...... •· ·• •. ~TRITION sirk~~~ kEPORT- ~1AYJ993
NUTRITION SURVEYS
SOFALA AND TETE PROVINCES
CAIA DISTRICT - CAIA SEDE
- SENA
CHEMBA DISTRICT - C~ASEDE
MUTARARA DISTRICT - MUTARARA
- INHANGOMA
May iM'P13 Clifford Wokveha, M.D. Terry Andrews, M.D. Veronique Kollhoff, M.D. INTERNATIONAL ADDRESS: &111 WESl HUN11NGTON DR!VE.IMONROYlA, CALIFOR.'-llA 9101! 18181 357-7979/CAB•E WORVIS/TELEX.: 67-5341 GRAEME. IRVINE, PRESIDENT WORLD TVISION INTERNATIONAL MOZAMBIQUE RELIEF PROGRAMME AV. PAULO SAMUEL KA.NKHOMBA 1170, MAPUTO P. O. BOX 2U1. MAPUTO MOZAMBIQUE TELEPHONE 42 29 22/U 03 It TELEX 6-124 WORV. MO TELEFAX 42 IHi
MAP/COMM/141/FY93-L June 08. 1993
Sidney Bliss USA ID Maputo
SUB: lWI'RITION SURVEY RESULTS- ZAMBEZI CORRIDOR Dear Sidney, We are pleased to forward to you the results of the nutrition surveys carried out during the month of May in Caia Sede, Murraca, Sena (Caia District), Chemba Sede (Chemba district), Mutarara and Inhangoma Walte Middleton Commodities Manager cc: John Yale, WVM cc: Leland Brenneman, WVRD/DC cc: Rich Moseanko, WVIO cc: Dr. Terry Andrews, WVM cc: Joe Seigle/Milton Amayum, WVRD cc: Phillip Clarke, WFP, Maputo 100.1.10 '\ / TABLE OF CONTENTS INTRODUCTION 1 SURVEY OBJECTIVES 1 TARGET POPULATION 2 METHODS 2 A. TYPE OF SURVEY SYSTEM USED B. SAMPLE SIZES/PREDICTED RA TES OF MALNUTRITION C. VARIABLES MEASURED D. PERSONNEL E. DATA ANALYSIS RESULTS 4 A. DISTRIBUTION OF CHILDREN ACCORDING TO GENDER B. RA TE OF GLOBAL ACUTE MALNUTRITION (MOH) C. RA TE OF GLOBAL ACUTE MALNUTRITION (WHO) D. RA TE OF SEVERE ACUTE MALNUTRITION COMPARISON WITH PREVIOUS SURVEYS 7 DISCUSSION/CONCLUSIONS 8 INTRODUCTION World Vision Emergency Response has been airlifting food and seeds to the vil1ages of Caia, Murrai;a, Mutarara and Inhangoma s_ince October 1991. Sena and Chemba were adde The airlifted food and seeds did much to improve food stores, as evidenced by comparative nutrition surveys carried out by WV in November 1991 and April 1992. Malnutrition levels in these 6 villages remained relatively stable through August 1992, at which time an influx of refugees from Renamo controlled wnes began. After the signing of the peace accord, migration of villagers in search of food increased dramatically with refugees pouring in from Renamo zones as well as the neighboring countries of Malawi and Zimbabwe. Airlift site populations increased 10 and 20 - fold during this period. Overcrowding combined with draught and lack of seeds led to a markerl increase in levels of malnutrition in all sites. A WV survey c6nducted in November 1992 showed global acute malnutrition ranging from 11 % to 35% by MOH standards. Severe malnutrition ranged from 2% to 15%. Since November, World Vision has increased amounts of airlifted food, seeds and tools. 6 feeding centers were opened - one in each airlift site to treat the severely malnourished who might not be strong enough to benefit from distributed food and seeds. Over the past 6 months, nearly all sites experienced meas1es epidemics, spread primarily by recent arrivals to airlift sites; cholera and dysentery epidemics were also widespread during the rainy season, spreading all the more easily because of overcrowding from the refugee influx. World Vision worked together with the MOH of Zambezia, Tete and Sofala provinces and Medecins Sans Frontieres to vaccinate against measles and transport supplies for the treatment of cholera. At present, no cases of cholera have been reported in the sites since March 1993 and measles cases are much fewer. The following nutritional surveys in the six sites of Caia, Murra\a, Sena, Chemba, Mutarara and Inhangoma were carried out in accordance with donor requirements for biannual nutrition surveillance in WV airlift sites. OBJECTIVES The objectives of this survey were to: 1. Confirm reported populations currently existing in airlift sites. 2. Evaluate the nutritional state of populations currently benefitting from airlifted seeds and food, using both Ministry of Health (MOH) and World Health Organization (WHO) standards. 3. Mobilize parents of malnourished children encountered during the survey to receive help at the intensive therapeutic feeding centers. i l 1 TARGET POPULATION Children aged 6 months to 5 years were evaluated. When mothers were unsure of childrens' ages, the criteria of 55 cm to 115 cm (height) was used. The following are population estimates based on numbers given by the administrator, and confirmed lists of returnees for each village at the time of the survey: VILLAGE F.STIMATED ESTIMATED NO. NO. OF CHILDREN % OF 0-5 YR POPULATION 0-5 YR OLDS* SURVEYED OLDS SURVEYED Caia 38,420 7,864 539 7.0% Murra~ 9,789 1,958 568 29.0% Sena 27,300 5,460 495 9.1% Chemba 7,509 1,502 479 31.9% Inhangoma 5,146 1,029 496 48.2% Mutarara 6,925 1,385 448 32.3% * 0 - 5 yr olds were estimated to be approximately 20% of the population (according to WHO standards for developing countries) :METHODS A. TYPE OF SURVEY SYSTEM USED: (1) the sample size was determined according to the expected prevalence of malnutrition and precision desired using the following formula: n = 1.962 *(p)*(l-p) d2 where n is population number; p = expected prevalence; d is desired precision. (2)-The World Health Organization system of 30 random clusters was used for villages with population~ greater than 10,000: Sena (May 4 - 6) Caia (May 22 - 26) (3) For villages with less than 10,000 population, as systematic random sampling method was used: the number of houses was estimated based on population (average of 4.5 people per household) or basec on a village house count prior to implementing the survey; this number was divided by the desired sample size to determine the sample interval in terms of houses. Mutarara (May 7 - 11) Chemba (May 12 - 14) Inhangoma (May 15 - 18) Murra~ (May 19 - 21) 2 B. SAl\fPLE SIZF..S I PREDICTED RA TES OF MAL!\'UTRITION: Sample sizes were initially determi11ed using predicted rate of malnutrition and level of precision desired. The number of children surveyed in most villages was actually more than initially planned due to the efficiency of the survey team. In the case of Chemba and Inhangoma, the numbers actually surveyed were less than planned because the populations of these villages were small and not enough children could be found. The number of children surveyed in Chemba and Inhangoma was 32% and 48% respectively however, giving a very accurate result in spite of the lower number~. Caia = 539 _ (expected malnutrition = 15%) - cluster size = 18 children Sena = 495 (expected malnutrition = 25%) - cluster size = 17 children Mutarara = 448 (expected malnutrition rate = 10%) Inhangoma = 496 (expected malnutrition rate = 30%) Chemba = 479 - (expected malnutrition rate = 20%) Murra~ = 568 (expected malnutrition rate = 15%) Expected rates of malnutrition were predicted using the results of the November 1992 survey in the same villages. Desired precision was between 2 % and 4 % , depending on rates of malnutrition predicted. C. VARIABLFS MEASURED: 1. Anthropometric measurements collected for all 6 month - 5 year-olds included their weight (with precision level of 100 grams) and height (with a precision of 0.5 cm). 2. The edema of kwashiorkor was evaluated using the following criteria: a depression created by pressing a finger against the anterior base of both legs must remain after the finger has been removed. 3. The child's gender and length or residence in the village was also measured. D. PERSONNEL: Four WV Health Mozambican Nurses spent 20 days in the Zambezia Valley: two of these were well versed in the techniques of height/weight calculations and measurements, while the other two received intensive training with a brief practical prior to beginning. In each vil1age, Ministry of Health nurses or health aids assisted. The teams were led by a medical doctor from Nigeria, Clifford Wokveha, with two years experience in medical work in Mozambique. Six community chosen literate volunteers from each village were briefly trained on how to implement the questionnaire and record answers. Data was analyzed by Veronique Kollhoff, R.N. and Theresa Andrews, M.D. E. DATA ANALYSIS: A formal analysis of all heights and weights was conducted using the NCHS standard height/weight charts. Weight was compared with length for children with heights 55-70 cm; weight was compared with stature ir children with heights from 71-115 cm as children of this height were measured in the upright (standing~ position. Weight-for-height was analyzed according to the following criteria: 1. Percentile: Children whose weights fell below the 3n1 percentile of the mean weight for height were classified as acutely malnourished. Though this is not the currently recommended classification of WHO, it is the classification used by the Mozambican MOH. The percentile analysis was conducted so that the information gathered would be useful to the MOH, as they will compare malnutrition rates in these sites with other districts in other parts of the country. 2. Deviation from the Median: Childrens' weights were classified according to the number of deviations from the median weight for height. This classification is currently recommended by WHO. F. DEFINITIONS OF ~1UfRITION: 1. Global Acute Malnutrition (MOH): is defined by the percentage of children with height for weight below the 3n1 percentile of the mean; children with kwashiorkor are added to this percentage, regardless of height for weight. 2. Global Acute Malnutrition (WHO>: is defined by the percentage of children whose weights fall below 2 standard deviations from the median weight-for-height; again, children with kwashiorkor are included in this category. 3. Severe Acute Malnutrition (WHO); is defined by the percentage of children whose weights fall below 3 standard deviations from the median weight-for-height; children with kwashiorkor are induded. RESULTS: A. DISTRIBUTION OF CHILDREN SURVEYED ACCORDING TO GENDER: VILLAGE NUMBER OF NUMBER OF NUMBER OF SEX CHILDREN SURVEYED MALE CHILDREN FEMALE CHILDREN RATIO CAIA 539 264 279 0.95 MURRA CA 568 289 275 1.05 SENA 495 246 249 0.99 CHEMBA 479 246 233 1.06 INHANGOMA 496 235 261 0.90 MUTARARA 448 229 219 1.05 0£ GWBAL ACUTE !'tfAL.NUTRITION (?l.10H) - EDEMA/ _:::;,. )nl GLOBAL ACUTE VILLAGES KW ASHIORKOR PERCENTILE ~!ALNUfRITION (r\10H) NO. % NO. % % PRECI- RANGE - SION CAIA 2 0.4% 98 18.2% 18.6% + 3.3% 15.3% - 21.9% MURRA CA 2 0.4% 75 13.2% 13.6% + 2.8% 10.8% - 16.4% SENA 15 3.0% 104 21.0% 24.0% + 3.8% 20.2% - 27.8% CHEMBA 4 0.8%~ 114 23.8% 24.6% + 3.9% 20. 7% - 28.5% INHANGOMA 1 0.2% 82 16.5% 16.7% + 3.3% 13.4% - 20.0% MUTARARA 0 0% 108 24.1 % 24.1% + 4.0% 20.1 % - 28.1 % GLOBAL ACUTE -MALNOTRITlON (MOH,) IN TETE I SOFALA SIX VILLAGES • JN ORDER OF DSCJtBASmG SEV.ERnT MJCr 1993 - WORLD VJ:sION EMERGEN'CT BEAVfH "GLOBAL ACUTE MALNU"llUTJON ·MOO (•••-•• •RANGE") CHEMBA MUTAR:\RA SENA CAIA INHANO. MURRACA Globtl kma Melnutriffoo (MOH): < OC - 3ni P""'t"rl'il• d DIM ~ h hMghl: ~ Rar.ge: p1w1 I lr.llznul !b.918NI d ~ C. RATE OF GLOBAL ACUTE MALNUTRITION.(WHO) EDEMA/ < 2 STANDARD GLOBAL ACUTE VILLAGES KWASHIORKOR DEVIATIONS MALNlITRITION (WHO) NO. % NO. % % PRECI- RANGE SION CAIA 2 0.4% 64 11.9% 12.3% + 2.8% 9.5% - 15.1% MURRA<;A 2 0.4% 54 9.5% 9.9% + 2.5% 7.4% - 12.4% SENA 15 3.0% 78 15.8% 18.8% + 3.4% 15.4% - 22.2% CHEMBA 4 0.8% 82 17.1 % 17.9% + 3.4% 14.5% - 21.3% INHANGOMA 1 0.2% 62 12.5% 12.7% + 2.9% 9.8% - 15.6% MUTARARA 0 0% 86 19.2% 19.2% + 3.7~ 15.5% - 22.9% D. RA TE OF SEVERE ACUTE l\1ALNUTRITION (\\'HO) EDEMA/ < 3 STANDARD GLOBAL SEVERE KW ASHIORKOR DEVIATIONS l\tf AT l'\JTT'T'l>JTr{)N c fl1TU0\ ~- '. .- . ·- ·~. .- "" - ;:? ...... NO. % NO. % % PRECI- RANGE SION CAIA 2 0.4% 16 3.0% 3.4% + 1.5% 1.9% - 4.9% MURRA<:;A 2 0.4% 13 2.3% 2.7% + 1.3% 1.4% - 4.0% SENA 15 3.0% 24 4.9% 7.9% + 2.4% S.5% - 10.3% CHEMBA 4 0.8% 18 3.8% 4.6% + 1.9% 2.7% - 6.5% INHANGOMA 1 0.2% 7 1.4% 1.6% + 1.1 % 0.5% - 2.7% MUTARARA 0 0% 27 6.0% 6.0% + 2.2% 3.8% - 8.2% SEVERE ACUTE MALNUTRITION IN TETE I SOFALA PROVINCES SIX VILLAGES - IN ORDER OF DECREASING SEVERJTY MAY 1993 - WORLD VISION EMERGENCY' HEAIJl'H % SEVERE ACUTE MALNUTRITION -WHO <----·- -RANGE., 12% 10% 8% 6% 496 2% 0% SENA MUTARARA CHEMB.A CAIA MURRA.CA INHANG. SEVERE ACUTE MALNUTR. (WHO): GREATER THAN 3 STANDARD DEVlATIONS BELOW MEDIAN WTMr OR KWASHIO.KOR •RANGE: PLUS I MINUS THE LEVEL Of' PRECISION COMPARISON OF l\IA Y'93 SlTRVEYS WITH SURVEYS FROM TIIE PREVIOUS YEAR ACUTE MALNUTRITION LEVELS (MOH) While global acute COMPARISON OF GLOBAL 6 VILLAGES OF TETE & SOFALA PROVINCES - APRIL 1992 - MAY 1993 malnutrition rates have improved for most of the % GLOBAL ACUTE MALNUTRITION (MOH) vil-lages, the rates in Chemba and Mutarara have increased. Mutarara re ceives the highest percen tage of refugees from Malawi of the six sites. Although Malawi refugees have previously arrived in Mozambique in well nour ished condition, the rate of malnutrition among Malawi refugees has increased as CHE:MBA MUTARARA. SENA CAIA INP..ANG. MURRA.CA they stay in the country without seeds or food I•APRIL'92 0 NOV'92 ~ MAY'93 I supply. WORLD VISION EMERGENCY HEAill'H Globel Acute Mslnutrifion (MOH); < or - 3rd percentile ol mean ....reight Cor height COMPARISON OF SEVERE MALNUTRITION LEVELS 6 VlLLAGES OF TETE & SOFALA PROVINCES - APRIL 1992 - MM 1993 Though most villages " SEVERE ACU'1'E MALNUTRITION experienced reductions ir 16% global malnutrition 14% (above), severe 129' malnutrition increased in 10% all villages except Sena .99'...... Inhangoma. 8% 69' ..... ··~:6%··· ...... 6% .••.... 3.4.% ...... "2.7%· .. . This may reflect a 4% widening distinction 2% between villagers who 0% _k'.ll~~z:m...... arrived prior to harvest SENA MUTARARA CHEMBA. CAIA MURRA.CA INHANG. (and now have some foe stores) and those who I• APRIL'92 D NOV'92 ~ MAY'93 I arrived afterwards. WORLD VISlON EMERGENCY HEALTH SEVERE ACUTE MALNU'I'Rl'J'lON: MORE THAN S STANDARD DEVIATlONS BEWW MEDIAN WT/HT OR J:WASlDOllOR ... DISCUSS IO Ni CONCLUSIONS It is clear that in spite of peace, rains and a harvest of some cereals in March/ April, malnutrition continues to be a problem in the Za.mbezi Valley area. Malnutrition rates have improved only very slightly at a time when (seasonally speaking) they should be at their lowest. It is likely that over the coming months, malnutrition rates will increase: (1) This year's harvest was not enough to provide adequate food stores until the next cereal harvest (2) A plague of locusts has destroyed many of the vegetable crops that could have been harvested in June/July (3) Refugees continue to pour in or pass through the WV airlift sites as they return to their homelands. To avoid famine, food distributions should continue to accompany seed and tool distributions until the next cereal harvest in March 1994. As refugee influx is likely to continue in the coming months, it is possible that food and seed distributions will not be able to keep up with the increasing populations. For this reason, the MOH, WV and other NGO's should be prepared to continue nutritional surveillance and intervention in terms of intensive therapeutic feeding and supplementary feeding throughout the coming year.