International Notes Rapid Nutrition Evaluation in Drought- Affected Regions of Somalia -- 1987

Somalia, a country bordering with Ethiopia on the Horn of Africa, experienced a severe drought in 1986. When the early spring rains failed again in 1987, the U.S. Agency for International Development requested a rapid evaluation of the population to assess the effects of the drought. Children under 110 cm tall (corresponding, in a normal population, to approximately 60 months of age) were surveyed in three drought-affected regions of the country (Bakool, Bay, and Gedo) that had not been recently surveyed and in one region (Hiraan) that had been partially surveyed by government or private voluntary organizations. Ten villages in each region were randomly selected for data collection. Survey teams consisted of representatives of the U.S. Agency for International Development, the World Health Organization, the United Nations Children's Fund, the Ministry of Interior and the Ministry of Health of the Somali Democratic Republic, and CDC.

By the time survey teams left the capital city in late May 1987, heavy rainfall and widespread flooding had begun in virtually all regions surveyed. Because attempts to reach randomly selected sites were hampered by severe weather and poor road conditions, only selected villages and alternates that were accessible, as well as several sites of convenience, were surveyed. The teams randomly selected 30 children from each village for measurement of height, weight, and arm circumference and for clinical evaluation for edema, scurvy, anemia, and vitamin A deficiency. A standardized questionnaire was administered to the mothers of these children to assess recent diarrheal illness, breastfeeding status, symptoms of night blindness, history of recent food assistance, and family structure.

Evidence of recent undernutrition (less than 80% of the median weight-for-height) (1,2) was found in 11.5% of the children in Bakool; 12.7% of the children in Hiraan; 15.0%, in Gedo; and 23.5%, in Bay (Table 1). Levels of severe undernutrition (less than 70% of median weight-for-height) ranged from 0.7% in Hiraan to 6.6% in the Bay region. However, an additional 20.6% to 26.4% of children in the surveyed regions were between 80% and 84% of median weight-for-height. Levels of undernutrition detected by arm circumference measurements (less than 12.5 cm) were similar to those detected by weight-for-height indices (less than 80% of the median) (Table 1). Children whose parents were agro-pastoralists* were more severely affected than children of strict nomads or strict agriculturalists (Table 2).

Clinical signs of vitamin C deficiency, as evidenced by swollen, bleeding gums and swollen joints, were detected in 3.6% of the children in the Bay region. Night blindness, a symptom of vitamin A deficiency, was reported in 3.1% of the children sampled. Night blindness was most prevalent in Bakool, where 7.0% of the children were reported to be affected and where three children with Bitot's spots** were observed in one village. Thirty-eight percent of the bleeding gums and swollen joints, were detected in 3.6% of the children in the Bay region. Night blindness, a symptom of vitamin A deficiency, was reported in 3.1% of the children sampled. Night blindness was most prevalent in Bakool, where 7.0% of the children were reported to be affected and where three children with Bitot's spots** were observed in one village. Thirty-eight percent of the children surveyed had had at least one diarrheal episode in the previous 2 weeks. Food assistance from government or voluntary agencies had been received in the previous 2 weeks by 33.1% of the families surveyed in Hiraan, 13.3% of the families surveyed in Bay, and none of those surveyed in Bakool and Gedo.

Recommendations emphasized 1) distributing general basic rations in the most severely affected districts to provide a minimum of 1,800 kcal per person per day as well as a digestible source of protein; 2) preventing and treating existing vitamin A and C deficiencies; 3) continuing surveillance in the drought-affected regions to monitor changes in nutritional status and effectiveness of food assistance programs; 4) developing the capacities within the country to implement in the most severely affected districts to provide a minimum of 1,800 kcal per person per day as well as a digestible source of protein; 2) preventing and treating existing vitamin A and C deficiencies; 3) continuing surveillance in the drought-affected regions to monitor changes in nutritional status and effectiveness of food assistance programs; 4) developing the capacities within the country to implement and maintain a nutrition monitoring system, especially during this emergency, through cooperation and coordination between the government and private organizations. Reported by: AA Suleiman, MD, Ministry of Health; Ministry of Interior, Somali Democratic Republic. S Lundgren, MD, World Health Organization, Mogadishu; US Agency for International Development, Mogadishu, Somali Democratic Republic. Office of Foreign Disaster Assistance, US Agency for International Development, Washington, DC. International Health Program Office; Div of Nutrition, Center for Health Promotion and Education, CDC.

Editorial Note

Editorial Note: Estimates of the prevalence of malnutrition from this survey in Somalia are higher than those reported during nondrought periods in Somalia (CDC, unpublished data) and comparable to other sub-Saharan countries under drought conditions (3-5). In addition, the 20% to 26% of the children who were between 80% and 84% of median weight-for-height are at risk of malnutrition due to further weight loss since several months lapsed between the survey and any potential harvest season.

This assessment of health and nutritional status may not accurately estimate the prevalence and severity of undernutrition among all children in the drought-affected areas because the surveyors were unable to sample the populations in the areas inaccessible because of floodwaters or impassable roads. Officials in the government and from voluntary organizations had reported many of the more remote, inaccessible sites to be more severely affected by the drought.

Recommendations resulting from the survey emphasized early provision of food, including adequate calories and protein to prevent further nutritional deterioration. Vitamin deficiencies are also of concern. Vitamin A deficiency is the major cause of permanent blindness in preschool-aged children in the developing world and is easily prevented by vitamin A supplementation. In one region, signs and symptoms of vitamin A deficiency were reported at levels that, according to World Health Organization guidelines, warrant widespread prophylaxis and treatment of the population with 200,000 IU vitamin A capsules*** (6). The detection of scurvy in a largely agricultural region indicates the possibility of substantial shortages of foods rich in vitamin C. The risk of micronutrient deficiencies will increase if local food sources dwindle and the population becomes increasingly dependent upon food aid consisting largely of grains low in vitamins A and C.

References

1. National Center for Health Statistics. NCHS growth curves for children, birth-18 years, United States. Rockville, Maryland: National Center for Health Statistics, 1977. DHEW publication no. (PHS)78-1650. (Vital and health statistics: data from the National Health Survey; series 11; no. 165).

2. World Health Organization. A growth chart for international use in maternal and child health care: guidelines for primary health care personnel. Geneva: World Health Organization, 1978.

3. Dillon JC, Lajoie N. Report of surveys of the nutritional status of the rural population in the Sahel from 1960 to 1979. Ottawa: International Development Research Center, 1981.

4. Centers for Disease Control. Rapid nutrition evaluation during drought conditions--Burkina Faso, 1985. MMWR 1986;35:5-6,11-2.

5. Rutherford GW, Mahanjane AE. Morbidity and mortality in the Mozambican famine of 1983: prevalence of malnutrition and causes and rates of death and illness among dislocated persons in Gaza and Inhambane Provinces. J Trop Pediatr 1985;31:143-9.

6. Ville de Goyet C, Seaman J, Geijer U. The management of nutritional emergencies in large populations. Geneva: World Health Organization, 1978. *Persons who were both agriculturalists and nomads. **Superficial, triangular spots on the conjunctiva that are associated with vitamin A deficiency. ***When such prophylaxis is given, priority should be given to children under 5 years of age and to other risk groups, as indicated by local findings.

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