International Notes Update: Health and Nutritional Profile of Refugees -- Ethiopia, 1989-1990

Since 1983, Ethiopia has provided refuge to hundreds of thousands of persons from northern Somalia and southern Sudan who have fled armed conflict in those areas. Relief efforts have included the ongoing public health surveillance of these populations. This report summarizes the nutritional and health status of these refugees.Eastern Ethiopia (Somali refugees)

In June 1988, refugees from northern Somalia began entering eastern Ethiopia, where they are now housed in six camps: Hartisheik A and B, Daror, Rabasso, Camaboker, and Aysha (Figure 1). By June 1990, approximately 360,000 Somali refugees had registered for relief assistance.* From late 1988 through mid-1989, the nutritional status of the population in Hartisheik A camp (population: approximately 170,000) was poor (1). In March 1989, the prevalence of acute protein-energy malnutrition (PEM)** peaked at 26%. Cases of scurvy were also reported.

Consequently, in May 1989, relief agencies implemented a dry supplementary feeding program in Hartisheik A camp for all children less than 5 years of age. The program provided 900-1000 extra kilocalories of energy per child per day and vitamin C supplements on a weekly basis. By June and August 1989, PEM prevalence among children aged less than 5 years had decreased to 15% and 7%, respectively; improvement was sustained through mid-1990 (Figure 2). In August, a more precise population estimate on which ration distributions could be based was obtained from a census conducted by the Government of Ethiopia (GOE) and the Office of the United Nations High Commissioner for Refugees (UNHCR).

In August 1989, to assess mortality during the first year of operation of Hartisheik A camp, a joint agency team*** conducted a cluster sample survey of 1350 households. A standard questionnaire was used to record the number of deaths during each of the preceding 12 months. From August 1988 through July 1989, the crude mortality rate (CMR) was an estimated 46 per 1000 population (95% confidence interval (CI)=39-53 per 1000), and the Under 5 Mortality Rate (U5MR) was 152 deaths per 1000 children aged less than 5 years (95% CI=124-182). CMRs were highest from February through May, when acute PEM prevalence rates were also high (Figure 2); the mean monthly CMR during this period was 6.6 per 1000, corresponding to an annual CMR of 79 per 1000. In contrast, annual CMRs reported for the nonrefugee populations of Ethiopia and Somalia were 24 and 20 per 1000, respectively (3). Annual U5MRs are not available for Ethiopia or Somalia; however, a 1988 demographic and health survey in nearby Uganda estimated the probability of dying between birth and age 5 years at 180.4 (equivalent to a mean annual U5MR of approximately 45 per 1000) (4).

Surveillance data for Hartisheik A camp determined that 89% of deaths among hospitalized children aged less than 5 years during 1989 were caused by diarrheal diseases, acute lower respiratory infections (ALRI), and malnutrition. No measles deaths were reported. The major causes of death among hospitalized adults were ALRI, hepatitis, and tuberculosis.

For persons of all ages, health center records documented 5185 cases and 96 deaths attributed to hepatitis. Of these, 1116 (22%) cases and three deaths were in children less than 5 years of age. Cases peaked during March 1989. Serologic testing of a small number of hepatitis cases failed to identify the etiologic agent. From January through June 1990, a second outbreak of hepatitis in Hartisheik A camp accounted for 730 cases and 22 deaths. For this outbreak, although the overall case-fatality ratio (CFR) was 3.1%, the CFR among pregnant women was 20%.

The improvement in nutritional status of children in Hartisheik A camp coincided with the onset of the rainy season (usually May-September), when local food availability traditionally improves. The rains also provided the refugees with increased quantities of water in local dams and tanks. In the dry season (usually October-April), the sole supply of water had been well water trucked from the town of Jijiga, approximately 100 km (62 miles) away. Water from Jijiga provided an average of 3 L per person per day. The UNHCR recommends 15-20 L of water per person per day for drinking and domestic purposes (5).

Although data on nutrition and mortality in the other four camps were limited, trends were similar to Hartisheik A: acute PEM prevalence rates steadily decreased after May 1989 (Table 1). Population-based mortality surveys in June 1990 indicated that substantial improvement had occurred in the five camps since 1989. The decrease in CMR between the two periods surveyed (August 1988-July 1989 and November 1989-May 1990) ranged from 32% to 62%.Western Ethiopia (Sudanese refugees)

Since 1983, refugees from southern Sudan have entered western Ethiopia, where they are now housed in three camps: Dimma, Fugnido, and Itang (Figure 1). By June 1990, an estimated 380,000 Sudanese refugees had been registered for relief assistance. In Dimma and Fugnido camps, less than 5% of the population were children aged less than 5 years; in Itang, greater than 20% of the population were children aged less than 5 years, which is more typical of rural African communities.

From April through June 1990, approximately 20,000 new refugees from Sudan entered Ethiopia and were placed in a well-defined area of Itang camp. Before the addition of these new arrivals, the population of the camp was approximately 240,000.

A June 1990 review of the health status of refugees in western Ethiopia indicated that CMRs were relatively low in all camp populations except the new refugees in Itang. From mid-April through May 1990, a community-based mortality surveillance system for this population, based on interviews with family members of deceased refugees, indicated a CMR equivalent to 6.9 per 1000 per month. In comparison, the monthly CMR in the remaining Itang population was 0.6 per 1000 during the same period, although this may be an underestimate because population data were incomplete. Clinic-based records suggested that the most common causes of morbidity in the newly arrived refugee population were febrile illnesses (most likely caused by malaria) and diarrheal diseases. These two diagnoses accounted for 72% of all clinic visits.

Based on anthropometric screening of children less than 5 years of age among the new group, the prevalence of acute PEM was 58% when they arrived at Itang. In July 1990, a cluster sample survey by the joint agency survey teamp indicated that in the new refugee population in Itang 36% of children less than 5 years of age were acutely malnourished (95% CI=32-40), compared with 7% (95% CI=5-10) of children in this age group in Fugnido. In March 1990, 12% (95% CI=9-15) of children less than 5 years of age in the stable Itang population were acutely malnourished.

Although a population-based vaccination coverage rate was not estimated in the review, the quantity of vaccine administered indicated that approximately 85% of the target population of children aged 6 months to 5 years received measles vaccinations during April and May 1990.

The June 1990 health status review indicated that adequate quantities of food rations were available for new arrivals in Itang; however, both enrollment and attendance rates of malnourished children in nutrition rehabilitation programs (supplementary and therapeutic feeding) were low. In addition, the quantity of water being provided to new refugees (an average of 0.8 L per person per day) was inadequate. Reported by: Administration for Refugee Affairs, Ministry of Internal Affairs; Regional Liaison Office of the United Nations High Commissioner for Refugees; Save the Children Fund (United Kingdom); Medecins Sans Frontieres (Belgium and Holland), Addis Ababa, Ethiopia. Bur for Refugee Programs, US Department of State. Technical Support Div, International Health Program Office, CDC.

Editorial Note

Editorial Note: Risk factors and diseases that increase mortality in dependent refugee populations in developing countries include malnutrition, diarrheal diseases, measles, malaria, and pneumonia (6). In this report, inadequate food rations contributed to high malnutrition prevalence rates among children aged less than 5 years. Inadequate food rations resulted from the remoteness of some of the refugee camps, difficult logistics of food transport and storage, and the limited variety of food items supplied to refugees. Imprecise refugee population counts also contributed to the distribution of inadequate food rations. In addition to inadequate rations, high PEM prevalence was probably associated with high incidences of diarrheal and other communicable diseases, which in turn were associated with insufficient water supplies. In western Ethiopia, new refugees from southern Sudan had high PEM prevalence rates when they arrived because of widespread food shortages in their native homelands.

In Hartisheik A camp, the increase in PEM in early 1989 resulted in substantial excess mortality. In this camp, two interventions improved nutritional status and decreased mortality: supplementary rations for all children aged less than 5 years and improved census data that allowed for more equitable distribution of rations. Supplementary rations were probably more effective because they were targeted for those at greatest risk: PEM prevalence decreased soon after supplementary feeding was instituted in May and before the August census. Improvements in Hartisheik A camp also coincided with increases in the quantity of water available and with normal seasonal improvements in childhood nutrition in the region.

Community-based mortality surveillance in refugee camps should be implemented as soon as possible after camps are established; however, when mortality surveillance cannot be implemented, PEM prevalence rates can be used reliably as indicators of death rates (6). In nonrefugee, nonfamine-affected populations in sub-Saharan Africa, which usually have acute PEM prevalence rates less than 5% (7), a PEM prevalence rate of 5.0%-9.9% has been associated with a more than twofold increase in CMR, and PEM prevalence rates of 10.0%-19.9%, with a mortality risk ratio of 4.7 (8). The 1989 data from Hartisheik A camp and the 1990 data from Itang are consistent with these findings.

The monitoring of vaccination coverage for measles, which should be an integral part of a health-information system in refugee populations, is facilitated through the routine distribution of vaccination record cards. Unlike some refugee emergencies (6), measles has not been a major cause of childhood deaths in eastern Ethiopia--possibly because measles vaccination coverage rates were high before the refugees' departure from northwest Somalia, where a community-based health-care program had been in place for several years (9).

Because diarrheal diseases are an important cause of death among children in refugee camps (6), health programs should emphasize provision of adequate supplies of clean water, sanitation, and prompt treatment of dehydration with Oral Rehydration Salts. The two hepatitis outbreaks in Hartisheik A camp may have been associated with the scarcity of water and its impact on personal hygiene. A similar outbreak during 1986 in a refugee camp in Somalia ( less than 100 km from Hartisheik) was attributed to enterically transmitted, non-A, non-B viral hepatitis (hepatitis E) (10). Although hepatitis has not contributed to a large proportion of all deaths in the camps, the outbreaks highlight the vulnerability of refugees to epidemics of potentially lethal water-related diseases.

In Itang, an acute health emergency was superimposed on an otherwise stable refugee-relief situation by the sudden arrival of a large group of severely malnourished refugees. Relief efforts have focused on the provision of adequate food rations, nutrition rehabilitation programs for the acutely malnourished, and measles vaccination. With high PEM prevalence rates and low feeding program enrollment rates in this new population, however, vigorous efforts are necessary to identify all malnourished children: supplementary feeding programs have limited effectiveness in the absence of effective community outreach (11).

Recommendations of the June 1990 review stressed improvements in water supply in both eastern and western camps; strengthening of surveillance for mortality, malnutrition, and potentially epidemic communicable diseases; active case-finding for malnourished children; better vaccination records; establishment of oral rehydration units; and formulation of standard public health policy guidelines for the camps. The emergency created by the large influx of new refugees into Itang and the recurrent outbreaks of communicable diseases in Hartisheik underscore the need for detailed emergency preparedness plans in each camp.

References

1. CDC. Nutritional status of Somali refugees--eastern Ethiopia,

September 1988-May 1989. MMWR 1989;38:455-6,461-3.

2. World Health Organization. Measuring change in nutritional status: guidelines for assessing the nutritional impact of supplementary feeding programmes for vulnerable groups. Geneva: World Health Organization, 1983.

3. United Nations Children's Fund. The state of the world's children 1990. New York: Oxford University Press, 1990:84.

4. Institute for Resource Development. Demographic and Health Survey, Uganda 1989. Columbia, Maryland: Macro Systems, 1989:53-8.

5. Office of the United Nations High Commissioner for Refugees. Handbook for emergencies. Geneva: United Nations High Commissioner for Refugees, 1982:100.

6. Toole MJ, Waldman RJ. Prevention of excess mortality in refugee and displaced populations in developing countries. JAMA 1990;263:3296-302.

7. Serdula M, Seward J. Diet, malnutrition, and mortality. In: Proceedings of Seminar on Mortality and Society in Sub-Saharan Africa, Yaounde, Cameroun, October 19-23, 1987. Liege, Belgium: International Union for the Scientific Study of Population, 1987.

8. Person-Karell B. The relationship between child malnutrition and crude mortality among 42 refugee populations (Thesis). Atlanta: Emory University, 1989.

9. Bentley C. Primary health care in northwestern Somalia: a case study. Soc Sci Med 1989;28:1019-30. 10. CDC. Enterically transmitted, non-A, non-B hepatitis--East Africa. MMWR 1987;36:241-4. 11. Taylor WR. An evaluation of supplementary feeding in Somali refugee camps. Int J Epidemiol 1983;12:433-6.

• As provided by the Government of Ethiopia, the Office of the

United Nations High Commissioner for Refugees, and other international agencies and private voluntary organizations.

** Defined as weight-for-height less than 80% of the median World Health Organization reference population (2).

*** Administration for Refugee Affairs and Ministry of Health, GOE; UNHCR; and Save the Children Fund (United Kingdom). **** Administration for Refugee Affairs and Ministry of Health, GOE; UNHCR; and Medecins Sans Frontieres (Belgium and Holland).

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