Health and Nutrition Situation

A Rapid Assessment in 5 States in Southern Sudan

Consultants Faith M. Thuita Stephen Macdowell

August 2009
1

TABLE OF CONTENTS
1. INTRODUCTION
1.1 1.2 EXECUTIVE SUMMARY 4 8

BACKGROUND TO ASSESSMENT

2.

METHODOLOGY
2.1 2.2 STUDY METHODS .. 10 11

NUTRITION STATUS INDICES

3.

FINDINGS
3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 DESCRIPTION OF THE SURVEY SAMPLE.. ANTHROPOMETRIC RESULTS: CHILDREN (BASED ON WHO STANDARDS 2006)...... MORTALITY RESULTS (Retrospective over 91 days prior to interview). CHILDRENS MORBIDITY.. VACCINATION RESULTS.. VITAMIN A SUPPLEMENTATION/SLEEPING UNDER LLITN PROGRAMME COVERAGE SUPPLEMENTARY RATION ADEQUACY INFANT FEEDING PRACTICES.. SECONDARY DATA REVIEW. STATE REVIEW. 13 13 19 20 21 21 22 23 23 25 26

4.
5. 6.

DISCUSSION. CONCLUSIONS.. RECOMMENDATIONS AND PRIORITIES. APPENDICES

31

32 32 35

Abbreviations
ACF-USA ANOVA ARTI ASAL CCC CDR CHS CI CBR CMR CSB EMOP ENA EPI FGDs GAM GFD GOK HAZ IEC IDP IMR ITN L/HAZ MOH MSF-B MUAC NCHS OTP PHC PLM SAM SC SD SFP SMART SMOH TFC U5MR UNICEF URTI WHM WAZ WHZ WFP WHO GoSS ACSI PCA SSRRC ANLA OCHA Action Contraire Faim-USA Analysis of Variance Acute Respiratory Tract Infection Arid and Semi-Arid Lands Comprehensive Care Center Crude Death Rate Community Health Strategy Confidence Interval Crude Birth Rate Crude Mortality Rate Corn Soya Blend Emergency Operations Programs Emergency Nutrition Assessment Extended Programme of Immunization Focus Group Discussions Global Acute Malnutrition General Food Distribution Government of Kenya Height-for-Age Z-score Information, Education and Communication Internally Displaced Persons Infant Mortality Rate Insecticide Treated Mosquito Nets Length/ Height for Age Z-score Ministry of Health Medecins Sans Frontieres-Belgium Mid-Upper Arm Circumference National Centre for Health Statistics Out-patient Therapeutic Program Primary Health Centres Pregnant and Lactating Mothers Severe Acute Malnutrition Stabilization Centre Standard Deviation Supplementary Feeding Programme Standardized Monitoring and Assessment of Relief and Transitions Sudan Ministry of Health Therapeutic Feeding Centre Under Five-Mortality Rate United Nations Childrens Fund Upper Respiratory Tract Infection Weight for Height Median Weight-for-Age Z-score Weight-for-Height/length Z-scores World Food Programme World Health Organization Government of Southern Sudan Accelerated Child Survival Initiative Partners Cooperative Agreement Southern Sudan Relief and Rehabilitation Commission Annual Needs and Livelihoods and Anthropometric Assessment Office of Coordination of Humanitarian Affairs

EXECUTIVE SUMARY
Since the Annual Needs and Livelihoods and Anthropometric Assessment ( ANLA) was conducted in October 2008, the food security and nutrition situation in Southern Sudan has continued to deteriorate because of heightened cross boarder and internal conflicts, population displacements, delayed rains, deterioration in road networks/market access, and rise in food prices. This has given rise to concerns that crisis conditions may be emerging. In view of this, the Southern Sudan Relief and Rehabilitation Commission (SSRRC) and the Office of Coordination of Humanitarian Affairs (OCHA) recommended a rapid assessment to determine the extent of deterioration in five states: Jonglei, Upper Nile, Eastern Equatoria, Warap, Northern Bahr el Ghazal. The assessment involved a rapid nutritional assessment in the five states as well as a review of secondary data which sought to distinguish seasonal deviations from chronic issues to identify potential crises. The nutritional assessment coupled with a review of current available secondary health data suggests seasonally stable health and nutrition conditions. The data also indicates three populations with acute health needs and an elevated risk of morality which are of immediate concern - the Murle households affected by Lou Nuer massacres who remain in Lekongole area or were displaced into Pibor town; Lou Nuer households from Nyandit, displaced by Murle massacres into Akobo town and displaced populations from Abyei in Aweil East. Within these groups, children under 5 are a particular concern. Each of the five states examined also has populations of concern which should be monitored in the coming months. Areas within each state that should be monitored in the coming months were identified by comparing livelihoods systems against potential impacts of rain or crop failure.

Key Findings
The prevalence of Global Acute Malnutrition (GAM) among all children surveyed was 15.8 % and is indicative of critical nutritional situation based on the WHO standards. The prevalence of Severe Acute Malnutrition (SAM) of 3.6 % is also suggestive of widespread malnutrition among children. However, these rates are seasonally common. High morbidity rates were reported in the five states two weeks prior to the study. These levels were however consistent with seasonal morbidity patterns recorded from health facilities in these states. Both crude and under five mortality rates are at emergency levels for emergency situations. Overall, data from both the nutritional survey and review of secondary data shows seasonally stable health & nutrition conditions in the 5 states, but with pockets of worsening nutritional situation among populations with acute health & nutrition needs in 3 states in Jonglei (Pibor and Akobo); NBEG (Aweil East County) and Upper Nile (Longichuk and Sobat area - Maiwut, Nasser & Uranga). Other populations groups in the 5 states that require close monitoring in the coming months were identified. Eastern interior areas of Upper Nile, Lou Nuer communities in central Jonglei, and communities which may be impacted by insecurity or which may receive IDPs should there be conflict in Abyei are areas which should be prepared for potential increase in medical and nutritional needs and should exercise increased surveillance. Surveillance should also be increased for areas of the west of Eastern Equatoria. The key underlying causes of the high rates of chronic malnutrition include high morbidity, inadequate coverage of selective feeding programmes, poor IYCF and care practices and household food insecurity. 4

There is weak capacity for prevention and management of acute malnutrition in the five states. This is attributed to: o o o o o Limited partners supporting management of malnutrition including withdrawal in some areas (Jonglei World Relief; Upper Nile ACF) Limited funding for nutrition response: GoSS, UN, NGOs (*human resources, capacity building & surveillance needs) Low technical capacity of SMOH in management of severe malnutrition Weak PHC infrastructure for integrating management of acute malnutrition to increase coverage especially at community level. Coordination challenges at central and state level

Recommendations
Intervention efforts that address both immediate needs for the acute malnutrition cases and chronic malnutrition in the vulnerable population should be mobilized. An integrated approach should be adopted in addressing the underlying causes of malnutrition at community level. Measures to increase access to health facilities and improved coverage of selective feeding programmes would play a critical role in both preventing and treating morbidity and malnutrition. An effective nutrition surveillance system needs to be established including an appropriate context specific tool that facilitates assessment of issues that are contributing to acute malnutrition. This will allow a clearer understanding of the underlying causes and therefore improve the specificity and design of future interventions. In addition, developing longer term strategies to enhance the provision of basic services, sustainable strategies for livelihood support and social protection mechanisms are recommended. Specific recommendations include:

Immediate Interventions
In line with the findings of this assessment, immediate action to avert worsening health and nutrition conditions among populations in the three states with acute health and nutrition needs is recommended as follows:

Upper Nile (Longichuk county)

Strengthen appropriate clinical and therapeutic management of severe cases of malnutrition through existing therapeutic feeding programmes. Strengthen capacity of community based organisations and mother support groups that were previously trained to undertake active case finding and referral. These groups should concurrently promote appropriate infant feeding practices and hygiene promotion. Immediate implementation of ACSI in upper Nile state beginning with counties in the Sobat area e.g Longichuk.

Jonglei (Akobo, Pibor and Wuror

Pibor: Monitor on-going therapeutic response as per amended PCA with MSF Belgium for Pibor county Akobo West: Monitor on-going therapeutic response as per amended PCA with Save the Childrens Fund UK. Akobo East: Develop programme corporation agreement with IMC for facility and community based management of severe acute malnutrition. Advocacy with WFP for scale up of the supplementary feeding programme in Akobo and Pibor counties 5

Amend existing PCA with ACF USA to accommodate increased case load of severely malnourished children Support on-going nutritional surveillance

NBEG - Awiel East county Advocacy with WFP for scale up of SFP in Akobo and Pibor counties Amend existing PCA with ACF USA to accommodate increased case load of severely malnourished children

In addition,
Scale up of targeted SFP in the 5 states, coupled with active case finding in order to identify moderately malnourished children for admission into SFP is critical. Nutritional status is highly sensitive to changes in the risk factors and therefore a childs nutritional status is likely to fluctuate considerably with seasonal changes. In addition, pregnant women and lactating mothers with infants less than 6 months require supplementary feeding during this period of high food stress.. Measles vaccination coverage is inadequate in the five states. Given the high prevalence of disease and severe acute malnutrition, it is necessary to implement a vaccination campaign. Specific attention should be made to ensuring that areas that are difficult to access are adequately covered, providing and reinforcing the importance of vaccination cards. Rehabilitation of acutely malnourished children through the existing selective feeding and outreach programs coupled with active case finding until household food security is restored is critical. Public health issues of concern identified and detailed in the secondary data should be are addressed.

Medium - Long-Term Interventions

Intensify health and nutrition education activities at the household level to address child care, targeting caregivers. The main areas of focus should include promoting exclusive breastfeeding, appropriate young child feeding, diet diversification and improvement in household hygiene including health care practices. This should also include development of local IEC nutritional education materials for community level health promoters. Establish a regular nutrition surveillance system. On-going capacity building of malnutrition SMOH staff and the community to manage severe

Assess and strengthen programmes and strategies currently addressing IYCF with a view to improving the protection, promotion, and support of optimal infant and young child feeding. Work to improve coverage of life saving interventions such as Vitamin A supplementation, immunization and use of LLITNs by children and pregnant mothers. Strengthening of hygiene practices to reduce the incidence of diarrhoeal disease including health education to educate the community on treatment of drinking water. Strengthening mobile clinic initiatives to cover the rural populations and support outreach services and community strategy to encourage caregivers to seek health services

Background to Assessment
An Annual Needs and Livelihoods and Anthropometric Assessment (ANLA) was conducted in Southern Sudan in October 2008 to provide a benchmark for assessing the scope of food security and nutrition needs in Southern Sudan for 2009, and also to guide food security and nutrition programming. This was a joint effort between SSRRC, FSTS/SSCCSE, WFP, UNICEF, MOA, FAO and MOH. Since the ANLA was conducted in October 2008, the food security and nutrition situation has continued to deteriorate because of heightened cross boarder and internal conflicts, population displacements, delayed rains, market fluctuations, deterioration in road networks/market access, and rise in food prices. This has given rise to concerns that crisis conditions may be emerging. In view of this, the Southern Sudan Relief and Rehabilitation Commission (SSRRC) and the Office of Coordination of Humanitarian Affairs (OCHA) recommended a rapid assessment to determine the extent of deterioration in five states: Jonglei, Upper Nile, Eastern Equatoria, Warap, Northern Bahr el Ghazal. These states were chosen based on pre-existing levels of food security and 2009 events. The assessment involved a rapid emergency nutritional assessment in the five states as well as a review of secondary data. Information for the secondary data was derived from MOH Integrated disease surveillance reports, consultations with health facilities and with local NGOs as well as a review of admission rates in selective feeding Programs. The health and nutrition assessment was designed to identify deviations from seasonal norms which may indicate deterioration which may lead to crisis conditions. This report presents findings of both the rapid nutritional assessment and secondary data review for Health and Nutrition conditions.

Methodology
Standard anthropometric procedures were used in assessment of nutritional status. Measurements of weight, height and mid upper arm circumference were taken for children in households with a child under five years. Age of children was entered in months, using documentation when available, else recorded as given by the mother to the nearest month. Weight was taken using Salter scales calibrated to 25 kg while length boards were used for length and height measurements of children. A precision of 0.1cm was used for recording height measurements and 0.1kg for weight measurements. The Mid-Upper Arm circumference (MUAC) was measured at the mid-point of the left upper arm (precision of 0.1 cm), using standard MUAC tapes.The presence of bilateral pitting oedema was assessed for all children, by applying pressure on the dorsal side of both feet for at least 3 seconds. If the pit remained after removing the pressure, the outcome was considered to be positive. Persons trained for the ANLA survey were used for data collection Retrospective morbidity: Caretakers were asked for episodes of illness in the last 2 weeks (14 days) prior to the survey. The cause of illness and whether treatment was sought was also recorded. The following case definitions were used: Fever with chills (Malaria) Diarrhea (watery stool >3/24H); Bloody (watery stool with blood >3/24H) Respiratory infection (fever with difficulty breathing or cough); Measles (fever with red rash) Coverage of life saving interventions: Measles vaccination and Supplementation with Vitamin A: Assessed by checking for measles vaccination and vitamin supplementation on EPI cards and/or verbal confirmation from the caretakers. Caregivers asked about utilization of treated nets. 7

Mortality data: Retrospective mortality data was collected using the current household census method in all the households visited, including those with no children aged less than five years old. The recall period was 94 days. Information was collected on the number of deaths over the recall period. The presumed causes of death were recorded based on the following case definitions: Secondary data Information for the secondary data was derived from MOH Integrated disease surveillance reports, consultations with health facilities, local NGOs as well as a review of admission rates in selective feeding Programs for OTP and SFP. Information on current health conditions sought to utilise existing health sector information systems. Health facility monthly morbidity reports were provided by supporting agencies. Agency and key stakeholder interviews helped inform on communities of special concern. To identify deteriorating health or nutrition conditions required distinguishing between chronically poor nutritional status indicators, their seasonal fluctuations and to identify deviation from the seasonal norm. The South Sudan Livelihood Profiles report was used to interpret the impact of current security and climatic conditions on livelihoods and their potential impacts on health conditions Nutrition and mortality baseline levels were estimated using historic survey data (1998 to 2009) and compared against 2008 ANLA levels. Morbidity baselines and health facility consultations used the Picture of Health Project findings and extrapolated those findings for the former Upper Nile Region to include Bahr el Ghazal and eastern Equatoria.

Procedure for data Analysis Data processing and analysis for the anthropometric data was carried out using ENA (SMART), ENA and SPSS 15.0 software. The calculation and analysis of anthropometric data and mortality was done using ENA, with the WHO 2006 1 and NCHS 19772 sex
averaged reference standards selected for the calculation of nutritional indices and cut-off points for malnutrition. The software flagged off any extremes, potentially incorrect or out of range values. The following lower and upper bounds are fixed to identify these extremes or potentially incorrect z-score values. All flagged off z-scores were excluded from the analysis. SMART flag limits: Indicat or WHZ HAZ WAZ Lower bound -3.0 -3 -3 Upper bound +3.0 +3 +3

To determine the nutritional status the following variables were considered for analysis: sex, age, weight, height or length and oedema. The cluster number was also included for segregation purposes and to allow for smooth merging up of data with the other household variables in the SPSS software. During the z-score calculations the following facts were taken into consideration. 1. If Sex is missing the observation is excluded from analysis. 2. If Weight is missing, no WHZ and WAZ are calculated, and the programme derives only HAZ. 3. If Height is missing, no WHZ and HAZ are calculated, and the programme derives only WAZ. 5. For any child records with missing age (age in months) only WHZ was calculated.
1 2

WHO Child Growth Standards- WHO Multicentre Growth Refrence Study

National Centre for Health Statistics (1977) NCHS growth curves for children, birth 18years. United States Vital Health Statistics. 165, 11-74.

6. If a child has oedema only his/her HAZ is calculated. Additional analyses for frequencies, descriptive, correlations and cross tabulations were conducted using SPSS 15.0 for Windows ENA Epi Info and Excel. Immunization/Supplementation, Morbidity and household questionnaire data was also analyzed using SPSS.

Nutritional Status Indices

Acute Malnutrition Indices Weight-for-height (WFH) index Acute malnutrition rates are estimated from the weight for height (WFH) index values and oedema. The WFH indices obtained were derived from comparison of children in the survey to the WHO 20063 references and are reflective of current nutritional conditions. WFH indices were expressed both in Z-scores Indicators of acute malnutrition using WFH z-scores and Percentage of the Median of the reference population:

Table 1: Acute Malnutrition Indicators

Weight for Height z- Weight for Height % score of the median Acute <-2 SD and/or oedema < 80% and/ or oedema

Global Malnutrition Moderate Acute <-2 SD and -3 SD < 80% and 70% Malnutrition Severe Acute <-3 SD and/or oedema < 70% and/or oedema Malnutrition Global acute malnutrition (GAM) is therefore defined as the proportion of children presenting with a weight for height index less than -2 Z scores or less than 80% percent of the median and/or oedema Mid-Upper Arm Circumference (MUAC) MUAC, like weight for height, is used to quantify wasting in a population. MUAC is easier to measure than Weight for Height and has recently been shown to be a better indicator of acute malnutrition than W/H4, using WHO standards for MUAC-for-age5. MUAC is used as a tool for rapid screening at community level and is a good predictor of the risk of mortality. The guidelines are as follows: MUAC MUAC MUAC MUAC < 11.5 11.5 12.5 13.5 cm Severe malnutrition and high risk of mortality cm and <12.5 cm Moderate malnutrition and < 13.5 cm At risk of malnutrition cm Satisfactory nutritional status

Chronic Malnutrition Index

Height-for-Age (HFA) - Stunting Chronic malnutrition rates are estimated from the height-for-age (HFA) index values. The HFA indices were compared with WHO standards and are reflective of long-term malnutrition. HFA indices are expressed in Z-scores and HFA % of median.

3 4

WHO Child Growth Standards. Myatt M, Duffield A(2007). Weight for Height and MUAC for estimating the prevalence of acute malnutrition? A review of survey data collected between September 1992 and October 2006. IASC Global Nutrition Cluster 5 Current cut-off for severe acute malnutrition revised at MUAC < 115

Table 2: Height for Age indices

Height score Chronic <-2 SD for Age z- Height for Age % of the median < 90%

Global Malnutrition Moderate Chronic <-2 SD and -3 SD < 90% and 80% Malnutrition Severe Chronic <-3 SD < 80% Malnutrition Global chronic malnutrition is therefore defined as the proportion of children presenting with a weight for age index less than -2 Z scores or less than 90% percent of the median and/or oedema Weight-for-Age (WFA)-Underweight Weight-for-Age (WFA)-Underweight WFA is a composite index that reflects both wasting and stunting. It is not a good indicator of current nutritional stress but can be used to follow individual children longitudinally in the community. The HFA indices were compared with WHO standards. WFA indices are expressed in Z-scores and WFA % of median.
Table 3: Weight for Age indices

Global Underweight Moderate Underweight Severe Underweight Mortality Indices

Weight for Age zscore <-2 SD and/or oedema <-2 SD and -3 SD <-3 SD and/or oedema

Weight for Age % of the median < 90% and/ or oedema < 90% and 80% < 80% and/or oedema

The crude mortality rate (CMR) is determined for the entire population surveyed for a given period. The CMR using the current census method is calculated as follows 6: CMR = 10,000 people x number of deaths during recall = Deaths/10,000/day Number of recall days number of current residents +1/2 (No. of deaths during recall) -1/2 (No. of births during recall) The proportion of deaths among children under-five years of age (U5MR) is also calculated the same way using the under five population data. The thresholds are defined as follows 7:
Table 4: Mortality Thresholds

Alert level: Emergency level:

Total population Under-five population CMR U5MR 1/10,000 people/day 1/10,000 children/day 2/10,000 people/day 2.3/10,000 children/day

6 7

Save the Children (November 2004) Emergency Nutrition Assessment Guidelines for field workers The Sphere Standards, 2006

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3. FINDINGS
3.1 DESCRIPTION OF THE SURVEY SAMPLE

Table 8: Sample characteristics: Health and nutrition Survey in 5 states ( July 2009) Number of children 0-59 months surveyed Number of children 6-59 months analysed Number of anthropometry data excluded (SMART Flags) Household Census: Number of total population surveyed for mortality Number of children under five surveyed for mortality Number of HH covered in the mortality survey Number and % of children referred to SFP (WHZ <-2SD) 15.8% 731 671 31

5424 1393 739

101

3.2 Anthropometric Results: Children (based on WHO Standards 2006) 3.1.2 Distribution by age and sex Table 9: Distribution of age and sex of sample
Boys no. 6-17 months 18-29 months 30-41 months 42-53 months 54-59 months Total % Girls no. % Total no. % Ratio Boy:girl

91 106 108 51 8 364

49.5 52.7 59.7 51.0 50.0 53.4

93 95 73 49 8 318

50.5 47.3 40.3 49.0 50.0 46.6

184 201 181 100 16 682

27.0 29.5 26.5 14.7 2.3 100.0

1.0 1.1 1.5 1.0 1.0 1.1

Of the children measured, 53.4% were boys and 46.6% were girls (Table 9). Despite the fact that there were more boys than girls in the sample, the overall sex ratio (calculated by dividing the total number of boys with the total number of girls) was 1.1 which is within the recommended range of 0.8 1.28 demonstrating an unbiased sample. The age and sex distribution of the study group is graphically shown in Figure 6.

Assessment and Treatment of Malnutrition in Emergency Situations, Claudine Prudhon, Action Contre la Faim (Action Against Hunger), 2002.

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Figure 6: Distribution by Age and Sex

3.1.3 Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex (Based on WHO and NCHS References) Table 10: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex
WHO Referenc e All n = 640 (101) 15.8 % (10.7 22.7 95% C.I.) (78) 12.2 % (8.0 18.2 95% C.I.) (23) 3.6 % (1.3 - 9.4 95% C.I.) NCHS Referenc e All n = 651 (110) 16.9 % (11.3 24.5 95% C.I.) (93) 14.3 % (9.2 - 21.4 95% C.I.) (17) 2.6 % (0.8 8.0 95% C.I.) WHO Referen ce Boys n = 340 (57) 16.8 % (9.2 28.6 95% C.I.) (48) 14.1 % (7.4 25.2 95% C.I.) (9) 2.6 % (0.9 7.6 95% C.I.) NCHS Referen ce Boys n = 345 (64) 18.6 % (11.6 28.2 95% C.I.) (60) 17.4 % (10.2 28.1 95% C.I.) (4) 1.2 % (0.3 - 4.7 95% C.I.) WHO Reference Girls n = 300 (44) 14.7 % (8.9 - 23.1 95% C.I.) (30) 10.0 % (6.6 15.0 95% C.I.) (14) 4.7 % (1.5 - 13.5 95% C.I.) NCHS Reference Girls n = 306 (46) 15.0 % (9.5 - 22.9 95% C.I.)

Prevalence of global malnutrition (<-2 z-score and/or oedema) Prevalence of moderate malnutrition (<-2 z-score and >=-3 z-score, no oedema) Prevalence of severe malnutrition (<-3 z-score and/or oedema)

(33) 10.8 % (7.0 - 16.3 95% C.I.)

(13) 4.2 % (1.3 12.9 95% C.I.)

The prevalence of oedema is 1.4 % Table 10 shows that the prevalence of Global Acute Malnutrition (GAM) among all children was 15.8 % (10.7 - 22.7 95% C.I.) indicative of a critical nutritional situation based on the WHO standards9. The prevalence of Severe Acute Malnutrition (SAM) of 3.6 %( 1.3 - 9.4 95% C.I.) is suggestive of widespread malnutrition among children. Analysis of the data by sex shows that a higher proportion of boys 16.8 % (9.2 - 28.6 95% C.I.)is malnourished than girls
9

WHO cut off points for wasting using Z scores (<-2 Z scores in populations: <5% acceptable; 5-9% poor; 10-14% serious; >15% critical).

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14.7 %(8.9 - 23.1 95% C.I.). However the overlapping confidence limits indicated that the difference in malnutrition between the boys and girls was NOT statistically significant - both genders are at equal risk of malnutrition.

Figure 7:Comparative graph of GAM and WHO 2006 Reference population

Prevalence of acute malnutrition by age based on weight-for-height z-scores and/or oedema Table 11: Prevalence of acute malnutrition by age based on weight-for-height zscores and/or oedema (WHO 2006)
Severe wasting (<-3 z-score) Age (mths ) 6-17 18-29 30-41 42-53 54-59 Total Total no. 173 192 169 95 11 640 No. 4 4 5 1 0 14 % 2.3 2.1 3.0 1.1 0.0 2.2 Moderate wasting (>= -3 and <-2 z-score ) No. % 19 23 18 15 3 78 11.0 12.0 10.7 15.8 27.3 12.2 Normal (> = -2 z score) No. 145 162 145 79 8 539 % 83.8 84.4 85.8 83.2 72.7 84.2 Oedema

No. 5 3 1 0 0 9

% 2.9 1.6 0.6 0.0 0.0 1.4

The above table categorizes the distribution of the acute malnutrition rate by age group based on weight and height in z-scores and or oedema. No consistent trend is evident for either severe or moderate wasting but analysis of variance (ANOVA) revealed that there was a highly significant differences (p=0.015) in group means. To verify this, the age groups are re-categorized in Table 13 below, for sub-analysis. Table 12: Distribution of acute malnutrition and oedema based on weight-forheight z-scores 13

Oedema present Oedema absent

<-3 z-score Marasmic kwashiorkor No. 2 (0.3 %) Marasmic No. 27 (4.0 %)

>=-3 z-score Kwashiorkor No. 7 (1.0 %) Not severely malnourished No. 635 (94.6 %)

This table shows that there were 9 cases of nutritional oedema observed in the analysed sample- 2 with marasmic kwashiorkor and 7 with frank kwashiorkor. There are 27 children (4.0%) who are severely wasted (marasmus). These point to a critical emergency situation.
Prevalence of acute malnutrition (weight-for-height z-scores) by comparison of age

groups Table 13: Prevalence of acute malnutrition based on weight-for-height z-scores and by age group
6-59months n = 640 (101) 15.8 % (10.7 - 22.7 95% C.I.) (23) 3.6 % (1.3 - 9.4 95% C.I.) 6-29 months n = 387 (58) 15.9% (12.120.6 C.I.) (16) 4.4% (1.3-13.3 C.I.)

ZScores

Global Acute Malnutrition: W/H < -2 Z-score and/or oedema Severe Acute Malnutrition: W/H < -3 Z-score and/or oedema

To analyze the effect of age on nutritional status, the whole sample was compared to a subsample of children (6-29months). This sub-sample would coincide approximately with the weaning period in a childs life cycle and thus highlight the effect of infant-feeding practices. The GAM of the younger children was slightly higher than the overall GAM and the burden of severe wasting (SAM) also higher. There is no statistically significant difference between acute malnutrition rates observed among children aged 6-29 months and the whole sample (p<0.05). This in this sample, age is not a risk factor for malnutrition.

Prevalence of acute malnutrition based on the percentage of the median and/or oedema Table 14: Prevalence of acute malnutrition based on and/or oedema percentage of the median

Prevalence of global acute malnutrition (<80% and/or oedema) Prevalence of moderate acute malnutrition (<80% and >= 70%, no oedema) Prevalence of severe acute malnutrition (<70% and/or oedema)

NCHS Reference n = 673 (74) 11.0 % (7.6 - 16.8 95% C.I.) (55) 8.2 % (6.1 - 11.6 95% C.I.) (19) 2.8 % (0.9 - 8.8 95% C.I.)

Table 15: Prevalence of malnutrition by age, percentage of the median and oedema (NCHS 1977)
Severe wasting (<70% median) Moderate wasting (>=70% and <80% median) Normal

based

on

weight-for-height

Oedema

(> =80% median)

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Age (mths ) 6-17 18-29 30-41 42-53 54-59 Total

Total no.

No.

No.

No.

No.

173 195 174 96 13 651

2 2 5 1 0 10

1.2 1.0 2.9 1.0 0.0 1.5

15 20 11 8 1 55

8.7 10.3 6.3 8.3 7.7 8.4

160 174 162 89 14 599

92.5 89.2 93.1 92.7 107.7 92.0

5 3 1 0 0 9

2.9 1.5 0.6 0.0 0.0 1.4

Once again, ANOVA revealed a significant difference in nutrition status between groups and this was explored in Table 16 below: Table 16: Prevalence of acute malnutrition based on percentage of the median and by age group
6-59months n=673 (74) 11.0 % (7.6 - 16.8 95% C.I.) (19) 2.8 % (0.9 - 8.8 95% C.I.) 6-29months n = 381 (47) 12.3 % (8.3 - 19.2 95% C.I.) (12) 3.1 % (0.9 - 11.5 95% C.I.)

% Median

Global Malnutrition: W/H < 80% oedema Severe Malnutrition: W/H < 70% oedema

Acute and /or

Acute and /or

Based on percentage of the median, the younger age group (6-29months) has a higher rate of GAM and SAM. However, a chi-square analysis revealed no statistically significant difference between malnutrition rates observed among children aged 6-29 months and the whole group (p<0.05). Risk of Mortality: Childrens MUAC (WHO Standards for MUAC-for-Age) Table 17: Distribution of MUAC by Nutritional Status
Nutritional Status Severe malnutrition Moderate malnutrition At risk of malnutrition Satisfactory nutritional status MUAC Criteria <11.5cm >=11.5 and <12.5cm >=12.5 and <13.5cm >=13.5cm TOTAL Number n 17 52 154 457 680 Percentage % 2.5 7.6 22.6 67.2 100

From Figure 8, it is evident that the younger children have a higher rate of GAM than those 30-59 months. According to the MUAC index, prevalence of malnutrition i.e. GAM (MUAC<12.5cm) in 680 children was 10.1% and severe malnutrition (SAM) at 2.5% (Table 17). Figure 8: Acute Malnutrition expressed in MUAC in Age Groups

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Generally, the younger age groups seem much more affected than the older age groups. Twoway ANOVA and chi-square analysis indicates that there is indeed a highly significant difference (p=0.00) between the younger (6-29 m) and whole (6-59) sample.

Table 18: Prevalence of Acute Malnutrition by State

States EEQ Warrap U.Nile NBEG Jonglei All States GAM 7.8 19.4 24.4 15.2 18.6 16.6 MAM 5.5 15.7 17.7 13.1 17.1 14.2 SAM 2.3 3.7 7.3 2 1.4 2.7 ODEMA 1.6 0 5.7 0 0 1.4

Prevalence of Chronic Malnutrition (stunting) expressed in Z scores Table 18: Chronic Malnutrition expressed by Z scores
Level of malnutrition Global CM (<2SD and/or oedema) 95% CI Moderate CM (<-2- -3 SD) 95% CI Severe CM (<-3SDand/or oedema) All n = 553 (116) 21.0 % (12.3 - 33.5 95% C.I.) (92) 16.6 % (10.0 - 26.4 95% C.I.) (24) 4.3 % (1.9 - 9.7 95% C.I.) Boys n = 288 (64) 22.2 % (13.4 - 34.5 95% C.I.) (54) 18.8 % (11.5 - 29.1 95% C.I.) (10) 3.5 % (1.2 - 9.7 95% C.I.) Girls n = 265 (52) 19.6 % (10.6 - 33.4 95% C.I.) (38) 14.3 % (8.0 - 24.3 95% C.I.) (14) 5.3 % (2.4 - 11.4 95% C.I.)

16

95% CI

Height for age (stunting) is an indicator of long term malnutrition arising from deprivation related to persistent poor food security situation, micronutrient deficiencies and recurrent illnesses and other factors which interrupt normal growth. A high rate of stunting, 21.0 % (12.3 - 33.5 95% C.I.) was reported. There was no difference in the level of stunting (Table 18) between the boys and girls, as judged by the overlap in the Confidence Intervals.

Figure 9: Height-for-Age z-scores

3.2

MORTALITY RESULTS (retrospective over 3 months prior to interview)

Mortality Indices The crude mortality rate (CMR) is determined for the entire population surveyed for a given period. The CMR using the current census method is calculated as follows 10: CMR = 10,000 people x number of deaths during recall = Deaths/10,000/day Number of recall days number of current residents +1/2 (No. of deaths during recall) -1/2 (No. of births during recall) The proportion of deaths among children under-five years of age (U5MR) is also calculated the same way using the under five population data. The thresholds are defined as follows 11: Total population Under-five population
10 11

Save the Children (November 2004) Emergency Nutrition Assessment Guidelines for field workers The Sphere Standards, 2004

17

Alert level: Emergency level:

CMR 1/10,000 people/day 2/10,000 people/day

U5MR 1/10,000 children/day 2.3/10,000 children/day

Mortality was assessed using the current household census method. There were 5424 individuals alive at the time of the survey, 1393 of who were children under-five years old. For all the deaths recorded, 41(35.3%) occurred in children less than 5 years and 75(64.7%) occurred in persons greater than 5 years old. Table 19: Mortality rates CMR (total deaths/10,000 people / day) : 2.35 (1.07-5.10) (95% CI) U5MR (deaths in children under five/10,000 children under five / day): 3.22 (1.218.34) (95% CI) Out of 739 households sampled for mortality data, a total of 41 children under five years and 75 over-5s were reported to have died 3 months before the survey, thus yielding a specific under five mortality rate of 3.22/10,000/day and crude mortality rate of 2.35/10,000/day respectively. Both the mortality rates are at emergency levels, by Sphere Standards. Table 20: Causes of Death 1 2 3 4 5 Cause of Death Fever/Malaria Diarrhoea Cough Unknown Others

<5
14 10 0 1 0

(n=25)

>5 (n=47)
26 0 0 5 16

The main presumed causes of death among children under-five years were Fever/malaria and diarrhoea. 1 unknown death occurred. For deaths over 5 years, 26 deaths were caused by Fever/Malaria, 5 by unknown causes and 16 by other specified illnesses. The information on number of deaths should be viewed with caution due to the inherent survey limitation of difficulties in measuring mortality. Possible reasons for this include manipulation of information and poor recall of date of death by the survey population, both of which that may lead to an overestimation of incidence of death 12.
3.3 CHILDRENS MORBIDITY

Table 21: Prevalence of reported illness in children in the two weeks prior to interview (n= 682) Symptoms of reported episodes of N of % illness responses Watery Diarrhoea 275 42.4 Bloody Diarrhoea 51 7.9 Cough with breathing difficulty 296 45.4 Fever 398 61.2 Some children had more than one reported disease during the recall period of 2 weeks prior to the survey, and thus the cumulative percentage of reported illness exceeds 100%. Thus, there were 1020 cases of disease reported in 682 children. Figure 10: Prevalence of Reported Illness
12

Save the Children (November 2004) Emergency Nutrition Assessment Guidelines for field workers- Difficulties with measuring mortality

18

The prevalence of reported illness was determined based on a two-week recall period (inclusive of the day of the survey). Figure 10 illustrates that most of the children suffered from cough/acute respiratory infections (ARIs), watery dirrhoea and fever. The three main conditions mentioned above, account for >95% of all the cases of disease reported.

Figure 11: Caretakers health Seeking behaviour

Health care seeking behaviour of caretakers determines the preference and quality of health care services obtained whenever a child falls ill. Of the 545 caretakers interviewed, More than half (67.7%) of caretakers sought assistance for illness of the child outside home. Quality of health care services and duration taken before a sick child receives medical attention contributes to the severity of the illness. However, only 49 (7.2%) of sick children received medical assistance from the hospital. This is indicative of poor health-seeking practices.
3.4 VACCINATION

Table 23: Vaccination coverage: Measles for 6-59 months

Measles (with card) 6-59 months N: 644 Ye s n = 224 34.8% (31.3-38.4 95%C.I) Measles (with confirmation) 6-59months N: 644 n = 313 48.6% (42.8-55.0 95%C.I) card or

When estimating measles coverage, only children 6 months of age or older were taken into consideration as they are the ones who were eligible for routine vaccination. The vaccination coverage was calculated as the proportion of children immunized based on 19

records and recall. Using both card and confirmation, there seems to be a low coverage rate (48.6%) for measles vaccinations- way below the recommended SPHERE coverage cut-off point of 90%13. Approximately 28% of the coverage reported here was based on recall and not evidenced by a health card.
3.5 VITAMIN A SUPPLEMENTATION/SLEEPING UNDER LLITN

Table 24: Vitamin A supplementation coverage

Vitamin A 59months) N:648

supplement

(6- LLITN Utilization 59months) N:648

n = 244 37.7% (34.2-41.4 95%C.I)

(6-

n = 244 46.8 % (43.1-50.6 95%C.I)

Vitamin A supplementation was assessed over a 6-month recall period during which the children should have received at least 1 dose. The coverage of Vitamin A supplementation is at 46.8%, below the optimum cut-off of 90%. The MoH reported a slightly rate of coverage for W. South district for the period Jan-June2009, averaging at 44.5%. This is a worrying trend as adequate micronutrient supplementation is crucial in the reduction of chronic malnutrition. This survey showed that only a very small proportion (37.7%) of the children was sleeping under LLITNs. Malaria remains a leading cause of morbidity and mortality for children and pregnant mothers in Southern Sudan. Pregnant women and young children are at particular risk of malaria infection. Health records for the month of January to February 2008 from the district hospital showed that malaria ranked two and one out of ten most common diseases affecting children under five years old and adults respectively. 3.6 PROGRAMME COVERAGE

Table 25: Selective Feeding Programmes Coverage Programme type Supplementary programme coverage feeding 16.7 % 95.7 %

Therapeutic feeding programme coverage

The currently accepted methods14 of estimating the coverage of selective feeding programmes uses the two-stage cluster- sampling survey methodology to estimate the prevalence of acute malnutrition in the programme area. Coverage is estimated either directly or indirectly using different formulas. The direct method was used in estimating coverage in this survey. It is the most commonly used method to assess coverage and it involves adding a question to the anthropometric questionnaire to record whether or not a child is currently registered in the feeding programme.

Cumulative number of children registered in SFP: 13 Cumulative number of children registered in OTP/TFP: Cumulative number of children referred for SFP/ (Children with WHM<80% and >= 70% that are not enrolled):
13 14

22 65

For the population to be protected against epidemics. Save the Children (November 2004) Emergency Nutrition Assessment Guidelines for Field Workers

20

Cumulative number of children referred for OTP/TFP (Children with WHM<70% that are not enrolled):

1 x

SFP coverage = Children registered in SFP in last 3 months 100

Children registered in SFP+ children with WHM<80% and >= 70% that are not enrolled = 13/13+65 x 100 = 16.7% /TFP in last 3 months x OTP coverage = Children registered in OTP 100

Children registered in OTP + children with WHM<70% that are not enrolled = 22/22+1 x 100 = 95.7% This formula estimats RECENT coverage in a given period (PERIOD PREVELENCE). This limitation has been minimised in this survey by inclusion of children recently discharged from the SFP/OTP i.e. those discharged in the past 3 months before survey date. This gives a more accurate picture of the programme impact in the survey area without logistical bias (caused by discharge before the survey period). The SFP coverage rate (16.7%) calculated using the formula above is below the accepted levels of 50.0% in rural areas according to the SPHERE Standards (2004). This may be partially attributed to the fact that children discharged before May 2009 (and still in the recovery phase) were not captured in this formula. The OTP coverage, on the other hand, was very good at 95.7%, within acceptable standards. It is important to note that the reported coverage rates at best, estimate the true picture of what is on the ground because of the limitations inherent in the survey design and formula. 3.7 SUPPLEMENTARY RATION ADEQUACY

For the supplementary ration to be effective in improving the nutrition status of the child enrolled in the SFP programme, it has to be adequate in terms of quantity and availability. To measure this, the duration which the ration lasts in the household was asked. In the 86 HH eligible, the average duration of ration utilization was 0.6weeks (SD 1.1) i.e. less than a week as shown below: This implies that the child did not have SFP ration for the duration of time recommended until the next distribution. To measure dilution of the ration by HH member usage of the ration, it was acknowledged that 5 (1.3%) of 396 HH share the SFP ration. These two findings are contradictory as the low SFP ration duration in the HH seems to suggest that its utilization was not sorely for the child. It may be beneficial to look for other underlying reasons for this situation. This may include reselling in the market, bartering or saving for seed.

3.8 INFANT FEEDING PRACTICES

Information on infant and young child feeding practices was obtained based on a 24-hour recall, in line with the WHO guidelines to minimize recall bias and thus obtain more valid information. The indicators used for infant feeding practices are based on Knowledge, Practice and Coverage (KPC) 2000+15 founded on WHO guidelines. These are also the key indicators
15

Arimond M & Ruel T. M Generating Indicators of Appropriate Feeding of children 6 through 23 months from KPC 2000+ November 2003. Food & Nutrition Technical Assistance Project (FANTA).

21

for the Global Strategy for Infant and Young Child feeding. The information on breastfeeding practices was obtained for children aged 0-24 months.

Table 26: Infant Feeding Practices

N = 491 Ever breastfed Yes No Child Currently breastfeeding Yes No Initiation of breastfeeding 0 1 hour > 1 hour Dont Know Frequency of Feeding None Once 2 - 3 three times 4 5 times Age at Introduction of Complementary feeds Average duration of breastfeeding

441 50 320 170 349 100 23

89.8 10.2 65.3 34.7 73.9 21.3 4.8

81 18.4 121 27.4 216 49.0 23 5.2 Average 6.2 mons (Sd 2.4) 16.5 mons (Sd 8.1)

Initiation of breastfeeding was nearly universal with 95.2% of the mothers having breastfed their children. Over half (65.3%) of the children 0-24 months were still being breastfed at the time of the survey. Approximately three quarters of the children (73.9%) had been to put to the breast within one hour after birth as recommended by WHO 16. The other percentage of caretakers started breastfeeding later or did not know the BF initiation. It will be important to establish the underlying causes of the prevalent IYCF practices to facilitate design of feasible interventions to improve IYCF practices which are a key underlying cause of malnutrition observed.

16

WHO (1989): Protecting, promoting and supporting breastfeeding: special role of maternity services: a joint WHO/UNICEF Statement. Geneva, WHO.

22

The survey questionnaire asked the caretakers when (in months) they had introduced food other than breast milk (if the child was still not being exclusively breastfed). The introduction to complementary foods should happen at 6months (24wks) of age. This is because breast milk alone is not sufficient to provide all the required nutrients for the childs optimal growth from this age onwards. From the table above, the average age of introduction to complementary foods is 6.2 months (mode=6.00) which implies that exclusive breastfeeding is practiced for up to 6 months by the majority of caretakers. This is a good practice that should continue to be encouraged. The average duration of BF is 16.5 months (SD 8.1) which implies that the majority of caretakers are not breastfeeding as recommended for at least 2 years. Beliefs and practices on IYCF in communities should be assessed and documented as a basis for programme planning. Complementary feeding practices Complementary feeding rate For the average healthy breastfed infant, meals of complementary foods should be 2-3 times per day at 68 months of age and 34 times per day at 924 months of age, with additional nutritional snacks offered 12 times per day as desired (FANTA, 2003, WHO, 2003). As a whole, the 341 children assessed (6-24 months of age) who received food/drinks (excluding breast milk and water) ate 1.8(0.39SD)) times. Analysis by age groups indicated that children 6-8 months of age ate 2.55 times (0.8 SD) and those 9-24 months ate 2.4 times (0.8 SD). The findings indicate that both the younger and older age group of children received inadequate number of meals within the recommended range of an average feeding frequency of 4-5 times per day.

3.9 Secondary dataSecondary data review

A review of the secondary health and nutrition data from MoH IDSR, health facility consultations and nutrition feeding programmes admission rates indicates seasonally normal conditions. The potential failure of rains or crops this year will likely have differing levels of health impact across the five states assessed. It is worth noting that at this time of the year, malnutrition rates can be almost twice WHO emergency thresholds and are some of the highest in the world. The data indicates the following three populations with acute health needs and an elevated risk of morality. The three populations of immediate concern are: The Murle households affected by Lou Nuer massacres who remain in Lekongole area or were displaced into Pibor town Lou Nuer households from Nyandit, displaced by Murle massacres into Akobo town Displaced populations from Abyei in Aweil East. Within these groups, children under 5 are a particular concern.

Each of the five states examined also has populations of concern which should be monitored in the coming months. These areas were identified by comparing livelihoods systems against potential impacts of rain or crop failure. There is currently no reported deterioration in these areas, but there is adequate reason to justify active surveillance. Based on recent history, current stable conditions could be expected to continue even with decreased crop yields in some areas. Rainfall fluctuations 2002 and 2005 resulted in dramatic grain reductions for some communities. Mortality and nutrition surveys done at that time were at seasonal expected levels. It would suggest that coping options utilised by affected communities are adequate to negotiate the loss of food or income source with minimal effect on morbidity. Notwithstanding unforeseen shocks, it would be unexpected to have a markedly different health or nutrition outcome than in 2002 or 2007. The assessment also examined other data sources to help explain the health and nutrition 23

stability during times of stress. In times of crisis in Sudan, children under-five can account for 50% of excess mortality17. The stress to households due to rainfall variation of the magnitude seen this year or 2002 does not appear likely to significantly disrupt child care to trigger deterioration into illness or malnutrition. Scale up of support to existing health services and nutrition programmes is however important because many health and nutrition indicators, even in the absence of an emergency are chronically above emergency thresholds. Continuing efforts to provide for the basic health needs for mothers and the elderly are also crucial in the coming months. Maternal mortality remains one of the highest in the world. Lastly, while stable conditions may be expected, additional unanticipated shocks in an already vulnerable community can lead to a spike in mortality and malnutrition 18. A high level of vigilance and preparedness is important during these periods.

3.10 State review

The following are highlights for each of the states from a review of secondary date on the nutrition situation, morbidity, mortality Jonglei The primary concern for Jonglei state are the displaced and victims of violence from Lekongole (Murle) or Nyandit (Lou Nuer). Dry conditions also increase the importance to the highly pastoral communities (particularly Lou Nuer) to move to the dry season grazing areas. If insecurity should interrupt that seasonal movement, mortality and malnutrition could increase as it has in the past. Beyond these areas of concern, indications are of otherwise stable conditions. Malnutrition and child morbidity rates recorded in the ANLA wereANLA were amongst the highest in the five states, but not exceptional for Jonglei at that time of year. While some areas of the state have relatively good health facility coverage and quality of services, others have no access to services. Outside the communities which experienced insecurity mortality may be stable .stable. Although there were no mortality surveys conducted this year in Jonglei, there were no reports of excess mortality from health facilities in the state. Mortality reported in the 2008 ANLA was comparable to mortality historic rates. Morbidity may be seasonally stable, outside of Pibor and Akobo. Morbidity reports from Wuror, an area experiencing very poor rainfall 19, indicated seasonal numbers and types of consultations. A seasonal decrease in ARI/pneumonia and diarrhoeas was observed through the dry season. The coming of the rains saw an increase in malaria/fever consultations, which is expected to continue and rise. The exceptions to the stable conditions were reported in Pibor and Akobo where comparatively higher U5 diarrhoeas were reported. Admission to OTP programmes in Wuror wereAdmissions to OTP programmes in Wuror were reported to be comparable to the previous year. Supplementary feeding

17 18

De waal, 1989. Such a spike was noted in 2002, in Lou Nuer areas. Lou communities in the Waat/Lankien area were engaged in a tribal fight which prevented their seasonal migration to grazing areas. The year was also a very dry one. They were forced to remain in wet season homes where there was little water and food. MSF Belgium responded to and documented those conditions.
19

Fewsnet, 2009

24

programmes programmes had slightly more admissions but were declining from their seasonal high point in May. Given the reports of diarrhoea in both Pibor and Akobo, sanitation may be a concern for the displaced in Akobo where queues at water points were observed. There are also indications of acute health needs in Pibor/Lekongole and Akobo, particularly for children, especially among the displaced populations. General conditions in Akobo are also poor as the area has been cut off from Malakal. In a worst case scenario, and outside of Pibor and Akobo, concern would be primarily for the Lou Nuer communities. Generally, for the state, if the crops were to fail or be reduced mortality and morbidity rates may experience little fluctuation. Mortality rates and malnutrition rates in previous dry years did not vary significantly from levels reported before and after those events. The greatest concern will be for the Lou Nuer of Wuror, Dirror, Nyrol. The areas from Pibor north-west through Wuror to Lankien are experiencing the most dramatic fluctuations in rainfall. Those counties are marginal rain-fed agricultural areas to which is accommodated in the Lou Nuers predominatly pastoral lifestyle. They are much more pastoral than many of their Gawar or Jikan neighbours. Disruption of their seasonal movement to the dry season grazing areas, particularly in drier years, has had significant impacts on mortality and malnutrition. Communities along the Nile, Zeraf and Pibor will may not be as as adversely affected by current rainfall fluctuations as they have more coping options. Annuak and Kachipo communities on the Ethiopian border, while predominantly agricultural benefit from robust agricultural conditions in those highland areas. They have not recorded crisis in previous dry years. The withdrawal of a long-standing health service provider from Pochalla leaves an important gap in service provision. Environmental health conditions and health behaviours are not expected to change.

Upper Nile The primary concerns in Upper Nile State are the potential effects of delayedof delayed rainfall and insecurity related to a Lou Nuer attack on a village outside of Nasir. Depending on the final performance of the rains and harvest, there may be concerns for increased morbidity in rural areas of Latjor. Upper Nile State generally performed very well in the ANLA exercise. Child morbidity, immunization, vitamin and latrine coverage ranked as one of the highest. Mosquito net utilisation was good. Malnutrition rates were amongst the lowest. In contrast, access to improved water sources was one of the poorest and they also reported some of the highest levels of chronic malnutrition. It is important to bear in mind the extremes that exist in the state between the relatively developed conditions and services available in Malakal or Nasir versus the regions to the east and north that continue to exist without development or services. There have been no reports of excess mortality in the state, beyond the 30 to 40 deaths in the village outside of Nasir. The ANLA CMR and U5CMR rates were consistent with rates documented in mortality surveys. Health facilities have reported seasonally normal levels and types of consultations (Fashoda, Panyikang). Fevers/malaria are increasing and are expected to continue to increase through the rains. The IDSR reported diarrhoeas in Nasir/Luakpiny and 25

fluctuating levels of malaria. Health facility coverage and quality varies with more and better services available along the Nile and Sobat. Malnutrition is likely to be seasonally normal. Malnutrition prevalence reported in the ANLA 2008 is similar to levels recorded in surveys previously during that time of year. OTP programmes are not reporting exceptional trends in admissions. In a worst case scenario, health issues may emerge in the drier areas in the interior if the rains fail. If seasonal movement is impeded (for example through insecurity) or if there is impeded access to grain, it could place additional stress on communities possibly leading to increased morbidity (ARI and diarrhoeas during the dry season). Alternate means of survei llance will be important as PHC coverage is weaker in the interior areas. Communities along the Nile and Sobat have many more coping and market options, reducing the impacts of a poor harvest year. Mortality surveys conducted during dry years report mortality levels similar to those in non-dry years. Malnutrition surveys conducted in dry years do not report significant deviation of either rates or their seasonal trends. Environmental health is unlikely to fluctuate considerably in rural locations, as are the behavioural health factors

Eastern Equitorial The State ranges from very dynamic economic areas in the west, along the Ugandan border to some of the most traditional pastoralist communities in the entire Sudan in the east of the country. This may explain the mixed performance of the state in the ANLA. EEQ reported the lowest malnutrition levels but highest chronic malnutrition. It had the lowest prevalence of child morbidity and poorest immunization coverage. The primary concern in Eastern Equatoria is the impact of the rainfall on the second season crops of the agricultural communities in the west of the state. The more pastoral communities are unlikely to be as affected by current rainfall conditions. Mortality may be stable. There have been no reports of fluctuations in mortality though few surveys have been conducted in this state. ANLA crude mortality rate was higher than rates reported in mortality surveys while the U5MR was lower than rates reported in a previous mortality survey (Kapoeta). Health facility coverage is fairly extensive in the east of the state, supported by agencies with a long-standing presence in those communities. They also have regular communication with Juba. The IDSR reported diarrhoeas, and fluctuating levels of malaria. Nutrition is likely to be at previously experienced levels. ANLA nutrition results were comparable to rates which had been recorded in the State. The only nutrition programme which was run in the region, operated for displaced Dinka communities, was closed in approximately 2004. A June 2005 nutrition survey in neighbouring Kajo Keji, reported GAM of 8.6, one of the lowest recorded in South Sudan. No new OTP admissions were recorded in Magwi in June. Increases in OTP admissions for April to June at SMoH were similar to those recorded in SMoH in CEQ and Jonglei states. There is no data on changes to baseline environmental health or social health factors. In a worst case scenario, the rains will result in a poor first and second harvest for the agricultural communities in the west of the state. The more pastoral communities in the West may be less affected as long as there are no impediments to their seasonal movement. Access to markets, and alternate coping strategies will assist households to cope, but it will place additional stress. 26

Increased surveillance will be important, particularly for immunizable diseases. Impacts on morbidity are likely to be less than those observed in 2002 or 2006 (in Kapoeta), much drier years. If those conditions emerge, a transitory increase in moderate malnutrition may emerge (more likely for those > 29 months). No emergency conditions were observed in Eastern Equatoria in 2002 or 2006.

Warrap The main concern in Warap is the rainfall and its potential impact on crop production. There is also a high risk of insecurity in the Abyei area. Concern also exists for the 5% of the population reported to be returnee in the ANLA. Together with Jonglei, Warap reported some of the poorest baseline health and nutrition indicators of the five states. The highest rate of acute malnutrition among the five states was also recorded here. The state also reported the highest rates of children underweight. Access to improved water source and sanitation were the lowest ranked. In contrast, child morbidity was average, stunting was low, immunisation was ranked in the middle and mosquito net coverage was the highest. Mortality rates may be stable. ANLA reported mortality rates were comparable to levels reported by previous mortality surveys. A June 2009 mortality surveys in Tonj South reported rates much lower than the ANLA rates. Morbidity appears to be stable. Health facilities are reporting levels and types of consultation that are seasonally normal and comparable with levels last year. Children are approximately 50% of consultations for diarrhoeas, ARI and fevers. Fevers are expected to increase through the rains. The IDSR reported diarrhoeas and malaria, with Twic reporting the highest number of cases. The WVI nutrition survey in June, reported levels of vaccination similar to those reported in the ANLA. Malnutrition appears to be at seasonal levels. The malnutrition rates reported in the ANLA were within the range reported by previous surveys. A WVI survey in Tonj South reported GAM levels comparable to other surveys conducted during that time of year. OTP and SFP programmes are reporting admissions following seasonal trends (decreasing from May peaks), and at levels comparable to last year. The WVI survey in Tonj South indicated access to improved water sources which was significantly lower than the level reported in the ANLA. It also reported a level of latrine prevalence that was still very low but two times higher than reported in the ANLA. It also reported that hand washing was done by less than 2% of women. In a worst case scenario, the poor rainfall, which is particularly affecting the north of the state, could reduce crop harvests. Livestock grazing is unlikely to be affected. In these largely rural communities, traditional coping mechanisms will be employed. Some households will be affected more than others (20% is food insecure or poor normally) and likely more so in the north of the state. These conditions will cause hardship rather than excess mortality. In 2003 and 2005, when harvests failed in NBEG, mortality rates reported in surveys were normal to lower than normal Insecurity and displacement from Abyei into Twic or Gogrial could precipitate emergency conditions in hosting communities.

Northern Bahr el Ghazal 27

The main concern for Northern Bahr el Ghazal is the delayed rainfall. The state is also recovering from a cholera outbreak this year. Some communities in Aweil East received persons displaced from Abyei 2008, and there concerns over the likelihood and potential repercussions of fighting in Abyei. Displaced households from Abyei continue to report serious health conditions and further conflict and fighting would likely exacerbate those conditions. In the absence of that conflict, conditions may be expected to remain stable across the state, including for returnee populations. Higher levels of AWD reported for <5s raises the need for surveillance of small children in particular as they may be more at risk of fevers in this peak season for fevers. Apart from malnutrition, the ANLA presented a generally poor picture of conditions in the State with child morbidity being one of the highest in the states surveyed. Immunization and vitamin A coverage rates were also some of the lowest. Access to improved water sources and sanitation are also some of the poorest. Acute malnutrition rate were however the third lowest and chronic malnutrition was ranked in the middle. Mosquito net coverage also ranked in the middle. The coverage and support to health facilities is comparable to other states. Mortality appears to be stable. Rates reported by ANLA in October were comparable to previous surveys. ACF USA conducted a mortality survey in Aweil East in June 2009 which returned some of the lowest CMR and U5MR rates recorded for the County. A cholera outbreak occurred throughout NBEG earlier this year. It was identified and managed and case mortality was similar to previous cholera outbreaks in South Sudan. Morbidity incidence is reported to be seasonally stable in the state, with ongoing concern for cholera/watery diarrhoea and possibly higher than normal malaria in Aweil East. Consultations in Aweil South are reported to be at levels and types comparable to last year. Anecdotal reports for other locations mirrored these observations. The IDSR still reports cases of cholera, almost entirely from Aweil Centre. Reported cases were for >5s. Watery diarrhoea is reported in all counties, but at higher rates in Aweil Centre. Water diarrhoea reports are mostly for <5s. Malaria is also being reported, particularly in Aweil East. Despite a report of a high rate of GAM in Aweil East, malnutrition prevalence may be at seasonally typical levels. The acute malnutrition for the state reported in the ANLA was low, even for that time of year. Historic rates will regularly double from the annual postrains low points. Reported rates of malnutrition are almost uniformly high across the state. There were two nutrition surveys conducted in the state in 2009. A VSFG survey in February in Aweil West reported rates GAM rates which were seasonally low and SAM rates which were commonly reported. The ACF USA survey in June in Aweil East, reported high GAM and SAM rates but at levels comparable to ones recorded in the past.

OTP programmes are reporting admissions in June which are at or above admissions for May. Admissions seasonally decrease in June or July. Levels of admissions are comparable to last year. ACF USA is reporting a spike in admissions continuing through June, when admissions normally decrease. They have attributed the increase to a combination of both the displaced from Abyei and the effects of the cholera/AWD outbreak.

28

In previous years of stress, like 2009, there have been recorded an extension of the seasonal peak in admissions through June and sometimes into July. SFP admissions are also reported to be increasing through June. Given the low coverage of both OTP and SFP programmes, a shift in incidence may reflect mothers decisions to enter their children in the programme rather than an increase in prevalence. There are also many difficulties with children entering multiple programmes in Aweil South. Both of these trends suggest increased energies expended to access particularly supplementary foods, not necessarily due to a change in the acute malnutrition prevalence. Concerns in a worst case scenario would focus on the displaced from Abyei. Otherwise, the state while under stress, may not show deterioration in mortality or morbidity. Poor rainfall and crop harvest appear to be most pronounced in the east of the state, and its impacts would be localised to certain communities. Like Warap, concern for a population level health crisis as a result of returnees, may be overstated. The vulnerable within that population is likely to be less than its estimated 0.8% of the total population. Morbidity and mortality may be comparable to 2005/6. After a very poor harvest in 2005 (75% staple crop production), nutrition and mortality surveys reported results comparable to previous and subsequent years. While crisis conditions would not be expected, as it is a year of greater stress for many households across the state, increased surveillance will be important. Surveillance should particularly consider <5s in areas which reported higher levels of AWD. DISCUSSION

4.

4.1 Nutritional Status The prevalence of severe malnutrition is indicative of critical levels of acute malnutrition since they are above the WHO critical levels set at 15% 20. These rates are however seasonally expected though the results must be interpreted with caution since the sample used is not statistically representative of the states covered. The levels of underweight (WFA) 18.7% and stunting (HFA) at 20.7% are also high but within range for sub Saharan Africa. The reported high rate of stunting is reflective of the cumulative effects of chronic food insecurity and recurrent illnesses. Looking beyond the seasonal shifts, it is important to address the causes of chronic malnutrition. Adequate food alone does not result to improved nutritional status if care practices and other underlying factors are not addressed.
Morbidity and Mortality

The mortality under five rates reported in this survey are unacceptably high and could predict future mortality especially if prevailing conditions of insecurity and internal displacements worsen. The main causes of U5 mortality in the area include malaria, ARTIs and diarrhoea. High morbidity rates were reported in the five states two weeks prior to the study. These levels were consistent with seasonal morbidity patterns recorded from health facilities in these states. Analysis showed that there was a strong significant association (p=0.01) between the two. As expected, morbidity has direct relationship with malnutrition where illness leads to increased nutritional demands to repair worn
20

Global Acute Malnutrition (GAM): prevalence of GAM <5% termed as acceptable, 5-9% poor, 10-14% serious and >15% critical.

29

out tissues and at the same time interfering with the intake, digestion, absorption and utilization of the nutrients in the body. Health seeking behaviour for ill children was poor with 93% of caretakers not seeking health care. Health and Nutrition Programme Coverage
Poor coverage for health and nutrition programmes are important risk factors to poor nutrition situation. There was a very poor coverage rate for measles vaccinations (48.6%), using the SPHERE cut-off point of 90%. This situation is precarious and the U5 population is vulnerable to an outbreak due to inadequate cover for an epidemic. Also of concern was the Vitamin A supplementation much lower than cut-off at 46.8%. The LLITN coverage for malaria during survey was low at 37.7%. This predisposes the vulnerable population (U5s and pregnant mothers) to a high risk of malaria. It is no wonder that the highest cause of morbidity and mortality in both U5 and over 5s is fever/malaria.The SFP coverage is poor while the OTP/TFC coverage is adequate. In general, the health and nutrition indices are poor and there is urgent need to address the immediate and underlying causes of malnutrition before the situation deteriorates further. Infant and Young Child Feeding and Care practices Poor child care and feeding practices persist and have been associated with high levels of malnutrition. Knowledge Attitudes and Practices on breastfeeding are mainly controlled by culture, customs and the social environment, such as through maternal grandmothers and other elderly women in the community. Though breastfeeding is acceptable to all caretakers, initiation of breastfeeding within the first hour of birth is not practiced universally (65%). Exclusive breastfeeding for the first six months of life is practiced by the majority of caretakers, as evidenced by the introduction of complementary foods at about 6.2 months on average. The average duration of breastfeeding is about 16 months. Lack of knowledge, inappropriate beliefs and very close birth spacing are major obstacles to successful breastfeeding for up to two years. It is also noteworthy that only 5.2% of the children aged 6 24 months were fed for the recommended 4-5 times per day. Poor breastfeeding and complementary feeding habits expose children to morbidity, malnutrition and death.

5.

CONCLUSION

The prevalence of Global Acute Malnutrition (GAM) among all children was 15.8 % and is indicative of critical nutritional situation based on the WHO standards. The prevalence of Severe Acute Malnutrition (SAM) of 3.6 % is also suggestive of widespread malnutrition among children. However, these rates are seasonally common. High morbidity rates were reported in the five states two weeks prior to the study. These levels were however consistent with seasonal morbidity patterns recorded from health facilities in these states. Both crude and under five mortality rates are at emergency levels for emergency situations. Overall, data from both the nutritional survey and review of secondary data shows seasonally stable health & nutrition conditions in the 5 states, but with pockets of worsening nutritional situation among populations with acute health & nutrition needs in 3 states in Jonglei (Pibor and Akobo); NBEG (Aweil East County) and Upper Nile (Longichuk and Sobat area - Maiwut, Nasser & Uranga). Other populations groups in the 5 states that require close monitoring in the coming months were identified. Eastern interior areas of Upper Nile, Lou Nuer communities in central Jonglei, and communities which may be impacted by insecurity or which may receive IDPs should there be conflict in Abyei are areas which should be prepared for potential increase in medical and nutritional needs and should exercise increased surveillance. Surveillance should also be increased for areas of the west of Eastern Equatoria. The key underlying factors are high morbidity, inadequate coverage of selective feeding 30

programmes, poor IYCF and care practices and household food insecurity. There is weak capacity for prevention and management of acute malnutrition in the five states. This is attributed to: o o o o o Limited partners supporting management of malnutrition including withdrawal in some areas (Jonglei World Relief; Upper Nile ACF) Limited funding for nutrition response: GoSS, UN, NGOs (*human resources, capacity building & surveillance needs) Low technical capacity of SMOH in management of severe malnutrition Weak PHC infrastructure for integrating management of acute malnutrition to increase coverage especially at community level. Coordination challenges at central and state level

6.

RECOMMENDATIONS

Intervention efforts that address both immediate needs for the acute malnutrition cases and chronic malnutrition in the vulnerable population should be mobilized. An integrated approach should be adopted in addressing these underlying causes at community level. Measures to increase access to health facilities and improved coverage of selective feeding programmes would play a critical role in both preventing and treating morbidity and malnutrition. An effective nutrition surveillance system needs to be established including an appropriate context specific tool that facilitates assessment of issues that are contributing to acute malnutrition. This will allow a clearer understanding of the underlying causes and therefore improve the specificity and design of future interventions. In addition, developing longer term strategies to enhance the provision of basic services, sustainable strategies for livelihood support and social protection mechanisms are recommended. Specific recommendations include:

Immediate Interventions
In line with the findings of this assessment, immediate action to avert worsening health and nutrition conditions among populations in the three states with acute health and nutrition needs is recommended as follows:

Upper Nile (Longichuk county) Conduct a SMART coverage survey Strengthen appropriate clinical and therapeutic management of severe cases of malnutrition through existing therapeutic feeding programmes. Strengthen capacity of community based organisations and mother support groups that were previously trained to undertake active case finding and referral. These groups should concurrently promote appropriate infant feeding practices and hygiene promotion. Immediate implementation of ACSI in upper Nile state beginning with counties in the Sobat area e.g Longichuk. Jonglei (Akobo, Pibor and Wuror Pibor: Monitor on-going therapeutic response as per amended PCA with MSF Belgium for Pibor county

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Akobo West: Monitor on-going therapeutic response as per amended PCA with Save the Childrens Fund UK. Akobo East: Develop programme corporation agreement with IMC for facility and community based management of severe acute malnutrition. Advocacy with WFP for scale up of the supplementary feeding programme in Akobo and Pibor counties Amend existing PCA with ACF USA to accommodate increased case load of severely malnourished children Support on-going nutritional surveillance

NBEG - Awiel East county Advocacy with WFP for scale up of SFP in Akobo and Pibor counties Amend existing PCA with ACF USA to accommodate increased case load of severely malnourished children

In addition,
Scale up of targeted SFP in the 5 states, coupled with active case finding in order to identify moderately malnourished children for admission into SFP is critical. Nutritional status is highly sensitive to changes in the risk factors and therefore a childs nutritional status is likely to fluctuate considerably with seasonal changes. In addition, pregnant women and lactating mothers with infants less than 6 months require supplementary feeding during this period of high food stress.. Measles vaccination coverage is inadequate in the five states. Given the high prevalence of disease and severe acute malnutrition, it is necessary to implement a vaccination campaign. Specific attention should be made to ensuring that areas that are difficult to access are adequately covered, providing and reinforcing the importance of vaccination cards. Rehabilitation of acutely malnourished children through the existing selective feeding and outreach programs coupled with active case finding until household food security is restored is critical. Public health issues of concern identified and detailed in the secondary data should be are addressed.

Medium - Long-Term Interventions Intensify health and nutrition education activities at the household level to address child care, targeting caregivers. The main areas of focus should include promoting exclusive breastfeeding, appropriate young child feeding, diet diversification and improvement in household hygiene including health care practices. This should also include development of local IEC nutritional education materials for community level health promoters.
Establish a regular nutrition surveillance system. On-going capacity building of malnutrition SMOH staff and the community to manage severe

Assess and strengthen programmes and strategies currently addressing IYCF with a view to improving the protection, promotion, and support of optimal infant and young child 32

feeding.

Work to improve coverage of life saving interventions such as Vitamin A supplementation, immunization and use of LLITNs by children and pregnant mothers. Strengthening of hygiene practices to reduce the incidence of diarrhoeal disease including health education to educate the community on treatment of drinking water. Strengthening mobile clinic initiatives to cover the rural populations and support outreach services and community strategy to encourage caregivers to seek health services

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SOUTH SUDAN - RAPID NUTRITION ASSESSMENT TOOL

NOTE TO ENUMERATORS: ONE form should be filled out for EVERY child in the household less than 59 months old.
SECTION 11 CHILD NUTRITION

Questions for adult caretaker of child 11.1 Relationship of respondent to child 1 2 3 11.2 11.3a Sex of child Age |__|__| months 1 Mother Father Other Male 2 Female

If Child is greater than 24months SKIP to 11.10

Questions 11.4 to 11.9 only for children 0- 24months 11.4 Has this child ever been breastfed? 1 2 3 11.5 Is this child still breastfeeding now? 1 2 3 11.6 11.7 If not breastfeeding now, how many months did you breastfed this child? How long after birth did you start breastfeeding? Yes No Dont Know Yes No Dont Know

|____|____| months 1 2 3 0-1hour More than 1hour Dont know |__| Still exclusively |______|_____| months breastfeeding

11.8

At what age did you begin to feed this child daily with any food or fluids other than breastmilk?

11.9

Since this time yesterday, how many times was this child given porridge (madida) or mashed food or solids?

1 2 3 4

None Once Two to three Four to five

Questions 11.10 to 11.23 are for children 6-59 months old 11.10 Has this child received a Vitamin A capsule in the last 6 months? Show capsules for different doses: 1 2 Yes No

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Blue for children 6-11 months old Red for children 12-59 months old 11.11 Since 2 weeks ago has this child had watery diarrhoea? (Diarrhoea is three or more loose or watery stools per day.)

Dont Know

1 2 3

Yes No Dont Know Yes No Dont Know Yes No Dont Know Yes No Dont Know

11.12

Since 2 weeks ago has this child had bloody diarrhoea? (Bloody diarrhoea is three or more loose or watery stools with blood in them per day)

1 2 3

11.13

Since two weeks ago has this child had a cough during which he/she had difficulty breathing?

1 2 3

11.14

Since two weeks ago has this child had a fever?

1 2 3

If respondent answered yes to 11.11 or 11.12 or 11.13 or 11.14 ask question 11.15. If they answered no, proceed to question 11.16 11.15 Did you seek advice or treatment for the illness outside of the home? 1 2 3 11.15a From where did you seek care? Circle all mentioned- but do not prompt respondent 1 2 3 4 5 6 7 8 9 10 11 11.16 Has this child received a measles vaccination? 1 2 3 4 11.17 Did this child sleep under a mosquito net (LLITN) last night? 1 2 3 11.18a 1 Yes No Dont Know Hospital Government clinic (PHCC/PHCU) NGO clinic (PHCC/PHCU) Mobile/outreach clinic Village health care worker Private physician Relative or friend Shop Traditional practitioner Pharmacy Other- specify Yes, by card Yes, by maternal recall/verbal history No Unknown Yes No Dont Know Yes

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Has this child been enrolled in a therapeutic feeding programme (where they stay overnight at a center where they are fed and treated) in the last 3 months?

No

Dont Know

11.18b

Is this child currently enrolled in an Out Patient therapeutic feeding programme (where the child stays at home)?

1 2 3

Yes No Dont Know Yes No Dont Know Yes No Dont Know

11.19a

Has this child been enrolled in a supplementary feeding programme (where he is provided

1 2 3 1 2 3

a ration of corn soy blend, oil

and sugar) in the last 3 months?

11.19b

Is this child currently enrolled in supplementary feeding programme (where he is provided a ration of corn soy blend, oil and sugar)?

11.19c

After distribution, on average how long does this supplementary ration provided last? Does anyone else in the home consume the supplementary ration provided?

|__|__| weeks 1 2 3 Yes No Dont Know

11.19d

Examination of child and anthropometry for children 6-59 months 11.20 Does this child have bilateral oedema? 1 2 3 11.21 Does this child have a physical deformity making it difficult to obtain an accurate height? 1 2 3 11.22 11.23 Weight Length/Height Yes No Dont Know Yes No Dont Know kgs cms

|__|__|.__|

|__|__|__|.__|

11.24

MUAC (Mid upper Arm Circumference) measurement

|__|__|.__| cms

Mortality questionnaire 11.25 11.26 How many people stay in this home? How many children below the age of five stay in this home? |_________| |____|_____|

11.27

How many people died in this household in the last 3 months

a. Adults

|_______|

b. Children (<5years) |_______|

11.28

What is the Cause of death?

a. Adults

|_______|

1=Fever/malaria, 2= diarrhea, 3= Cough, 4= unknown, 5=others ( specify)

b. Children (<5years) |_______|

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