Nutritional Anthropometric and Retrospective Mortality Survey Children Aged 6 to 59 Months Kamber-Shahdadkot and Dadu Districts

Nutritional Anthropometric and Retrospective Mortality Survey

Children aged 6 to 59 months

Kamber-Shahdadkot and Dadu Districts

Sindh Province

Pakistan

May – June 2008

Funded by:

Table of contents ACKNOWLEDGMENTS ...... 3 LIST OF ACRONYMS ...... 4 EXECUTIVE SUMMARY ...... 5 1. INTRODUCTION ...... 11 2. OBJECTIVES OF THE SURVEY ...... 16 3. METHODOLOGY ...... 16

3.1. POPULATION DATA ...... 17 3.2. SAMPLE SIZE...... 17 3.3. SAMPLE SELECTION ...... 18 3.4. DATA COLLECTION AND MEASUREMENT TECHNIQUES ...... 19 3.4.1. Anthropometric data ...... 19 3.4.2. Household and Mortality Data ...... 19 3.5. INDICATORS AND FORMULAS USED ...... 20 3.5.1. Acute Malnutrition...... 20 3.5.2. Mortality ...... 20 3.6. FIELD WORK ...... 21 3.7. DATA ANALYSIS ...... 21 4. RESULTS ...... 22

4.1. KAMBER-SHAHDADKOT SURVEY ...... 22 4.1.1. Age and sex distribution ...... 22 4.1.2. Malnutrition rates ...... 22 4.1.3. Measles vaccination ...... 25 4.1.4. Feeding programs ...... 25 4.1.5. Mortality ...... 25 4.2. DADU SURVEY ...... 26 4.2.1. Age and sex distribution ...... 26 4.2.2. Malnutrition rates ...... 26 4.2.3. Measles vaccination ...... 29 4.2.4. Feeding programs ...... 29 4.2.5. Mortality ...... 30 5. DISCUSSION ...... 30 6. RECOMMENDATIONS ...... 32 APPENDIXES ...... 33 APPENDIX 1: MAP OF THE FLOOD AFFECTED AREAS SURVEYED ...... 33 APPENDIX 2: CLUSTER SELECTED, KAMBER-SHAHDADKOT SURVEY ...... 34 APPENDIX 3: CLUSTER SELECTION DADU SURVEY ...... 35 APPENDIX 4: ANTHROPOMETRIC QUESTIONNAIRE ...... 36 APPENDIX 5: MORTALITY QUESTIONNAIRE ...... 37 APPENDIX 6: LOCAL EVENT CALENDAR ...... 38 APPENDIX 7: THE CONCEPTUAL FRAMEWORK OF MALNUTRITION ...... 39

Acknowledgments

ACF-USA (Action Against Hunger) thanks Health executive district officers (EDO) of Dadu and Kamber- Shahdadkot, as well as the nazims of the two districts surveyed, for their assistance and collaboration.

ACF-USA would like to thank all nutrition surveyors for their enthusiasm and good will to do a fantastic job. Special thanks to Waseem Abbas Isran and Sajjad Ahmed Khand, the two nutrition survey assistants for their support and good working spirit.

ACF-USA is also extremely grateful to the community members for their cooperation and hospitality.

List of acronyms

ACF Action Contre la Faim ARI Acute respiratory infection BCG Bacillus Calmette-Guérin, a vaccine for tuberculosis BHC Basic Health Centers CI Confidence interval CMR Crude mortality rate DHQ District Head Quarter Hospitals DTP Diphtheria, Tetanus, and Pertussis EDO Executive district office ENA Emergency Nutrition Assessment FAO United Nations Food and Agricultural Organization FPB Flood Protection Bund GAM Global acute malnutrition GD Government Dispensaries GDP Gross Domestic Product IRC Indus Resource Center Kcal Kilocalories Km Kilometer LGO Local government Ordinance JADE Japan Agency for Development and Emergency MHC Mother and Child Health MUAC Mid upper arm circumference NCHS National Centre of Health Statistics NDS National Development Society NFI Non-Food Items NGO Non governmental organization OTP Outpatient Therapeutic Program PKR Pakistani rupees PPP Purchasing Power Parity PRC Pakistan Red Crescent RHC Rural Health Centers SAM Severe acute malnutrition SC Stabilization centre SD Standard deviation SFP Supplementary Feeding Program SMART Standardized Monitoring and Assessment of Relief and Transitions SRC Spanish Red Cross TFC Therapeutic feeding centers THQ Taluka Head Quarter Hospitals U5 Under five U5MR Under-5 mortality rate UC Union Council UNICEF United Nations children’s Fund USA United States of America WHO United Nations World Health Organization

Executive summary

Sindh province is one of the four provinces of Pakistan, located on the Southeastern corner of the country. There are 23 districts in Sindh province, including Dadu and Kamber-Shahdadkot. The total population of the province is estimated between 50 to 54 million inhabitants (1.1 million in Kamber- Shahdadkot and 1.7 million in Dadu)1.

In July 2007, heavy monsoon rains coupled with the landfall of Cyclone Yemyin on 26th June led to extensive flooding in Northern Sindh. Although the cyclone-associated rainfalls affected first the Balochistan Province, they drained then through the Indus River, and ultimately the Arabian Sea. Because the floods were the result of breaches on the Flood protected Bond (FPB) rather than direct flows, water levels rose relatively slowly in the two districts, and the local population had time to escape from their villages and seek shelter on higher ground (frequently along elevated roadways) or in nearby towns. In Kamber-Shahdadkot, 12 union councils (UC) were affected in 5 talukas; in Dadu, 15 union councils were affected in 3 talukas, displacing more than 100,0002. In June 2008, most of the displaced people have returned to their village of origin. Although some households migrated permanently seeking better living conditions and/or job opportunities.

Humanitarian assistance started one week after the floods by the Government, international and local NGOs: food and tent distributions, water and sanitation programs and cash distributions were implemented. During the month of August, flood waters started to recede, allowing some of the displaced people to return home. Most of the aid stopped by September/October, at the end of the emergency phase. However, the negative impact of the flood was not over: households continued to face difficulties as their principal livelihood source – agriculture production– was destroyed during the floods.

In May 2008, the population in rural Kamber-Shahdadkot and Dadu are still living in precarious conditions. Health facilities are scare, far away from the villages, expensive for the target population and lacking resources. Many diseases like diarrhea, hepatitis, tuberculosis and skin diseases are reported by partner NGOs and EDO health.

Besides this, poor hygiene situation and no access to safe water are common problems faced by the villagers. This situation does not seem to be related to the floods exclusively, as similar reports are produced from areas that were spared, but the recent events aggravated their impact.

Landownership is very uneven in the area: most of the land is owned by a small number of important landlords. A food security assessment conducted by ACF-USA in September 2007 found that 89% of interviewed households ranked agriculture as their most important source of income. The rice crop was almost completely destroyed by the floods, which will prolong the annual “hunger gap” 3 until the first post- floods harvest.

Supplementary and therapeutic feeding programs have been implemented in Kamber-Shahdadkot (September 07 to mid January 08) and Dadu (mid August 07 to end December 08) districts, targeting moderate and severely malnourished children and pregnant and lactating mothers. In Dadu district, the program had restarted and during the writing of this report the program has restarted in Kamber- Shahdadkot as well.

ACF-USA conducted a nutrition survey in both districts in October (Kamber-Shahdadkot) and November 2007 (Dadu). The results can be seen in table 1.

1The population reported during the census of 1998. 2 Approximately 10% of the total population of Kamber-Shahdadkot and 20% of the total population of Dadu 3 “The harvest of rice in November and of wheat in April provides households an increase in food and income for 4-5 months, depending on the year. The hunger gap period happens just before the harvests, when the food and income from the previous harvest has run out. Of these two periods, the one just before the rice harvest (August and September) is generally considered to be the more difficult. in A Food Security Assessment of Flood-Affected Populations in Kamber-Shahdadkot and Dadu Districts, Sindh Province, Pakistan, ACF USA, 2007

Table 1: Results summary, Kamber-Shahdadkot and Dadu surveys, Sindh province, October-November 2007

Index Indicator Kamber-Shahdadkot Dadu Global Acute Malnutrition 16.7%4 15.6% W/H< -2 z and/or oedema (12.9% - 20.5%) (12.8% - 18.3%) Z- scores Severe Acute Malnutrition 2.2% 0.9% W/H < -3 z and/or oedema (1.2% - 3.2%) (0.1% - 1.7%) NCHS Global Acute Malnutrition 9.5% 9.1% W/H < 80% and/or oedema (6.9% - 12.2%) (6.9% - 11.4%) % Median Severe Acute Malnutrition 0.4% 0.3% W/H < 70% and/or oedema (0.0% - 0.8%) (0.0% - 0.8%) Global Acute Malnutrition 18.7% 17.8% W/H< -2 z and/or oedema (15.0% - 22.3%) (14.8% - 20.9%) Z-scores Severe Acute Malnutrition 4.1% 3.2% W/H < -3 z and/or oedema (2.6% - 5.6%) (1.9% - 4.5%) WHO Global Acute Malnutrition 6.0% 5.2% W/H < 80% and/or oedema (4.3% - 7.8%) (3.5% - 6.9%) % Median Severe Acute Malnutrition 0.3% 0.3% W/H < 70% and/or oedema (0.0% - 0.6%) (0.0% - 0.8%) Total crude retrospective mortality (last 3 months) 0.37 (0.11-0.63) 0.11 (0.00 – 0.22) /10,000/day 1.27 (0.35-2.19) 0.08 (0.00 – 0.23) Under five crude retrospective mortality /10,000/day By card 2.0% 6.5% Measles immunization According to caretaker5 73.3% 76.1% coverage Not immunized 16.1% 17.4% (children ≥ 9months old) Do not know 8.6% 0.0%

The surveys presented in this report were undertaken 6 months after the previous one, as a follow up of the nutrition situation in the flood affected areas.

Objectives

• To assess the nutritional status of children from 6 to 59 months of age and to estimate the global and severe acute malnutrition rates in Kamber-Shahdadkot and Dadu districts. • To estimate the crude mortality rate and the mortality rate in children less than 5 years of age in Kamber-Shahdadkot and Dadu districts • To estimate the measles vaccination coverage in children from 9 to 59 months. • To make future recommendations concerning possible programs in health or nutrition sector.

Methodology

In these surveys, a multi-stage cluster sampling method based on the Standardized Monitoring and Assessment of Relief and Transition (SMART) methodology was used. Clusters were selected at random – using Emergency Nutrition Assessment (ENA) for SMART - with the probability of being selected proportional to the size of the population.

In Kamber-Shahdadkot, 5 Union Councils (UC) were selected for the survey while in Dadu, 6 UC were selected. They were all part of the previous Food Security assessment, and were amongst the most floods-affected. The list of villages and the number of population from the selected UC were obtained from the Government department, local Government and local NGOs. Villages under less than 100 people were merged with the closest ones. A total of 32 clusters with 22 households and 20 children in each were surveyed to provide representative and valid data. Data were analyzed with ENA for SMART software.

4 Results in bracket are at 95% confidence intervals. 5 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker

Limitation of the survey Age was difficult to determine as the target population was not always aware of the age of their children. Corrections were made after the field work for 59 children in Kamber-Shahdadkot and 42 children in Dadu district to allow a realist representation of the age distribution of the sample. Age is not use as an indicator or nutrition index; therefore these corrections will not affect the calculated prevalence.

Results

• Kamber-Shahdadkot district

In Kamber-Shahdadkot district, a total of 648 children aged 6-59 months were selected in the 703 households surveyed. Of those 648 children, 10 were absent and could not be measured during the survey (all other information could be gathered). 21 were excluded due to incorrect or aberrant data. This leads to 617 children included in the nutritional anthropometric survey (and 627 for other indicators’ analysis). The total sample for the retrospective mortality survey was 5172 individuals. Table 2: Results summary, Kamber-Shahdadkot district, Sindh province, June 2008

Index Indicator Results Global Acute Malnutrition 22.0 % W/H< -2 z and/or oedema (17.5% - 26.6%) Z- scores Severe Acute Malnutrition 1.1 % W/H < -3 z and/or oedema (0.3% - 1.9%) NCHS Global Acute Malnutrition 12.5 % W/H < 80% and/or oedema (9.7% - 15.3%) % Median Severe Acute Malnutrition 0.0 % W/H < 70% and/or oedema (0.0% - 0.2%) Global Acute Malnutrition 22.7 % W/H< -2 z and/or oedema (18.5% - 26.9%) Z-scores Severe Acute Malnutrition 3.7 % W/H < -3 z and/or oedema (2.3% - 5.2% ) WHO Global Acute Malnutrition 6.0 % W/H < 80% and/or oedema (4.0% - 8.0%) % Median Severe Acute Malnutrition 0.0 % W/H < 70% and/or oedema (0.0% - 0.2%) Global Acute Malnutrition 5.7% MUAC<120 mm MUAC Height> 65 cm Severe Acute Malnutrition 0.6% MUAC<110 mm Total crude retrospective mortality (last 3 months) /10,000/day 0.48 (0.18 – 0.78) Under five crude retrospective mortality /10,000/day 1.51 (0.29 – 2.72) By card 11.1 % Measles immunization coverage According to caretaker 56.0% (children ≥ 9months old) Not immunized 32.9 % Do not know 0.0 %

No case of kwashiorkor was found during the survey.

• Dadu district

In Dadu district, a total of 650 children aged 6-59 months were selected in the 704 households surveyed. Of those 650 children, 21 were absent and could not be measured during the survey (all other information could be gathered). One child was abnormal making it impossible to measure height but all other measurements were taken. 4 children were excluded due to incorrect or aberrant data. This leads to 624 children included in the nutritional anthropometric survey (and 646 for other indicators’ analysis).

The total sample for the retrospective mortality survey was 5142 individuals. Table 3: Results summary, Dadu district, Sindh province, June 2008

Index Indicator Results Global Acute Malnutrition 25.4 % W/H< -2 z and/or oedema (21.2% - 29.6%) Z- scores Severe Acute Malnutrition 1.5 % W/H < -3 z and/or oedema (0.6% - 2.3%) NCHS Global Acute Malnutrition 15.3 % W/H < 80% and/or oedema (12.0% - 18.7%) % Median Severe Acute Malnutrition 0.0 % W/H < 70% and/or oedema (0.0% - 0.2%) Global Acute Malnutrition 28.3 % W/H< -2 z and/or oedema (23.6% - 33.0%) Z-scores Severe Acute Malnutrition 5.7 % W/H < -3 z and/or oedema (3.8% - 7.6%) WHO Global Acute Malnutrition 9.3 % W/H < 80% and/or oedema (7.0% - 11.5%) % Median Severe Acute Malnutrition 0.0 % W/H < 70% and/or oedema (0.0% - 0.2%) Global Acute Malnutrition 7.2% MUAC<120 mm MUAC Height> 65 cm Severe Acute Malnutrition 1.1% MUAC<110 mm Total crude retrospective mortality (last 3 months) /10,000/day 0.23 (0.11 – 0.35) Under five crude retrospective mortality /10,000/day 0.58 (0.05 – 1.11) By card 3.0% Measles immunization coverage According to caretaker 44.2% (children ≥ 9months old) Not immunized 52.8% Do not know 0.0%

Discussion

The global acute malnutrition rate as found during this survey can be considered as extremely high being far above the emergency cut off point of 15 %. Remarkable is the absence of a relative high severe acute malnutrition rate to accompany this high global acute malnutrition rate: moderate malnutrition is the most prevalent one. This might indicate that although acute malnutrition rates are measured, the situation is becoming chronic. Long term deprivation can lead to stunting and growth retardation. The difficulties faced to measure age accurately make that there was no possible way to investigate if these high prevalence of moderate malnutrition has had a long impact on the development and growth showing in a low height-for-age z-score. Nevertheless, if this situation continues, a negative impact can be expected. There is a need for treatment and prevention of moderate malnutrition to improve the overall situation for children living in the flood-affected areas. Table 4 : Summary of results for the Kamber-Shadahdkot and Dadu, 2007 and 2008 surveys.

Year Indicator6 Kamber-Shahdadkot Dadu Global Acute Malnutrition 16.7%7 15.6% W/H< -2 z and/or oedema (12.9% - 20.5%) (12.8% - 18.3%) 2007 Severe Acute Malnutrition 2.2% 0.9% W/H < -3 z and/or oedema (1.2% - 3.2%) (0.1% - 1.7%) Global Acute Malnutrition 22.0 % 25.4 % W/H< -2 z and/or oedema (17.5% - 26.6%) (21.2% - 29.6%) 2008 Severe Acute Malnutrition 1.1 % 1.5 % W/H < -3 z and/or oedema (0.3% - 1.9%) (0.6% - 2.3%)

6 Results expressed in Z-scores, NCHS reference 7 Results in bracket are at 95% confidence intervals.

Results can be compared to the results of the survey conducted in November 2007 as the same methodology and target population were used. It can be calculated that: • There is not significant increase in malnutrition rates in Kamber-Shahdadkot between both surveys • There is a significant increase in malnutrition rates in Dadu between both surveys • There is no significant difference in malnutrition rates in both districts for the present set of surveys.

It should be mentioned that the present surveys were conducted after the harvest of wheat, barley, legumes and mustard/oil seed in April. The food availability is better than during other periods of the year, which shows that the situation can further deteriorate.

Public health and hygiene and household food security are two direct causes of acute malnutrition, as mentioned in the Conceptual Framework of Malnutrition (cf. annex 7). They will be discussed below in an attempt to understand the current malnutrition rates

1. Public health and hygiene

Many diseases like diarrhea, hepatitis, tuberculosis and skin diseases are reported by partner NGOs and EDO health (2 to 6 family members were affected by skin disease in a rapid assessment conducted by MuslimAid in Qubo Saeed Khan). The health situation is precarious in the flood affected areas.

After the flooding, emergency medical activities have been implemented by NGOs. But since the people returned to their villages, they fully rely on health facilities provided by the government of Sindh province, that are understaffed and where drugs and equipment are not available. Another limitation of these centers is their accessibility: as transportation costs are high, visiting a doctor is time consuming and expensive.

There is also a problem of awareness and education, as the need to have a medical consultation is not always understood when a family member is sick.

At the health facilities level, the nutritional status of children is not often evaluated, and when it is, it rarely induces a referral to the existing nutritional program. There is a general lack of understanding toward acute malnutrition, its potential impact and causes.

The hygienic situation in many villages can be seen as precarious during the fieldwork of these surveys: • Absence of latrines: feces are disposed of in the house property or in the bush surrounding the village. • Cooking or playground places are not protected against contamination by animals, that are frequently living in the houses • Lack of education on basic hygiene practices (washing hands, clean cooking environment, hygienic storage of food, etc.) • Lack of access to clean drinkable water • Lack of proper water storage All these elements increase the potential of risks of water borne diseases like diarrhea, cholera, hepatitis and skin diseases.

Diarrhea has a major impact on the nutritional status of the patient. When a child has diarrhea, absorption and intake of food are reduced while there is a higher need of energy. Besides this, malnourished children are more vulnerable towards diarrhea resulting in a vicious circle (diarrhea leads to malnutrition and malnutrition worsen diarrhea) that needs to be broken. Sick children are also more vulnerable for other diseases. Besides this, sick children need more energy and thus more food to recover.

There is a clear need for an immediate improvement of the health situation of the target population. Targeting nutrition alone without making an effort on the general health situation might be insufficient as diseases and nutrition are so clearly linked.

2. Food security

Agriculture is the main source of income for villagers in Kamber-Shahdadkot and Dadu districts.

Due to the flooding, at least one season of rice crops was destroyed. There has been no assessment afterwards to assess the level of planting and harvesting but in September only 32 % of the households expected to plant in the upcoming season while other had to wait till November 2008 for the harvest of rice. Moreover, the interviewed humanitarian partners mentioned that due to the flooding the irrigation system was destroyed resulting in water shortage in certain areas and thus a lack of water to plant rice. The reduction of harvest induces that families need to rely more on the market than usually to cover their needs.

But in the mean time, the prices of food have increased by 25.5% in average, making it more difficult for families to buy food on the market. Moreover, the flooding has affected the families’ capital, mainly the livestock that was killed, or got sick or was sold below the normal market price after the floods.

This combination of reduced availability and reduced purchasing power leads to high vulnerability towards food shortage and thus malnutrition.

There is a clear need for more independent information on what can be expected in terms of food availability and accessibility in the coming months, and the high malnutrition rates put even more emphasis on the precarious food security situation in the two districts.

Recommendations

The results presented in this report show that the nutrition situation of flood-affected population is of concern. The following recommendations are made for donors, agencies, and organizations interested to intervene or already present in the recovery phase of the flood crisis:

• To continue the treatment of moderately malnourished children, and extend the coverage of the supplementary feeding programs to target all malnourished children in the flood affected areas. • To implement as part of the supplementary feeding program a promotion campaign covering malnutrition and all its underlying causes to have a long term impact on the nutritional situation. • To implement screening activities with a focus on most vulnerable areas with mobile screeners and develop screening/ nutrition surveillance at health structures level. • To improve child health by assessing the health situation and facilities present in the districts and develop a long term strategy. • To strengthen knowledge of governmental institutes, local and international humanitarian actors present in Kamber-Shahdadkot and Dadu district on malnutrition, the underlying causes and possible activities focusing on prevention. A special focus should be given to children (6 – 59 months) and pregnant and lactating women. • Reassess the food security situation, in order to propose actions with a focus on long term improvement and flood preparedness • To improve access to clean water, hygiene situation and hygiene awareness of the population • To improve coordination of all different actors working in the area, to monitor the nutrition situation and its underlying causes.

1. Introduction

The Islamic Republic of Pakistan is a South Asian country, marking the region where South Asia converges with Central Asia and the Middle East. Pakistan has a 1,046 km coastline along the Arabian Sea in the south, and is bordered by Afghanistan and Iran in the west, India in the east and China in the far northeast. It is a federation with four provinces, a capital territory and several federally administered tribal areas. Sindh province is one of the four provinces of Pakistan, located on the South eastern corner of the country. The capital is Karachi, located on the coastline.

Figure 1: Map of Pakistan8 and main statistical characteristics9 Statistics:

Total population: 160,943,000

% of population urbanized (2006): 35%

Gross national income per capita (PPP international $): 770

Life expectancy at birth (years): 65

Probability of dying under five (per 1 000 live births): 97

% of infants with low birth weight (1999-2006): 19%

Total expenditure on health as % of GDP (1995-2005): 1%

Percentage people living below 1 $ a day: 17%

Total adult literacy (2000-2005): 50%

Sindh province is the third largest Province of Pakistan, stretching about 579 km from north to south, and 442 km (extreme) or 281 km (average) from east to west, with a total acreage of 140,915 km. The province is subdivided into 23 districts, further subdivided into numerous talukas and local governments.

The total population of the Province during the 1998 census was 30,439,893 and with a growth rate

8 Map from Mideastweb found at http://www.mideastweb.org/pakistan.htm 9 Statistics from UNICEF statistics Pakistan found at www.unicef.org/infobycountry/pakistan_pakistan_statistics

11 between 2.6 % and 2.810 can be estimated between 50 to 54 million inhabitants. According to Pakistan Demographics 2003, 48.75 % of the population lives in urban context.

Sindh's population is predominantly Muslim, but also home to nearly all of Pakistan's Hindus, numbering roughly 1.8 million. Smaller groups of Christians, Parsis or Zoroastrians, Ahmadis, and a tiny Jewish community can also be found in the province.

• Floods and massive population displacement

Flooding is a chronic issue in the Indus Valley. Minor flooding in the irrigated regions of Sindh occurs on an annual basis during the summer monsoon rains in July and August. Major floods induced by unusually heavy monsoon patterns occur roughly once a decade. The current system of barrages, bunds, canals, and drains was developed in the 1930’s under the British colonial administration, which expanded on a network built in the 18th century. People complain about the insufficient maintenance of these structures from the Government. The main problem is that this system is not sufficient to control important floods, and their devastating effects on areas around the Indus River.

In 2007, heavy monsoon rains coupled with the landfall of Cyclone Yemyin on 26th June led to extensive flooding in Northern Sindh. Although the cyclone-associated rainfalls affected first Balochistan Province, they drained then through the Indus River, and ultimately the Arabian Sea. Kamber-Shahdadkot and Dadu Districts were the most acutely affected. Because the floods were the result of breaches rather than direct flows, water levels rose relatively slowly in the two districts, and the local population had time to escape from their villages and seek shelter on higher ground (frequently along elevated roadways) or in nearby towns. More than 100,000 people were displaced by the floods in Kamber-Shahdadkot and Dadu or stranded in villages built on the tops of hills and completely surrounded by water. It was reported that approximately 10% of the total population11 of Kamber-Shahdadkot has been affected comprising 25% of the total district area12 and 20%13 of the total population of Dadu District14. In June 2008, most of the displaced people have returned to their village of origin. Although some households migrated permanently seeking better living conditions and/or job opportunities.

The last flooding destroyed parts of the drainage system present to protect against flooding. Although an effort is made by the government to rebuild the drainage system, it might be insufficient to prevent from a new flooding when the monsoon season starts in July 2008.

• Health

Public and private health care systems are operating in the region. The public health care system operates on a four-tier system: Government Dispensaries (GD), Basic Health Centers (BHC), Rural Health Centers (RHC’s) and Mother and Child Health (MHC), Taluka Head Quarter (THQ) Hospitals and District Head Quarter (DHQ) Hospitals. Within the public health system, there is a charge (2 to 5 Pakistani Roepies15) for a consultation. Besides this, villagers are living sometimes far away from those health care facilities and transportation costs are high especially for the most vulnerable households. Extra expenditures including buying medicines increase the price of a visit to the doctor. Moreover, there is a lack of resources available to run those health facilities properly. There are also a number of ‘health houses’ operated by lady health workers, providing primary health care, family planning, growth monitoring, immunizations and antenatal care.

10 As reported by the federal bureau of statistics 11 The total population of Kamber-Shahdadkot District is 1.2 million persons, according to Pakistan Demographics 2003. 12 Source: WHO Pakistan floods Situation report 7 July. And Rapid Assessment Report Floods Pakistan ACF. 13 Source: Revenue Department Dadu 14 The total population of Dadu District is 1.7 million persons, Population as per census of 1998. 15 1 USD = 60 PKR

Table 5: List of Public Health facilities in Kamber-Shahdadkot and Dadu districts, before the floods

Health Facilities Kamber-Shahdadkot Dadu District Head Quarter Hospitals 0 1 Taluka Head Quarter Hospitals 4 3 Rural Health Centers 4 3 Basic Health Centers 27 44 Government Dispensaries 25 2416 Mother and Child Health centers 2 3 Total doctors 95 100 Total population 1.2 million 1.7 million

The facilities have been heavily affected by the floods, and some of them are still not completely functional, almost a year later. Although this is difficult to assess as all problems faced in the area are associated by the target population and humanitarian partners to the flooding while the health facilities might have been precarious before the flooding as well.

After the flooding many NGOs like Kachho Foundation (local NGO), JADE, Pirbhat women’s development society and MuslimAid established medical camps, visited the flood affected areas providing free heath care and medicines to the population. Although most activities have stopped after the emergency phase, MuslimAid has implemented a three day medical campaign due to the high prevalence of skin diseases and other waterborne diseases, and plans to implement more in the future. The main difficulty faced is to cover the whole area as villages are scattered, especially in Kamber-Shahdadkot compared to Dadu district where the population is gathered in fewer and bigger villages.

Increasing cases of acute respiratory infections (ARI), diarrhea, malaria, skin diseases, eye infections, heat stroke, snake bites and viral infection have been reported during the floods. During the survey many cases of skin diseases, diarrhea, tuberculosis and hepatitis were reported by partner NGOs and the EDO health Kamber. There are also at this moment five cases reported of polio in Sindh province (source, the polio UNICEF representative of the province).

• Immunization coverage

In Dadu an immunization campaign (BCG, DTP, typhoid, Hepatitis A, Polio, measles and vitamin A) was performed in the affected area after the floods. In Kamber-Shahdadkot an immunization campaign (BCG, tetanus, diphtheria, typhoid, Hepatitis B, Polio, measles and vitamin A) took place during the month of July 0717. Since then regular campaigns were organized.

• Food security

The Sindh Province is a major centre of economic activity in Pakistan and has a highly diversified economy, ranging from heavy industry and finance centered in and around Karachi, to a substantial agricultural base along the Indus. The main crops are cotton, rice, wheat, sugar cane, bananas, and mangoes. Agriculture is clearly the most important source of income in the rural areas of Kamber- Shahdadkot and Dadu districts. Landownership is very uneven in the area: most of the land is owned by a small number of important landlords. There are two main agricultural seasons each year: the kharif season, from June to November, is timed around the monsoon rains, which fall from mid-June to mid-

16 In Dadu District, there are Government Dispensaries and Experimental Dispensaries. Experimental Dispensaries are health centres that MoH integrated from the local government in the Public Health system after 2001 (LGO 2001) when the Health System was transferred to the Districts. 17 EDO’s of Health of both districts. Dadu coverage measles campaign: 103% (590587 total vaccinated/572934 total target). Kamber-Shahdadkot: 64085 children vaccinated.

August, and includes the cultivation of water-intensive crops like rice; and the rabi season, from October to April, during which are grown crops that require less water (wheat, barley, legumes, mustard/oil seed, and animal fodder).

The 2007 floods arrived shortly after households had finished transplanting their rice crop from the nursery beds and sowing it in their main fields. Almost all the rice crop in flood-affected areas was destroyed. As a result of the loss of the rice crop, the annual hunger gap18 was expected to continue this year until the first post-flood harvest. Seed and tool distributions were distributed by FAO and implementing partners.

After the flooding, the NGOs Kachho Foundation and Caritas set up livestock camps where animals got vaccinated as prevalence of diseases increased due to stagnated water. Even so, during and after the flooding, many families lost their cattle or were forced to sell it for cash.

According to the ACF food security assessment (September 2007): • 89% of interviewed households ranked agriculture as their most important source of income before the flooding. Only 32% of households expect to plant for the upcoming wheat season, while the remainder will have to wait until next year’s rice harvest in October 2008. ). Yields are expected to be low during the first few seasons after the flood but will slowly return to normal over the course of several years. Landowners and tenants primarily use their harvest for their own household consumption. Sale of crops is done only if the household is in need of cash for things like tea, sugar, or medicines, or if the harvest exceeds the amount needed to cover the household’s food consumption. When there is insufficient own production to cover food needs, extra food is bought on the markets of bigger towns. 70% of interviewed households report that they are consuming less food than a normal year. Daily food intake is estimated at 1350 kcal, or 64% of daily requirements. Flood-affected households are currently relying on three main coping strategies: casual labour, the sale of livestock, and the taking of credit. These coping strategies are used in a normal year to bridge the “hunger gap” period but are unsustainable for periods of longer than six months. The main needs identified by interviewed households include food, shelter, household items, and seeds/fertilizer. With limited cash available, households are having to choose between competing daily expenses and are unable to save up for the larger investments that are needed for them to fully recover.

9 months later it is difficult to assess in what degree the target population has planted and harvested in April 2008. No assessment has been done and gathering objective information is difficult.

Moreover, Pakistan is affected by the global price increase for food items. The federal bureau of statistics reported in April 2008 that the cost of living including food prices had increased significantly in the last year, more specific the consumer price index of food increased by 25.5%. This factor may lead to an increase of vulnerability of the rural population mainly, and particularly in this case, the flood affected communities.

• Water and Sanitation

In the new system of local government (LGO 2001), provision of water and sanitation facilities is the responsibility of the tehsil administration (sub-district, also called taluka). In small towns and cities, these facilities exist, and are more or less functional. In the rural areas and villages they are hardly found; shallow wells with hand pumps and water from irrigation channels are common sources of water for drinking purposes.

18 “The harvest of rice in November and of wheat in April provides households an increase in food and income for 4-5 months, depending on the year. The hunger gap period, happens just before the harvests, when the food and income from the previous harvest has run out. Of these two periods, the one just before the rice harvest (August and September) is generally considered to be the more difficult”. In A Food Security Assessment of Flood-Affected Populations in Kamber-Shahdadkot and Dadu Districts, Sindh Province, Pakistan, ACF USA, 2007

After the flooding, many NGOs (ACF, Premiere Urgence, Pakistani Red Crescent (PCR), Spanish Red Cross (SRC), Oxfam, Mercy corps, MuslimAid, Care international and many others) have been implementing water and sanitation programs. Hundreds of hand pumps were built and thousands of latrines constructed in Kamber-Shahdadkot and Dadu districts, and emergency water trucking was done regularly. But all activities stopped when the emergency phase was finished. There is still a shortage of safe water sources in many villages. One of the many challenges faced is the fact that due to the nature of soil aquifer, topographical features and salinity, the underground water is mostly brackish, except for a narrow strip along irrigation channels and canals.

Beside safe water sources, sanitation facilities are not always present either. People use open spaces or backyards. During the field work, the hygiene seen in the villages could be described as precarious. Animals are living within the house infrastructure and feces could be found in the same area where the children were playing, mothers were cooking etc. Children and adults can be seen as dirty and soap is rarely available and used.

Open defecation and unsafe water have a major impact on the health situation due to contamination and risk of water borne diseases.

• Care practices

No information is available on care practices in the Sindh province. UNICEF reports that in Pakistan only 16 % of the children below six months are exclusively breastfed. 31% of the children 6 – 9 months are breastfed with complementary food and 56 % are still breastfed at 20 – 23 months.

• Nutrition

ACF-USA conducted a nutrition survey in both districts in October (Kamber-Shahdadkot) and November 2007 (Dadu). The results can be seen in table 6.

Table 6: Results summary, Kamber-Shahdadkot and Dadu surveys, Sindh province, October-November 2007

Index Indicator Kamber-Shahdadkot Dadu Global Acute Malnutrition 16.7% 15.6% W/H< -2 z and/or oedema (12.9% - 20.5%) (12.8% - 18.3%) Z- scores Severe Acute Malnutrition 2.2% 0.9% W/H < -3 z and/or oedema (1.2% - 3.2%) (0.1% - 1.7%) NCHS Global Acute Malnutrition 9.5% 9.1% W/H < 80% and/or oedema (6.9% - 12.2%) (6.9% - 11.4%) % Median Severe Acute Malnutrition 0.4% 0.3% W/H < 70% and/or oedema (0.0% - 0.8%) (0.0% - 0.8%) Global Acute Malnutrition 18.7% 17.8% W/H< -2 z and/or oedema (15.0% - 22.3%) (14.8% - 20.9%) Z-scores Severe Acute Malnutrition 4.1% 3.2% W/H < -3 z and/or oedema (2.6% - 5.6%) (1.9% - 4.5%) WHO Global Acute Malnutrition 6.0% 5.2% W/H < 80% and/or oedema (4.3% - 7.8%) (3.5% - 6.9%) % Median Severe Acute Malnutrition 0.3% 0.3% W/H < 70% and/or oedema (0.0% - 0.6%) (0.0% - 0.8%) Total crude retrospective mortality (last 3 months) /10,000/day 0.37 (0.11-0.63) 0.11 (0.00 – 0.22) Under five crude retrospective mortality /10,000/day 1.27 (0.35-2.19) 0.08 (0.00 – 0.23) By card 2.0% 6.5% Measles immunization According to caretaker 73.3% 76.1% coverage Not immunized 16.1% 17.4% (children ≥ 9months old) Do not know 8.6% 0.0%

The prevalence of Global Acute Malnutrition (GAM) rates found in both surveys revealed an alarm situation, while the Severe Acute Malnutrition rates are very low. Therefore, the malnutrition found in the flood affected areas of Kamber-Shahdadkot and Dadu can be described as of a high magnitude, as it affects a high percentage of the under-five, but of low intensity, as malnutrition cases are almost exclusively moderate. There was no baseline regarding the nutrition situation in the target areas, which could inform on the impact of the floods and their consequences on those rates. It is nevertheless very probable that the later led to a deterioration of the nutritional status of the affected population: the agricultural production -their principal livelihood source- was ruined during the floods, inducing an unusually long hunger gap. As a result, families decreased their food consumption. Other sources of income, like casual labor and selling livestock, have not been enough to sustain food security19.

In Dadu, a nutritional program conducted by a local NGO HOPE with the assistance of UNICEF, was initiated after the floods. The program targeted children 6-59 months and pregnant and lactating women with several components: • Detection of the cases, through screening by community or self-referral. • Supplementary feeding Program (SFP) for the cases of moderate acute malnutrition • Outpatient Therapeutic Program (OTP) for the cases of severe malnutrition with no medical complications • Inpatient treatment in an inpatient Stabilization Centre (SC) in the civil hospital of Dadu district for the cases of severe malnutrition presenting medical complications The program was implemented till December 2007 but has reopened recently.

In Kamber-Shahdadkot, another local NGO National Development Society (NDS) implemented a nutritional program after the flooding with the assistance of ActionAid and UNICEF. They targeted 6 - 59 months old children and pregnant and lactating women with the following activities: • SFP for the cases of moderate acute malnutrition • OTP Program for the cases of severe malnutrition with no medical complications • A stabilization centre in the hospital of Shahdadkot for the cases of severe malnutrition presenting medical complications • Community mobilization on importance of nutrition for children, and pregnant and lactating women The program has closed down mid January but reopened the 7th of July 2008.

The surveys presented in this report were undertaken 6 months after the previous one, as a follow up of the nutrition situation in the flood affected areas.

2. Objectives of the survey • To assess the nutritional status of children from 6 to 59 months of age and to estimate the global and severe acute malnutrition rates in Kamber-Shahdadkot and Dadu districts. • To estimate the crude mortality rate and the mortality rate in children less than 5 years of age in Kamber-Shahdadkot and Dadu districts • To estimate the measles vaccination coverage in children from 9 to 59 months. • To make future recommendations concerning possible programs in health or nutrition sector

3. Methodology These assessments targeted populations that were the most affected by the floods, and were benefitting as such humanitarian programs at the end of 2007, in both Kamber-Shahdadkot and Dadu Districts, which represents around 200.000 people. To ensure the validity of the results, after analysis of both districts, it was decided to conduct 2 nutrition surveys (one in each district), to ensure the principle of homogeneity in each of the areas surveyed. For both surveys, a cluster sampling was chosen. The SMART protocol was applied in the training, planning, collection and analysis of both anthropometric and mortality data.

19 A Food Security Assessment of Flood-Affected Populations in Kamber-Shahdadkot and Dadu Districts, Sindh Province, Pakistan, ACF USA, 2007

3.1. Population Data

In Pakistan, provinces are subdivided into districts, subdivided into numerous talukas which are further divided into Union Councils (UC). A UC consists in several villages.

In Kamber-Shahdadkot, 5 UC were selected for the survey while in Dadu, 6 UC were selected. They were all part of the Food Security assessment, and were amongst the most floods-affected. The same UC were surveyed in the nutrition survey 6 months ago making comparison possible.

The list of villages and the number of population from the selected UC were obtained from the Government department, local Government and local NGOs. Villages under less than 100 people were merged with the closest ones. Table 7: Population estimates in selected Talukas and Union Councils

District Taluka Union Council Population Warah Mirpur 12,230 Bago Dero 11,185 Qubo Saeed Khan Hazar Wah 11,346 Kamber- Miro khan Khaber 14,820 Shahdadkot Qamber Ghaibi Dero 49,982 TOTAL 99,563 Children < 5years old (26 %)20 26,560 Khan Jo Goth 12,750 Mehar Fareedabad 17,910 Gozo 28,000 K.N. Shah Chhor Qamber 13,050 Dadu Sawro 9,915 Johi Kamal Khan 9,100 TOTAL 90,725 Children < 5years old (25 %)21 22,681

There has been a population movement since the flood, but as the survey took place almost one year after the flooding, most people are expected to have returned. Therefore, the official population figures were used for the calculation of the sampling size.

3.2. Sample Size

Based on the SMART methodology, 512 children needed to be covered in the nutritional survey in Kamber-Shahdadkot and in Dadu districts to predict an expected estimated prevalence global malnutrition rate of 20 % with a precision of 5 % and a design effect of 2.

The mortality rate is estimated on 0.5 death/10 000/day with a precision of 0.25 and a design effect of 2. 4487 people in Kamber-Shahdadkot and 3899 in Dadu district are needed to be included, with 6.8 in Kamber-Shahdadkot and 7.5 people per household in Dadu district19 leading to 660 households in Kamber-Shahdadkot and 520 in Dadu district.

The calculated sample led to a total of 704 households to be surveyed (one household extra per cluster was added to take absence of households into account). After looking at time needed to go to the field, team expertise and experience and size of the area to discover, 22 households were surveyed a day

20 Results found during the survey of November 2007 21 Results found during the survey of November 2007

17 leading to 32 clusters in total. Taking absence children and incorrect data into account, 4 children per cluster were extra measured leading to a minimum of 20 children per cluster will be included into the anthropometric questionnaire. Although there is a difference in sample size needed between Dadu and Kamber-Shahdadkot, in both areas the same amount of households and children is included to prevent confusion with the nutrition survey teams.

3.3. Sample selection

In these surveys, a multi-stage cluster sampling method was carried out using a standardized questionnaire (appendix 4). Clusters were selected at random, with the probability of being selected proportional to the size of the population in the defined sub zones (appendix 2 and 3) based on the SMART methodology.

The second level of sampling was done directly on the spot. Two methodologies or selecting the households surveyed were used depending on the sample size of the selected village.

Villages with less than 1000 people In small villages, a systematic sampling is used. The nutrition survey teams first counts all houses in the village. Thereafter the first house is chosen using the interval (amount of houses present in the village/22 houses needed) and the random table. If there are insufficient houses present in the village, all houses in this village are surveyed where after the team moves to the nearest village. If this village has more than 1000 citizens, the EPI method is used: the nutrition survey team counts the houses again, and calculates another interval to complete the cluster.

Villages with more than 1000 people In large villages, the nutrition survey teams use the EPI method. In the centre of each cluster, the survey team choose a direction by using the “spinning pencil method”, whereby a pen is thrown into the air to decide the way of direction. When the border was reached, the pen was thrown again until it pointed into the body of the village. The team walked in the direction indicated, to the edge of the village counting each house on the way. The first house was selected by using a random table. The second house was taken by proximity, always choosing the houses on the right hand side when leaving the houses, and so on.

A household was considered all people eating from the some cooking pot as this is considered one household in the Pakistani culture. If several households were to be found in the same compound, all households were counted and the one to be visited was chosen randomly.

In every chosen household, all its children aged from 6 to 59 months (and 65-110cm) were included in the survey. Absent children were followed (i.e. at home, in hospital, TFC…) the same day in the afternoon. Children, who could not be found, were not replaced in the data set but as much data as possible (age, measles vaccination, sex, etc…) was collected. Children who had a physical disability or abnormality were surveyed taken their disability into account when the disability did not have an impact of the weight and/or the weight.

Children present the day of the survey, but who are not living in the household are not included in the survey.

In all households selected the retrospective mortality questionnaire was filled, even if there were no children present in the requested age group.

3.4. Data collection and measurement techniques

3.4.1. Anthropometric data The following was collected for children 6 months of age to 59 months of age (as age was difficult to asses, children between 65 and 110 cm were included in the survey). (See appendix 4 for the questionnaire): Age: The age (in months) of the children is, in the first instance, established by asking the mother for the birth date of the child. If the mother does not know the birth date, the member of the team asks for birth cards or vaccination cards. An event calendar using religious, agricultural and seasonal events is used to determine the age when the mother does not know the exact date of birth (see appendix 6). Sex: Male children are recorded as ‘M’ and female as ‘F’. Weight: Children are weighed in kilograms, to the nearest 0.1kg, using 25kg hanging sprint Salter scale. The scale is hung from a stick held by two measurers, and recalibrated to zero before the child is put into the weighing pants. All children are measured without any clothes. Height: The height of the children is recorded in centimeters, to the nearest 0.1cm, using a 1,30m height board with a movable block. Children less than 85cm are measured lying down and those more than 85cm standing up. All children are measured barefoot. For children measured standing up, the measurers are trained to ensure that the child’s head, shoulder blades, buttocks, calves and heels are touching the board and that they are looking straight ahead. Children measured lying down are placed in the middle of the board with the head touching the fixed end, the knees pressed down and the heels touching the movable base of the board. Mid upper arm circumference (MUAC): MUAC is measured in centimeters, to the nearest 0.1cm, using a MUAC tape. The measurers are trained to locate the mid-point between the shoulder and the tip of the elbow on the left arm with the arm bent at a right angle. The measurement is taken at this mid-point with the arm extended and relaxed. Edema: is measured by applying normal thumb pressure to the anterior surface of both feet for three seconds. If an indentation remains after the pressure is removed, presence of edema is considered positive and a “Y” is entered on the data collection form. If the thumb imprint does not persist, or if the edema is not bilateral, the child is recorded as not having edema and an “N” is entered on the data collection form. The supervisor has to check all positive or questionable cases of edema. Measles immunization status: The mother/caretaker is asked whether the children was vaccinated against measles. If an immunization card is available confirming that a measles vaccination was given, the date is checked and the child recorded as having received the vaccination (1=yes). If the caretaker states that the child was not vaccinated, the child is recorded as not having received the measles vaccine (2=no), If the caretaker states that the child is vaccinated, but they do not have an immunization card, the child is recorded as having a history of measles vaccination (3=history). If the caretaker does not know about the immunization status of the child, then “does not know” is recorded (4). UNIMIX distribution: All mothers were asked if their children received and ate UNIMIX in the last six months. PLUMPYNUT distribution: All mothers were asked if their children received and ate PLUMPYNUT in the last six months.

3.4.2. Household and Mortality Data Each family selected following the random selection (even if there is no child under 5 years old) was asked about the number of people living in the household, how many under fives are present, how many people and under five joined or left the household, how many were born and how many above five and children under 5 have died since Ashoura, an official Islamic holiday in Pakistan (19 January 2008). Another question asked at household level was concerning UNIMIX distribution: all households were asked if the mothers of the household received any UNIMIX in the last six months.

3.5. Indicators and Formulas used

3.5.1. Acute Malnutrition ¾ Weight for Height Index For the children, acute malnutrition rates are estimated from the weight for height (WFH) index values combined with the presence of edema. The WFH indices are compared with the NCHS22 and the 2005 WHO23 references. The indexes are presented in both NCHS and WHO references, but currently, only the NCHS reference is used at field level for identification of malnourished cases. The WHO reference indexes are mentioned for information. WFH indices are expressed in both Z-score and percentage of the median. The expression in Z-score has true statistical meaning, and allows inter-study comparison. The percentage of the median on the other hand is commonly used to identify eligible children for feeding programs.

Guidelines for the results expressed in Z-score: • Severe malnutrition is defined by WFH < -3 SD and/or existing bilateral oedema on the lower limbs of the child. • Moderate malnutrition is defined by WFH < -2 SD and ≥ -3 SD and no oedema. • Global acute malnutrition is defined by WFH < -2 SD and/or existing bilateral oedema.

Guidelines for the results expressed in percentage of median: • Severe malnutrition is defined by WFH < 70 % and/or existing bilateral oedema on the lower limbs • Moderate malnutrition is defined by WFH < 80 % and ≥ 70 % and no oedema. • Global acute malnutrition is defined by WFH <80% and/or existing bilateral oedema ¾ Children’s Mid-Upper Arm Circumference (MUAC) The weight for height index is the most appropriate index to quantify wasting in a population in emergency situations where acute forms of malnutrition are the predominant pattern. However the mid-upper arm circumference (MUAC) is a useful tool for rapid screening of children at a higher risk of mortality. MUAC measurements are presented for all children from 6 to 59 months, divided by height groups, as MUAC is a malnutrition indicator in children taller than 65 cm in some protocols, and children taller than 75 cm in others. The guidelines are as follows:

MUAC < 110 mm severe malnutrition and high risk of mortality MUAC ≥ 110 mm and <120 mm moderate malnutrition and moderate risk of mortality MUAC ≥ 120 mm and <125 mm high risk of malnutrition MUAC ≥ 125 mm and <135 mm moderate risk of malnutrition MUAC ≥ 135 mm adequate nutritional status

3.5.2. Mortality The crude mortality rate (CMR) is determined for the entire population surveyed for a given period. The CMR is calculated using the ENA software.

22 NCHS: National Center for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics. 165, 11-74. 23 WHO Child Growth Standards: length /height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age. Methods and development. Geneva, Switzerland: World Health Organization, 2006.

The formula below is applied: Crude Mortality Rate (CMR) = 10,000/a*f/ (b+f/2-e/2+d/2-c/2), where: a = Number of recall days b = Number of current household residents c = Number of people who joined household d = Number of people who left household e = Number of births during recall f = Number of deaths during recall period

The result is expressed per 10,000-people / day. The thresholds are defined as follows:

Total CMR: Alert level: 1/10,000 people/day Emergency level: 2/10,000 people/day

Under five CMR: Alert level: 2/10,000 people/day Emergency level: 4/10,000 people/day

3.6. Field work

Four survey teams achieved the surveys, each including three people (one team leader and two measurers). The teams consisted out of 6 men and 6 female. Due to the cultural context, each team included at least one female member. To ensure that the teams had a good knowledge of the survey area, the measurers were recruited locally. The same teams were in charge of both surveys.

The nutritional team members attended a four day training (two theory days and two practical ones) conducted by the Nutrition survey Officer. The training covered: basic introduction to nutrition and malnutrition, rationale of the surveys, sampling methodology, interview skills, and criteria of malnutrition, anthropometric measurements, and household /mortality questionnaires. Finally, a pilot survey took place in two villages (two teams per village) that were not selected during the random cluster selection.

The teams were supervised by two nutrition survey assistants and the nutrition survey officer. One cluster was surveyed per team per day. During the survey, debriefing session was conducted with all team members at the end of every day.

At village level, the local authorities were explained the purpose and the running of the survey. A facilitator was identified among the local community to guide the teams around. The facilitators did not measure or interview any household.

3.7. Data analysis

The team leaders returned their completed questionnaires at the end of each day. All data collected that day were reviewed, and necessary corrections were made immediately, when possible. Data were entered and analyzed with the ENA software and Excel.

4. Results

4.1. Kamber-Shahdadkot survey

The field work for the survey was done from May 28th of to June 5th 2008. In Kamber-Shahdadkot district, a total of 648 children aged 6-59 months were selected in the 703 households surveyed. Of those 648 children, 10 were absent and could not be measured during the survey (all other information could be gathered). 21 children were excluded due to incorrect or aberrant data. This leads to 617 children included in the nutritional anthropometric survey (and 627 in the total analysis). The total sample for the retrospective mortality survey was 5172 individuals.

4.1.1. Age and sex distribution

The distribution of the sample by age group and sex is shown in the table below. The total sex ratio of boys/girls is 1.1. This is within the accepted limits of 0.8-1.2. The sex ratio is not within the accepted limits for the oldest age groups. But as age has to be taken with caution, sex ratios in subgroups need to be taken with caution as well. Table 8: Distribution of age and sex of sample, Kamber-Shahdadkot survey, June 2008

Boys Girls Total Ratio Age Boy/ No. % no. % no. % girl 6-17 months 67 54.9 55 45.1 122 19.5 1.2 18-29 months 51 46.8 58 53.2 109 17.4 0.9 30-41 months 90 53.3 79 46.7 169 27.0 1.1 42-53 months 75 53.2 66 46.8 141 22.5 1.1 54-59 months 50 58.1 36 41.9 86 13.7 1.4 Total 333 53.1 294 46.9 627 100.0 1.1

4.1.2. Malnutrition rates

a. Z-scores

In the total sample, the prevalence of global acute malnutrition (GAM, WHZ<-2 and/or oedema) was 22.0% and that of severe acute malnutrition (SAM, WHZ<-3 and/or oedema) 1.1%. No case of Kwashiorkor was found. No difference in malnutrition rates could be found between boys and girls. Table 9: Prevalence of acute malnutrition by sex expressed in weight-for-height in z-scores and/or oedema, Kamber-Shahdadkot survey, June 2008

Index Total Global Acute Malnutrition 22.0 % W/H< -2 z and/or edema (17.5% - 26.6%) NCHS Severe Acute Malnutrition 1.1 % W/H < -3 z and/or edema (0.3% - 1.9%) Global Acute Malnutrition 22.7 % W/H< -2 z and/or edema (18.5% - 26.9%) WHO Severe Acute Malnutrition 3.7 % W/H < -3 z and/or edema (2.3% - 5.2% )

Table 10: Prevalence of acute malnutrition by age expressed in weight-for-height in z-scores and/or edema, Kamber-Shahdadkot survey, June 2008 Moderate Severe wasting wasting Normal Total Oedema Age (<-3 z-score) (>= -3 and <-2 z- (> = -2 z score) no. score ) No. % No. % No. % No. % 6-17 months 117 2 1.7 31 26.5 84 71.8 0 0.0 18-29 months 107 2 1.9 31 29.0 74 69.2 0 0.0 30-41 months 167 0 0.0 36 21.6 131 78.4 0 0.0 42-53 months 140 2 1.4 15 10.7 123 87.9 0 0.0 54-59 months 86 1 1.2 16 18.6 69 80.2 0 0.0 Total 617 7 1.1 129 20.9 481 78.0 0 0.0

Figure 2 shows the weight for height distribution curve of the survey sample in Z-scores compared to the NCHS reference population. The entire weight for height distribution curve of the sample is shifted to the left, which indicated that the surveyed population has a poorer nutritional status that the reference one. Figure 2: Weight for Height distribution in Z-scores, Kamber-Shahdadkot survey, June 2008

Table 11: Repartition of types of malnutrition, Kamber-Shahdadkot survey, June 2008 <-3 z-score >=-3 z-score Marasmic kwashiorkor Kwashiorkor Oedema present 0 (0.0%) 0 (0.0%) Marasmic Normal Oedema absent 7 (1.1%) 610 (98.9%)

b. % of the median

In the total sample, the prevalence of global acute malnutrition (GAM, WHM<80 % and/or oedema) was 12.5 % and that of severe acute malnutrition (SAM, WHM<70 and/or edema) 0.0 %. No case of Kwashiorkor was found. Table 12: Prevalence of acute malnutrition by sex expressed in % of the median and/or oedema, Kamber- Shahdadkot survey, June 2008

Index Total Global acute malnutrition 12.5 % (<80% and/or oedema) (9.7 - 15.3 %) NCHS severe acute malnutrition 0.0 % (<70% and/or oedema) (0.0 - 0.2 %) global acute malnutrition 6.0 % (<80% and/or oedema) (4.0 - 8.0 %) WHO severe acute malnutrition 0.0 % (<70% and/or oedema) (0.0 - 0.2 %) Table 33: Prevalence of acute malnutrition by age expressed in % of the median and/or edema, Kamber- Shahdadkot survey, June 2008 Moderate Severe wasting wasting Normal Total Oedema Age (<70% median) (>=70% and (> =80% median) no. <80% median) No. % No. % No. % No. % 6-17 months 117 0 0.0 22 18.8 95 81.2 0 0.0 18-29 months 107 0 0.0 19 17.8 88 82.2 0 0.0 30-41 months 167 0 0.0 17 10.2 150 89.8 0 0.0 42-53 months 140 0 0.0 8 5.7 132 94.3 0 0.0 54-59 months 86 0 0.0 11 12.8 75 87.2 0 0.0 Total 617 0 0.0 77 12.5 540 87.5 0 0.0

c. MUAC

Using MUAC criteria, 0.6 % of the children are severely malnourished and 5.0 % of them moderately malnourished. Table 44: Distribution of MUAC in height groups, Kamber-Shahdadkot survey, June 2008

Height (cm) MUAC < 75 75 – 89.9 > 90 Total (mm) No. % No. % No. % No. % < 110 4 3.4 0 0.0 0 0.0 4 0.6 110 – 119 22 19.0 8 3.4 1 0.4 31 5.0 120 – 124 22 19.0 25 10.8 5 1.9 52 8.4 125 – 134 41 35.3 78 33.6 47 17.5 166 26.9 > 135 27 23.3 121 52.2 216 80.3 364 59.0 Total 116 100.0 232 100.0 269 100.0 617 100.0

4.1.3. Measles vaccination For 597 children aged 9 to 59 months old, measles vaccination status could be collected. 43.9% of the sampled children aged 9 to 59 months were reported to be vaccinated against measles. Among them, 11.1% could have their vaccination status confirmed by a vaccination card and 32.8 % had no card. Table 15: Vaccination status, Kamber-Shahdadkot survey, June 2008

Vaccination Status N Percentage Vaccination (confirmed by card) 66 11.1 Vaccination (no card) 196 32.8 No vaccination 335 56.1 Total 597 100

4.1.4. Feeding programs Table 16: Children received UNIMIX, Kamber-Shahdadkot survey, June 2008

Children received UNIMIX N Percentage Yes 128 20.4 No 499 79.6 Total 627 100

All 31 children that received Plumpynut received UNIMIX as well. Table 17: Children received Plumpynut, Kamber-Shahdadkot survey, June 2008 Children received Plumpynut N Percentage

Yes 31 4.9 No 596 95.1 Total 627 100

There has to be said that those 141 mothers and 128 children that received UNIMIX lived in only 8 villages. In all of those villages, almost all children and mothers were targeted. Table 18: Mothers received UNIMIX, Kamber-Shahdadkot survey, June 2008

Mothers received UNIMIX N Percentage Yes 141 20.1 No 562 79.9 Total 703 100

4.1.5. Mortality The beginning of the recall period selected was Ashoura, an Islamic holiday (corresponding with January19th). As at the time of the survey, a total of 5,172 persons were present in the households assessed; 1,126 of them being children under five years of age. The demographic data below was also gathered from these households for the period from January 19th to the date of the survey. 13 people had joined the households, 4 of them being children under five years of age 36 persons had left the households, 6 of them being children below 5 years of age 78 births 33 deaths were reported; 22 being children below five years of age

This leads to: • A crude mortality rate (CMR) of 0.48 (0.18 – 0.78) / 10.000 persons / day • A U5MR24 of 1.51 (0.29 – 2.72) / 10.000 children / day.

Both findings are below the alert thresholds25 although U5MR is close to the alert level.

4.2. Dadu survey The field work for the survey was done from May 9th to June 17th 2008. In Dadu district, a total of 650 children aged 6-59 months were selected in the 704 households surveyed. Of those 650 children, 21 were absent and could not be measured during the survey (all other information could be gathered). One child was abnormal making it impossible to measure height but all other measurements were taken. Fifteen children were excluded due to incorrect or aberrant data. This leads to 614 children included in the nutritional anthropometric survey (and 636 in the total analysis). The total sample for the retrospective mortality survey was 5142 individuals.

4.2.1. Age and sex distribution The distribution of the sample by age group and sex is shown in the table below. The total sex ratio of boys/girls is 1.1. This is within the accepted limits of 0.8-1.2. The sex ratio is not within the accepted limits for the middle age groups. But as age has to be taken with caution, sex ratios in subgroups need to be taken with caution as well. Table 19: Distribution of age and sex of sample, Dadu survey, June 2008

Boys Girls Total Ratio Age Boy/ No. % no. % no. % Girl 6-17 months 69 48.9 72 51.1 141 22.2 1.0 18-29 months 68 54.4 57 45.6 125 19.7 1.2 30-41 months 90 57.7 66 42.3 156 24.5 1.4 42-53 months 63 48.8 66 51.2 129 20.3 1.0 54-59 months 44 51.8 41 48.2 85 13.4 1.1 Total 334 52.5 302 47.5 636 100.0 1.1

4.2.2. Malnutrition rates

1. Z-scores

In the total sample, the prevalence of global acute malnutrition (GAM, WHZ<-2 and/or oedema) was 25.4 % and that of severe acute malnutrition (SAM, WHZ<-3 and/or oedema) 1.5 %. No case of Kwashiorkor was found. No difference in global malnutrition rates could be found between boys and girls.

24 Mortality rate in children below the age of 5 years (Under 5 mortality rate) 25 U5: Alert level: 2/ 10 000 people / day and Emergency level: 4/ 10 000 people/ day Total population: Alert level: 1/ 10 000 people / day; and Emergency level: 2/ 10 000 people/ day

Table 20: Prevalence of acute malnutrition by sex expressed in weight-for-height in z-scores and/or edema, Dadu survey, June 2008

Index Total Global Acute Malnutrition 25.4 % W/H< -2 z and/or edema (21.2 - 29.6 %) NCHS Severe Acute Malnutrition 1.5 % W/H < -3 z and/or edema (0.6 - 2.3 %) Global Acute Malnutrition 28.3 % W/H< -2 z and/or edema (23.6 - 33.0 %) WHO Severe Acute Malnutrition 5.7 % W/H < -3 z and/or edema (3.8 - 7.6 %)

Table 21: Prevalence of acute malnutrition by age expressed in weight-for-height in z-scores and/or edema, Dadu survey, June 2008 Moderate Severe wasting wasting Normal Total Oedema Age (<-3 z-score) (>= -3 and <-2 z- (> = -2 z score) no. score ) No. % No. % No. % No. % 6-17 months 137 18 13.1 29 21.2 90 65.7 0 0.0 18-29 months 118 3 2.5 21 17.8 94 79.7 0 0.0 30-41 months 150 5 3.3 31 20.7 114 76.0 0 0.0 42-53 months 126 6 4.8 29 23.0 91 72.2 0 0.0 54-59 months 83 3 3.6 29 34.9 51 61.4 0 0.0 Total 614 35 5.7 139 22.6 440 71.7 0 0.0

Figure 3 shows the weight for height distribution curve of the survey sample in z-scores compared to the NCHS reference population. The entire weight for height distribution curve of the sample is shifted to the left, which indicated that the surveyed population has a poorer nutritional status that the reference one. Figure 3: Weight for Height distribution in Z-scores, Dadu survey, June 2008

Table 21: Repartition of types of malnutrition, Kamber-Shahdadkot survey, June 2008 <-3 z-score >=-3 z-score Marasmic kwashiorkor Kwashiorkor Oedema present 0 (0.0%) 0 (0.0%) Marasmic Normal Oedema absent 9 (1.5%) 605 (98.5%)

2. % of the median

In the total sample, the prevalence of global acute malnutrition (GAM, WHM<80 % and/or oedema) was 15.3 % and that of severe acute malnutrition (SAM, WHM<70 and/or oedema) 0.0 %. No case of Kwashiorkor was found. Table 22: Prevalence of acute malnutrition by sex expressed in % of the median and/or edema, Dadu survey, June 2008

Index Total global acute malnutrition 15.3 % (<80% and/or edema) (12.0 - 18.7 %) NCHS severe acute malnutrition 0.0 % (<70% and/or edema) (0.0 - 0.0 %) global acute malnutrition 9.3 % (<80% and/or edema) (7.0 - 11.5 %) WHO severe acute malnutrition 0.0 % (<70% and/or edema) (0.0 - 0.0 %) Table 23: Prevalence of acute malnutrition by age expressed in % of the median and/or edema, Dadu survey, June 2008 Moderate Severe wasting wasting Normal Total edema Age (<70% median) (>=70% and (> =80% median) no. <80% median) No. % No. % No. % No. % 6-17 months 137 0 0.0 35 25.5 102 74.5 0 0.0 18-29 months 118 0 0.0 16 13.6 102 86.4 0 0.0 30-41 months 150 0 0.0 15 10.0 135 90.0 0 0.0 42-53 months 126 0 0.0 15 11.9 111 88.1 0 0.0 54-59 months 83 0 0.0 13 15.7 70 84.3 0 0.0 Total 614 0 0.0 94 15.3 520 84.7 0 0.0

3. MUAC

Using MUAC criteria, 1.1 % of the children are severely malnourished and 6.2 % of them moderately malnourished.

Table 24: Distribution of MUAC in height groups, Kamber-Shahdadkot survey, June 2008

Height Total MUAC (mm) >65 and < 75 cm >=75 and < 90 cm >=90 cm No. % No. % No. % No. % < 110 5 4.5 1 0.5 1 0.3 7 1.1 110 – 119 24 21.4 13 6.4 1 0.3 38 6.2 120 – 124 22 19.6 28 13.7 10 3.4 60 9.8 125 – 134 42 37.5 79 38.7 67 22.6 188 30.7 > 135 19 17.0 83 40.7 218 73.4 320 52.2 Total 112 100.0 204 100.0 297 100.0 613 100.0

4.2.3. Measles vaccination For 597 children aged 9 to 59 months old, measles vaccination status could be collected. 55.0 % of the sampled children aged 9 to 59 months were reported to be vaccinated against measles. Among them, 3.3 % could have their vaccination status confirmed by a vaccination card and 51.7 % had no card. Table 25: Vaccination status, Dadu survey, June 2008

Vaccination Status N Percentage Vaccination (confirmed by card) 21 3.3 Vaccination (no card) 329 51.7 No vaccination 286 45.0 Unknown 1 0.2 Total 597 100

4.2.4. Feeding programs Table 26: Children received UNIMIX, Dadu survey, June 2008

Children received UNIMIX N Percentage Yes 212 33.3 No 425 66.7 Total 637 100

All children that received Plumpynut received UNIMIX as well. Table 26: Children received Plumpynut, Dadu survey, June 2008 Children received Plumpynut N Percentage

Yes 15 2.4 No 622 97.6 Total 637 100

Table 28: Mothers received UNIMIX, Dadu survey, June 2008

Mothers received UNIMIX N Percentage Yes 185 26.3 No 562 73.7 Total 703 100

4.2.5. Mortality The beginning of the recall period selected was Ashoura, an Islamic holiday (corresponding with January19th). As at the time of the survey, a total of 5,142 persons were present in the households assessed; 1,124 of them being children under five years of age. The demographic data below was also gathered from these households for the period from January 19th to the date of the survey. 6 people had joined the households, none of them being children under five years of age 24 persons had left the households, 3 of them being children below 5 years of age 98 births 17 deaths were reported; 9 being children below five years of age

This leads to: • A CMR of 0.23 (0.11 – 0.35) deaths/10.000 persons /day • A U5MR of 0.58 (0.05 – 1.11) deaths / 10.000 children / day.

5. Discussion

The global acute malnutrition rate as found during this survey can be considered as extremely high being far above the emergency cut off point of 15 %. Remarkable is the absence of a relative high severe acute malnutrition rate to accompany this high global acute malnutrition rate: moderate malnutrition is the most prevalent one. This might indicate that although acute malnutrition rates are measured, the situation is becoming chronic. Long term deprivation can lead to stunting and growth retardation. The difficulties faced to measure age accurately make that there was no possible way to investigate if these high prevalence of moderate malnutrition has had a long impact on the development and growth showing in a low height-for-age z-score. Nevertheless, if this situation continues, a negative impact can be expected. There is a need for treatment and prevention of moderate malnutrition to improve the overall situation for children living in the flood-affected areas. Table 29: Summary of results for the Kamber-Shadahdkot and Dadu, 2007 and 2008 surveys.

Year Indicator26 Kamber-Shahdadkot Dadu Global Acute Malnutrition 16.7%27 15.6% W/H< -2 z and/or oedema (12.9% - 20.5%) (12.8% - 18.3%) 2007 Severe Acute Malnutrition 2.2% 0.9% W/H < -3 z and/or oedema (1.2% - 3.2%) (0.1% - 1.7%) Global Acute Malnutrition 22.0 % 25.4 % W/H< -2 z and/or oedema (17.5% - 26.6%) (21.2% - 29.6%) 2008 Severe Acute Malnutrition 1.1 % 1.5 % W/H < -3 z and/or oedema (0.3% - 1.9%) (0.6% - 2.3%)

It should be mentioned that the present surveys were conducted after the harvest of wheat, barley,

26 Results expressed in Z-scores, NCHS reference 27 Results in bracket are at 95% confidence intervals.

30 legumes and mustard/oil seed in April. The food availability is better than during other periods of the year, which shows that the situation can further deteriorate.

Public health and hygiene

There is also a problem of awareness and education, as the need to have a medical consultation is not always understood when a family member is sick.

Food security

Agriculture is the main source of income for villagers in Kamber-Shahdadkot and Dadu districts.

31 rice. Moreover, the interviewed humanitarian partners mentioned that due to the flooding the irrigation system was destroyed resulting in water shortage in certain areas and thus a lack of water to plant rice. The reduction of harvest induces that families need to rely more on the market than usually to cover their needs.

This combination of reduced availability and reduced purchasing power leads to high vulnerability towards food shortage and thus malnutrition.

6. Recommendations The results presented in this report show that the nutrition situation of flood-affected population is of concern. The following recommendations are made for donors, agencies, and organizations interested to intervene or already present in the recovery phase of the flood crisis:

• To continue the treatment of moderately malnourished children, and extend the coverage of the supplementary feeding programs to target all malnourished children in the flood affected areas. • To implement as part of the supplementary feeding program a promotion campaign covering malnutrition and all its underlying causes to have a long term impact on the nutritional situation. • To implement screening activities with a focus on most vulnerable areas with mobile screeners and develop screening/ nutrition surveillance at health structures level. • To improve child health by assessing the health situation and facilities present in the districts and develop a long term strategy. • To strengthen knowledge of governmental institutes, local and international humanitarian actors present in Kamber-Shahdadkot and Dadu district on malnutrition, the underlying causes and possible activities focusing on prevention. A special focus should be given to children (6 – 59 months) and pregnant and lactating women. • Reassess the food security situation, in order to propose actions with a focus on long term improvement and flood preparedness. • To improve access to clean water, hygiene situation and hygiene awareness of the population. • To improve coordination of all different actors working in the area, to monitor the nutrition situation and its underlying causes.

Appendixes

Appendix 1: Map of the flood affected areas surveyed

Appendix 2: Cluster selected, Kamber-Shahdadkot survey Population Taluka Union Council Geographical unit Cluster size selection Moli Dino Khoso 1050 1 Niazal Aadmani 210 2 Miro Khan Khabar Khabhar 1320 3 Mohd Bux Brohi 300 4 Pandhi Khoso 300 5 shahbaz 280 6 ghaibidero 2800 7 sona khan chandio 530 8 vahandary buriro 288 9 dhani bux chandio 207 10 wali muhammad chandio 438 11 faqir muhammad buriro 248 12 ali sher chandio 338 13 Qamber Ghaibi Dero yaktar buriro 518 14 gaincha 318 15 qazi fazullah 278 16 habibullah nooriyani 155 17 liaque ajbani 277 18 lashkar khan budhani 871 19 suhrab khan karo chandio 255 20 pathan 108 21 mir pur buriro 800 22 himath ali chandio and baharo khan chandio 100 23 arz mohd khoso 70 24 pir bux khoso and gaji bux khoso and wali mohd 112 Qubo Saeed Khan Bago Dero khoso 25 suhnal shah 230 26 rais piral khan mochi 100 27 moula bux magsi 150 28 lal magsi and ranjho magsi 330 29 Patt Wara Sakhni 500 30 Warah Mirpur Karyo Sabar 2000 31 Shafi Muhammad Chhutto 200 32

Appendix 3: Cluster selection Dadu survey

Population Cluster Taluka Union Council Geographical unit size selection syeed pur/sayedpur 2000 1 raban faqir soomro 300 2 Khan Jo Goth qaim jatoi 3500 3 ghari jager 3000 4 garkan 1000 5 Mehar seelra 2000 6 faridabad 4000 7 hathien akh kadhai 600 8 Fareedabad faiz mohammad khoso 300 9 Sidher pehnwer 1500 10 qadir bux(khan) rind 700 11 gozo 6000 12.13 panjani chandio 1500 14 haji jan korijo/jan mohammad korejo 3000 15 Gozo jaro khan panhwar 800 16 ibrahim chandio 2500 17 K. N. Shah wah sobdar 2500 18 sattani chandia 4000 19.2 kario ghulamullah 3500 21 mado 7500 22,23,24 Chhor Qamber allah dino khoso 2000 25 shahdad khunharo 400 26 Shahak rodnani 1785 27 Sawro Bachal khan 200 28 Abdul rehmani rodnani/Dhani bux rodnani 280 29 Johi Chapper khan jamali 2000 30 Khamal Khan Arab jamali 200 31 Sahib khan solangi 1500 32

Appendix 4: Anthropometric questionnaire ANTHROPOMETRIC NUTRITION SURVEY, Qamber Shadahdadkot district, June 2008

DATE : Zone: TEAM NB: CLUSTER NB:

Did the Did the child child Age Oedema MUAC in Measles receive receive HH Sex 1=Male, Date of birth Weight in Height in Child NB ID (months) W/H % 1=yes mm 1=yes 2=no unimix in plumpynut NB 2=Female (DD/MM/YY) kg (00.0) cm (000.0) 2=no 3=history the last 6 in the last 6 months? months? 1=yes; 2=No 1=yes; 2=No

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Appendix 5: Mortality questionnaire

RETROSPECTIVE MORTALITY SURVEY,Qanber and Shadahdadkot district, Pakistan June 2008

DATE : Zone: TEAM NB: CLUSTER NB:

Did the mother <5 years <5 years Total Total Join Total leave No of births Total of <5 years receive any House-hold Nb <5 years joined HH leave HH population HH since HH since since death since dieath since unimix in NB in HH since since in HH Arousha Arousha Arousha Arousha Arousha the last six Arousha Arousha months 1=Yes, 2=No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Appendix 6: Local event calendar

Appendix 7: The Conceptual Framework of Malnutrition