International Notes
Nutritional and Health Assessment of Mozambican Refugees in Two
Districts of Malawi, 1988
Since January 1987, over 400,000 displaced persons from Mozambique
have emigrated to Malawi, a country in southern Africa with a
population of 7.9 million people. This mass population migration is
considered to be a consequence of armed conflict in Mozambique.
Displaced families have settled primarily along the international
border in southern Malawi, and several large refugee camps have
been
established in this area. In May 1988, the Office of the United
Nations
High Commissioner for Refugees and the Bureau of Refugee Programs
of
the U.S. Department of State requested assistance from CDC to
evaluate
the nutritional status of refugees from Mozambique. A nutritional
assessment was conducted of Mozambican and Malawian children living
in
Ntcheu and Nsanje, two districts in Malawi where refugees had
concentrated. Additional information was gathered on immunization
status and recent diarrheal disease.
The nutrition survey targeted children 6 months to 5 years of age
or,
if no docu- mentation of age was available, children 65-110 cm in
height. Two-stage cluster sampling methods were used (1). The
sampling
frame for Malawians was based on 1977 census data adjusted for
estimated population growth; for Mozambicans, it was based on
recent
refugee registration lists. Thirty villages or camp sectors in each
district were randomly chosen from a cumulative population list.
The
probability of an individual site being included in the survey was
proportional to its population. Within each site, the survey
proceeded
from a randomly selected starting point to the next nearest
household
until 30 eligible children were identified. Each child was weighed,
measured for height, and examined for signs of vitamin
deficiencies.
Evidence of acute undernutrition (less than 80% of the World
Health
Organization (WHO)/ National Center for Health Statistics reference
median weight-for-height) (2) was similar in Mozambican and
Malawian
children in both districts, although Mozambican children had
slightly
higher levels (Table 1). Severe undernutrition (less than 70% of
the
median weight-for-height) was found in none and in 0.6% of children
in
Ntcheu and Nsanje Districts, respectively. In Nsanje District,
which
had a recent large influx of refugees, undernutrition was less
among
Mozambican children who had lived in Malawi for greater than or
equal
to3 months than among those who had arrived more recently (Table
2).
More than 95% of refugee families in the two districts (97.1% in
Ntcheu, 95.7% in Nsanje) reported receiving food rations during the
4
weeks preceding the survey. Signs of vitamin C deficiency
(hemorrhagic
gingivitis) were seen only in Ntcheu District (0.2% of children),
and
signs of vitamin A deficiency were seen only in Nsanje District
(0.2%
had either a history of night blindness or visible Bitot's spots).
Because diarrhea and measles are important causes of mortality
among
refugee children (3), these illnesses were also assessed. In the 2
weeks before the survey, 17.7% of refugee children in Ntcheu and
16.6%
of those in Nsanje were reported to have had diarrhea. Similar
rates of
diarrhea were observed in Malawian children. Nearly half (49.8%) of
children 12-23 months of age had been immunized against measles
(57.9%
in Ntcheu, 42.9% in Nsanje). Immunization policy includes an
attempt to
require vaccinations in families applying for food distribution. In
both areas, Mozambican children had substantially higher measles
vaccination coverage than Malawian nationals--53% vs. 33% in
Ntcheu,
68% vs. 37% in Nsanje.
Reported by: GW Lungu, MD, Office of the United Nations High
Commissioner on Refugees, Blantyre; JR Sulger, International Rescue
Committee, Lilongwe; A Renneson, M*$$*Aaedecins Sans
Fronti*$$*Ageres,
Blantyre, Malawi. Technical Support Div, International Health
Program
Office; Nutrition Epidemiology Br, Div of Nutrition, Center for
Health
Promotion and Education, CDC.
Editorial Note
Editorial Note: The levels of childhood undernutrition reported
here
are consistent with levels reported during noncrisis periods from
developing countries in Africa (4) and are substantially lower than
those reported from other recent refugee situations in Africa and
southeast Asia (Table 3). Malawi enjoyed a bountiful harvest in
mid-1988, and the ready availability of fruits, vegetables,
and grains in the affected districts may have enhanced the
nutritional
status of both local and refugee populations at the time of the
surveys. Continued provision of rations should prevent any
worsening of
childhood undernutrition, and ongoing surveillance may help detect
deterioration in the nutritional status of children as local food
supplies diminish during the year. Although the prevalence of
Vitamin A
deficiency was low, vitamin A prophylaxis (200,000 International
Units
of vitamin A every 6 months for infants and children, for lactating
women, and for women beyond the first trimester of pregnancy) is
indicated, according to WHO guidelines (8).
Measles and diarrhea are major causes of childhood morbidity and
mortality in refugee populations. Childhood immunization levels
reported here are unlikely to prevent further measles outbreaks.
Despite attempts to link childhood immunizations to food
distributions,
reinforced efforts will be required to improve coverage levels in
susceptible children. In addition to the current policy of
providing
measles immunization to susceptible Mozambican children greater
than 6
months of age at the time of registration, other recommendations
included immunizing susceptible children at every health contact
and
assuring the immunization status of severely undernourished
children
enrolled in therapeutic feeding programs. To lower diarrheal
morbidity
and mortality, early detection of diarrheal illness and treatment
with
oral rehydration therapy was also emphasized.
References
Henderson RH, Sundaresan T. Cluster sampling to assess
immunization
coverage: a review of experience with a simplified sampling method.
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Lavoipierre GJ, Keller W, Dixon H, Dustin J-P, ten Dam G, eds.
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nutritional impact of supplementary feeding programmes for
vulnerable
groups. Geneva, Switzerland: World Health Organization, 1983:86-97.
Toole MJ, Waldman RJ. An analysis of mortality trends among
refugee
populations in Somalia, Sudan, and Thailand. Bull WHO
1988;66:237-47.
Serdula MK, Aphane JM, Kunene PF, et al. Acute and chronic
undernutrition in Swaziland. J Trop Pediatr 1987;33:35-42.
Glass RI, Cates W Jr, Neiburg P, et al. Rapid assessment of
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emergency camps in Sudan, 1985. Br Med J 1987;295: 314-8.
Nieburg P, Waldman RJ, Leavell R, Sommer A, DeMaeyer EM. Vitamin
A
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