HealthHealth andand MortalityMortality SurveySurvey amongamong InternallyInternally DisplacedDisplaced PersonsPersons
GuluGulu,, KitgumKitgum andand PaderPader Districts,Districts, NorthernNorthern UgandaUganda
JulyJuly 20052005 BackgroundBackground
•• GuluGulu,, KitgumKitgum andand PaderPader DistrictsDistricts mostmost severelyseverely affectedaffected byby NorthernNorthern UgandaUganda conflictconflict •• 1.31.3 millionmillion displaceddisplaced
•• PriorPrior surveyssurveys showshow elevatedelevated mortalitymortality •• NoNo comprehensivecomprehensive datadata onon IDPIDP healthhealth statusstatus availableavailable
•• MoHMoH/UNICEF/UNICEF requestrequest toto WHOWHO ObjectivesObjectives
•• RetrospectiveRetrospective mortalitymortality (crude,(crude, underunder 5,5, monthly,monthly, violenceviolence--related)related)
•• OtherOther issuesissues investigated:investigated: – Under 5 morbidity (pending analysis) – Measles vaccination coverage – Bednet coverage – Water availability
•• IndependentIndependent estimateestimate forfor eacheach districtdistrict MethodsMethods (1)(1)
•• 3030 clustersclusters ofof 3232 householdshouseholds interviewedinterviewed inin 1) Gulu District registered camps (pop. 601 000) 2) Gulu Municipality unregistered camps (pop. 99 000 > WHO estimation) 3) Kitgum District camps (pop. 293 000) 4) Pader District camps (pop. 318 000)
Total: 120 clusters (3840 households)
•• ClustersClusters allocatedallocated proportionatelyproportionately toto campcamp populationpopulation sizesize MethodsMethods (2)(2)
• Standardised, pre-piloted questionnaire – teams of two interviewers – consenting adult household respondents • Mortality information using past household census method – evolution of each household member through recall period (1 Jan 2005 to survey date) – increasingly the standard
• Data entry on EpiData 3.0 • Analysis on EpiInfo 6.04, Stata 8.0 – one large survey with four strata (populations): weighted averages for all of Acholiland, 95%CIs adjusted for design effects TeamTeam compositioncomposition
•• Epidemiologist,Epidemiologist, logisticslogistics andand securitysecurity officersofficers (WHO(WHO--HQ)HQ)
•• SurveySurvey coordinatorscoordinators (2(2 WHOWHO--Kampala,Kampala, 11 MoHMoH,, 11 UNICEF,UNICEF, 11 IRC)IRC) ++ DDHSDDHS facilitatorsfacilitators
•• InterviewersInterviewers (12(12--15/district)15/district) identifiedidentified byby eacheach DDHSDDHS
ResultsResults StudyStudy profileprofile
Gulu Gulu District Kitgum District Pader District Municipality Camps visited 27 11 19 19 19-25 July Data collection period 2-14 July 2005 15-20 July 2005 12-21 July 2005 2005 Average mortality recall 188 days 197 days 196 days 201 days period
Households replaced 430 (31.1%) 6 (0.6%) 61 (6.0%) 159 (14.2%) (percent of total selected) absent 427 2 57 159
non-consenting 3 4 4 0
Households interviewed 952 960 959 959
Demographics:Demographics: ex.ex. PaderPader
Current age/sex structure: 6636
present on 1 65 to 99 January 2005 Females Males 60 to 64
55 to 59 1052 left household 50 to 54
16 abducted 45 to 49 777 were born into 40 to 44 or joined household 1 disappeared 35 to 39
30 to 34
246 died groupage 25 to 29
20 to 24
6098 15 to 19
present on 10 to 14 survey date 5 to 9
under 5
800 600 400 200 0 200 400 600 800 persons YearYear ofof arrivalarrival
400 Kitgum District: 350 300
250
200
150
100 number ofhouseholds 50
0 before 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 1995 year
200 180 Gulu Municipality: 160
140 120 100 80 60
number ofhouseholds 40 20 0 before 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 1995 year MortalityMortality ratesrates
deaths person-time CMR 95%CI (n) (days) (/10 000/day) Gulu District 154 1 263 753 1.22 1.00-1.44
Gulu Municipality 178 1 383 006 1.29 1.04-1.53
Kitgum District 239 1 249 563 1.91 1.45-2.37
Pader District 246 1 321 966 1.86 1.53-2.19
Acholiland total 817 5 218 288 1.54 1.38-1.71
under 5 person-time U5MR 95%CI deaths (n) (days) (/10 000/day) Gulu District 61 264 032 2.31 1.76-2.86
Gulu Municipality 63 253 484 2.49 1.79-3.18
Kitgum District 99 245 089 4.04 3.17-4.91
Pader District 111 261 741 4.24 3.40-5.08
Acholiland total 334 1 024 346 3.18 2.81-3.56 MortalityMortality ratesrates
deaths person-time CMR 95%CI (n) (days) (/10 000/day) Gulu District 154 1 263 753 1.22 1.00-1.44
Gulu Municipality 178 1 383 006 1.29 1.04-1.53
Kitgum District 239 1 249 563 1.91 1.45-2.37
Pader District 246 1 321 966 1.86 1.53-2.19
Acholiland total 817 5 218 288 1.54 1.38-1.71
under 5 person-time U5MR 95%CI deaths (n) (days) (/10 000/day) Gulu District 61 264 032 2.31 1.76-2.86
Gulu Municipality 63 253 484 2.49 1.79-3.18
Kitgum District 99 245 089 4.04 3.17-4.91
Pader District 111 261 741 4.24 3.40-5.08
Acholiland total 334 1 024 346 3.18 2.81-3.56 MonthlyMonthly CMRCMR evolutionevolution
2.5
2
1.5
1
emergency threshold
CMR (deaths/10 000/day) 0.5
0 Jan Feb Mar Apr May Jun Jul month in 2005 CausesCauses ofof deathdeath (all(all ages)ages)
Gulu District Gulu Municipality Kitgum District Pader District Watery diarrhoea 8 5.2% 6 3.4% 3 1.3% 10 4.1% (cado) Non-watery diarrhoea 4 2.6% 6 3.4% 12 5.0% 13 5.3% (cado rehmu/ringring) Cough, difficulty 12 7.8% 8 4.5% 23 9.6% 28 11.4% breathing Malaria (lyeto) 1 39 25.3% 40 22.5% 83 34.7% 71 28.9% Measles (anyo) 1 0.7% 2 1.1% 6 2.5% 4 1.6% AIDS (slim, achui) 2 24 15.6% 35 19.7% 36 15.1% 15 6.1% Two-lango, gimiru† 5 3.3% 4 2.3% 22 9.2% 19 7.7% Violence inflicted by 18 11.7% 6 3.4% 25 10.5% 28 11.4% others 3 Other cause 32 20.8% 49 27.5% 22 9.2% 43 17.%
Cause unclear 11 7.1% 22 12.4% 7 2.9% 15 6.1%
Total deaths 154 178 239 246 CausesCauses ofof deathdeath (under(under 5)5)
Gulu District Gulu Municipality Kitgum District Pader District Watery diarrhoea 6 9.8% 4 6.4% 1 1.0% 9 8.1% (cado) Non-watery diarrhoea 1 1.6% 3 4.8% 4 4.0% 5 4.5% (cado rehmu/ringring) Cough, difficulty 4 6.6% 2 3.2% 6 6.1% 9 8.1% breathing Malaria (lyeto) 1 29 47.5% 27 42.9% 52 52.5% 50 45.1% Measles (anyo) 0 0.0% 2 3.2% 3 3.0% 3 2.7%
AIDS (slim, achui) 0 0.0% 0 0.0% 2 2.0% 0 0.0% Two-lango, gimiru 2 5 8.2% 3 4.8% 20 20.2% 17 15.3% Violence inflicted by 1 1.6% 0 0.0% 1 1.0% 1 0.9% others Other cause 10 16.4% 13 20.6% 5 5.1% 12 10.8%
Cause unclear 5 8.2% 9 14.3% 5 5.1% 5 4.5%
Total deaths 61 63 99 111 CircumstancesCircumstances ofof deathdeath
•• 31.2%31.2% ((GuluGulu District)District) toto 46.1%46.1% ((GuluGulu Municipality)Municipality) outsideoutside campcamp
•• 41.7%41.7% (95%CI(95%CI 36.8%36.8% toto 46.5%)46.5%) inin healthhealth facilityfacility – highest in Gulu Municipality, lowest in Pader (p<0.05) ExcessExcess mortalitymortality
• Assumption: non-crisis CMR 0.44/10 000/day
• Period: January to July 2005 excess CMR estimated IDP average recall excess deaths
(95%CI) population (n) period (days) (95%CI) 0.78 8814 Gulu District 601 059 188 (0.56-1.00) (6328-11 300) 0.85 1667 Gulu Municipality 99 535 197 (0.60-1.09) (1177-2137) 1.47 8435 Kitgum District 292 763 196 (1.01-1.93) (5796-11 075) 1.42 9090 Pader District 318 488 201 (1.09-1.75) (6978-11 203)
1.10 28 283 Acholiland total 1 311 845 196 (0.94-1.27) (24 169-32 654)
• Under 5 excess deaths: 16 818 (95%CI 12 261 to 21 376) ViolenceViolence andand abductionabduction
•• 43714371 personspersons (95%CI(95%CI 28282828 toto 5400)5400) killedkilled – 70.1% among older males – 16.9% children under 15
•• 12861286 personspersons (95%CI(95%CI 771771 toto 2057)2057) abductedabducted – all under 35 years old – 46.4% children under 15 – 19/9 were males MeaslesMeasles vaccinationvaccination coveragecoverage
Gulu District Gulu Municipality Kitgum District Pader District
Card available (C) 782 (23.0%) 768 (23.4%) 759 (26.8%) 937 (29.2%)
vaccinated (a) 700 724 497 751
not vaccinated 82 44 262 937
Card not available 2619 (77.0%) 2518 (76.6%) 2075 (73.2%) 2273 (70.8%) apparently vaccinated 2524 2420 1916 2156 (b) apparently not 18 6 50 46 vaccinated doesn’t know/unclear 77 92 109 71
Total children (T) 3401 3286 2834 3210
Card-verified coverage= 89.5% 94.3% 65.5% 80.1% a/C (86.5%-92.5%) (91.9%-96.7%) (57.8%-73.2%) (74.9%-85.4%) (95%CI)
Card-verified or caregiver-reported 94.8% 95.7% 85.1% 90.6% coverage= (a+b)/T (93.5%-96.1%) (94.3%-97.1%) (81.9%-88.4%) (88.4%-92.7%) (95%CI) MeaslesMeasles vaccinationvaccination coveragecoverage
Gulu District Gulu Municipality Kitgum District Pader District
Card available (C) 782 (23.0%) 768 (23.4%) 759 (26.8%) 937 (29.2%)
vaccinated (a) 700 724 497 751
not vaccinated 82 44 262 937
Card not available 2619 (77.0%) 2518 (76.6%) 2075 (73.2%) 2273 (70.8%) apparently vaccinated 2524 2420 1916 2156 (b) apparently not 18 6 50 46 vaccinated doesn’t know/unclear 77 92 109 71
Total children (T) 3401 3286 2834 3210
Card-verified coverage= 89.5% 94.3% 65.5% 80.1% a/C (86.5%-92.5%) (91.9%-96.7%) (57.8%-73.2%) (74.9%-85.4%) (95%CI)
Card-verified or caregiver-reported 94.8% 95.7% 85.1% 90.6% coverage= (a+b)/T (93.5%-96.1%) (94.3%-97.1%) (81.9%-88.4%) (88.4%-92.7%) (95%CI) BednetBednet coveragecoverage
•• 60.1%60.1% (2299/3828)(2299/3828) ofof householdshouseholds interviewedinterviewed hadhad nono netsnets
•• UnderUnder 55 coverage:coverage:
Gulu District Gulu Municipality Kitgum District Pader District
Under 5 children 1425 1300† 1254 1284†† Under 5 children sleeping 363 394 369 400 under a bednet
Coverage 25.5% 30.5% 29.4% 31.2%
(95%CI) (19.2%-31.7%) (26.8%-34.3%) (21.7%-37.1%) (22.3%-40.1%)
•• RollRoll BackBack MalariaMalaria goal:goal: >60%>60% SourceSource ofof drinkingdrinking waterwater
Gulu District Gulu Municipality Kitgum District Pader District
Protected sources 833 88.5% 847 89.4% 828 86.7% 821 86.2%
(95%CI) (82.6%-94.5%) (82.5%-96.2%) (80.6%-92.8%) (78.6%-93.7%) protected tap 55 5.8% 355 37.5% 116 12.2% 66 6.9%
protected spring 83 8.8% 166 17.5% 0 0.0% 6 0.6%
protected borehole 695 73.9% 326 34.4% 712 74.6% 749 78.6%
Unprotected sources 108 11.5% 101 10.6% 127 13.3% 132 13.8%
(95%CI) (5.5%-17.4%) (3.8%-17.5%) (7.2%-19.4%) (6.3%-21.4%) unprotected well 84 8.9% 64 6.8% 37 3.9% 95 10.0%
stream or river 23 2.4% 14 1.5% 90 9.4% 36 3.8%
water seller 0 0.0% 23 2.4% 0 0.0% 1 0.1%
other/unclear 1 0.1% 0 0.0% 0 0.0% 0 0.0%
Total households 941 948 955 953 QuantityQuantity ofof waterwater collectedcollected
Gulu District Gulu Municipality Kitgum District Pader District
less than 5 L 103 10.8% 56 5.9% 166 17.3% 176 18.4%
5 to 9 L 344 36.2% 274 28.6% 398 41.5% 440 45.9%
10 to 14 L 298 31.4% 324 33.8% 245 25.6% 233 24.3%
15 to 19 L 93 9.8% 141 14.7% 60 6.3% 51 5.3%
20 L or above 112 11.8% 163 17.0% 90 9.4% 58 6.1% mean L/person/day 11.0 12.8 9.7 8.8
(95%CI) (10.2-11.7) (12.1-13.5) (9.0-10.5) (8.3-9.3)
•• Standard:Standard: 2020 LL perper personperson perper dayday minimumminimum
TimeTime neededneeded toto collectcollect waterwater
Gulu District Gulu Municipality Kitgum District Pader District less than 1 hour 271 28.9% 409 43.1% 67 7.0% 45 4.7%
1 to 2 hours 178 19.0% 275 29.0% 98 10.3% 117 12.3%
2 to 3 hours 194 20.7% 158 16.7% 155 16.2% 176 18.5%
3 to 4 hours 131 14.0% 63 6.7% 154 16.1% 189 19.8%
4 or more hours 165 17.6% 43 4.5% 481 50.4% 426 44.7% mean time (hours) 2.0 1.3 3.6 3.5
(95%CI) (1.8-2.3) (1.2-1.4) (3.2-4.0) (3.2-3.7) Discussion:Discussion: studystudy limitationslimitations
•• HighHigh %% ofof replacedreplaced householdshouseholds inin GuluGulu DistrictDistrict (selection(selection bias?)bias?)
•• CausesCauses ofof death:death: malariamalaria andand twotwo maymay langolango havehave maskedmasked diarrhoealdiarrhoeal diseasedisease
•• CuriouslyCuriously lowlow CMRCMR inin JanuaryJanuary ((mismis-- classificationclassification ofof deathdeath date?)date?) Discussion:Discussion: importanceimportance ofof studystudy
•• FirstFirst representativerepresentative mortalitymortality datadata forfor allall ofof AcholilandAcholiland andand individualindividual districtsdistricts
•• FirstFirst healthhealth surveysurvey inin GuluGulu MunicipalityMunicipality IDPIDP campscamps
•• QuantificationQuantification ofof NorthernNorthern UgandaUganda crisiscrisis’’ directdirect andand indirectindirect impactimpact onon civilianscivilians HowHow ourour figuresfigures comparecompare
•• Uganda:Uganda: – DHS (2000-2001): CMR 0.46, U5MR 0.98 (very close to Sphere standards used to calculate excess mortality)
•• GuluGulu:: – MoH/WFP/UNICEF (Oct 2004): CMR 2.33, U5MR 3.47 – SCF (Nov 2004): CMR 2.1, U5MR 3.2 •• KitgumKitgum:: – IMC (Apr 2005): CMR 0.86, U5MR 1.97 •• PaderPader:: – MSF-H (Pader TC, Nov 2004): CMR 2.0, U5MR 5.3 – GOAL (Kalongo, Mar 2005): CMR 0.7, U5MR 1.3 Discussion:Discussion: implicationsimplications
• Acholiland IDPs are experiencing a severe humanitarian emergency – CMR/U5MR far in excess of emergency thresholds, especially in Kitgum and Pader
• Conflict still very much ongoing
• Minimum IDP services standards very far from being met: – Water and latrine provision extremely inadequate – Most people die outside health facilities – Bednet coverage very low – Measles vaccination coverage borderline PreliminaryPreliminary recommendationsrecommendations
• Scale up humanitarian interventions, especially in Kitgum and Pader: this is an emergency!
• Gulu Municipality IDPs need help like all others
• Focus on life-saving interventions: – Water (quantity and quality) – Latrines – Efficacious drugs (esp. for malaria) available at camp level – Effective IPD referrals – HIV prevention and HIV/AIDS management (more complex but needed)
• Monitor and enforce minimum humanitarian relief standards (ex. Sphere) ThankThank you!!!you!!!
•• DedicatedDedicated surveysurvey teamsteams •• WHOWHO GuluGulu subsub--officeoffice
•• DDHSDDHS ofof GuluGulu,, KitgumKitgum,, PaderPader •• MoHMoH
•• FundingFunding agencies:agencies: WHO,WHO, DFID,DFID, UNICEF,UNICEF, WFP,WFP, UNFPA,UNFPA, IRCIRC
•• AndAnd manymany manymany others!others!