.0% (72.3 79.7) 74.5% (71.0 78.0) 70.7% (75.7 65.6) 72.7% (67.4 78.0) 73.2% (68.6 - 77.8) 68.5% (64.8 72.4) 68.3% (67.6 74.5)

36

Annex II Locally developed calendar for anthropometric measurements Month January February March Event to refer Sudan Independent day 2003 2004 54 53 52 2005 42 41 40 2006 30 29 Arrival of IDPs in Goz Beida 28 2007 18 17 16 Tiero and Moreno attacked 15 14 13 12 11 10 9 Ramadan 8 7 2008 6

April May June Juily August September October November December

Chad Independence

59 58 57 56 Ramadan 55 end of Ramadan

51 50 49 48 47 46 45 44 Ramadan 43 end of Ramadan

39 38 37 36 35 34 33 Ramadan 32 31

27 26 25 24 23 22 21Ramadan 20 attack in Abeche 19 attack in Biltine

Noel

Annex III Locally developed calendar for retrospective mortality measurements Month April 2008 Weeks Week 14 Week 15 Week 16 Week 17 Week 18 Week 19 Week 20 Week 21 Week 22 Week 23 Week 24 Week 25 Week 26 Week 27 Week 28 Week 29 Monday 100 93 86 79 72 65 58 51 44 37 30 23 15 8 1 Tuesday 99 92 85 78 71 64 57 50 43 36 29 22 14 7 Wednesday 98 91 84 77 70 63 56 49 42 35 28 21 13 6 Thursday 97 90 83 76 69 62 55 48 41 34 27 20 12 5 Friday 96 89 82 75 68 61 54 47 40 33 26 19 11 4 Saturday 95 88 81 74 67 60 53 46 39 32 25 18 10 3 Sunday 94 87 80 73 66 59 52 45 38 31 24 17 9 2

May 2008

June 2008

July 2008

37

Annex IV 2008 Nutrition Survey Time table; a collaboration with UNICEF, WFP and WHO
Dates 3-Jun-08 5-Jun-08 17-Jun-08 Activities /Period Depart Tanzania to Chad Arrival Ndjamena - Chad Arival in Abeche & Briefing Preparatory activities ( Adoption of nut survey documents, protocol of survey,final budget, training programme, invitations letters, official communication of survey schedule)) Preparatory activities ( Printing documents, logistic packages)) Training of nutrition team leaders( Surveyors) Training of supervisors of UN Agencies and IPS on SMART software. En route to Koukou Training of CHWs in Goz-amer camp Nutrition Survey in Goz-Amer camp En route to Gozbeida Training of CHWs in Djabal Nutrition surveys in Djabal En route to Abeche En route to Amleyouna Training CHWs in Gaga camp Nutrition Survey in Gaga En route to Farchana Training of CHWa in Farchana camp Nutrition Survey in Farchana camp En route to Bredjing and Training of CHWs in Bredjing camp Nutrition survey in Bredjing camp Training of CHWs in Treguine camp Nutrition survey in Treguine camp En route to Abeche En route to Bahai Training of CHWs in Oure Cassoni camp Nutrition survey in Oure Cassoni camp En route to Iriba Training of CHWs in Amnabak camp Ndjamena Abeche Abeche Administrative procedures delayed Nutrition team, Places Over night Remarks( Needs)

18-19 June 2008 20--23 June 2008 24--26 June 2008 27-28 June 2008 30-Jun-08 1st July 2008 2d July 2008 3d July 2008 04-Jul-08 5-6 July 2008 07-Jul-08 08-Jul-08 09-Jul-08 10-11 July2008 12-Jul-08 13-Jul-08 14-15 July /2008 16-Jul-08 17-18 July 2008 19-Jul-08 20-21 July 2008 22-Jul-08 23-Jul-08 24-Jul-08 25-26 July 2008 27-Jul-08 28-Jul-08

Abeche Abeche Abeche Abeche Koukou Koukou Goz-amer Farchana camp Gozbeiida Djabal Djabal Amleyouna Gaga Gaga Farchana Farchana Farchana Bredjing Bredjing Treguine Treguine Abeche Oure Cassoni camp Oure Cassoni camp Oure Cassoni camp Iriba Amnabak

Abeche Abeche Abeche Abeche Koukou Koukou Koukou Farchana Gozbeida Gozbeida Gozbeida Amleyuna Amleyuna Amleyuna Farchana Farchana Farchana Hadjer Hadid Hadjer Hadid Hadjer Hadid Hadjer Hadid Abeche Bahai Bahai Bahai Iriba Iriba

Nutrition team, Nutrition team, Ecole de la sant Ecole de la Sant COOPI COOPI COOPI UNHCR Gozbeida COOPI COOPI UNHCR Gozbeida Nutrition team, IMC IMC UNHCR Farchana MSF-H/IMC MSF-H/IMC IRC IRC FICR/CRT FICR/CRT Nutrition team, Nutrition team, ACTED/IRC ACTED/IRC Nutrition team, IMC

38

29- 30 July 2008 31-Jul-08 1-3 Aug 2008 04-Aug-08 05-Aug-08 6 -7 Aug 2008 08-Aug-08 9-10 Aug 2008 11-Aug-08 12-14Aug 2008 15-20 Aug 2008 21-Aug-08

Nutrition survey in Amnabak camp Training of CHWs in Iridimi & Touloum camps Nutrition survey in Iridimi & Touloum camps En route to Guereda Training of CHWs in Mile camp Nutrition survey in Mile camp Training of CHWs in Konoungou camp Nutrition Survey in Konoungou camp En route to Abeche Data entry -Cleaning & analysis Data interpretation & Report writing Presentation of results findings to partners

Amnabak Iridimi Iridimi Guereda Mile Mile Kounoungou Kounoungou Abeche Abeche Abeche Abeche

Iriba Iriba Iriba Guereda Guereda Guereda Guereda Guereda Abeche Abeche Abeche Abeche

IMC MSF-L MSF-L UNHCR Iriba IMC IMC IMC IMC Nutrition team, Nutrition team, Nutrition team, Nutrition team,

39

Filename: Final Draft Nutri Surv Report.doc Directory: C:\Documents and Settings\UNHCRUser\Local Settings\Temp Template: C:\Documents and Settings\UNHCRUser\Application Data\Microsoft\Templates\Normal.dot Title: UNHCR Chad Subject: Nutrition, Mortality and Anaemia survey Author: Lucas Machibya Keywords: Malnutrition, Mortality, Anemia Comments: Creation Date: 9/16/2008 1:43 PM Change Number: 14 Last Saved On: 9/16/2008 2:18 PM Last Saved By: UNHCRUser Total Editing Time: 18 Minutes Last Printed On: 9/21/2008 3:20 PM As of Last Complete Printing Number of Pages: 39 Number of Words: 14,751 (approx.) Number of Characters: 84,081 (approx.)