IDPs (ACF) - PFEDA / Page d'accueil PFEDA

Action Contre la Faim
Jon CUNLIFFE
Kaouthar GHARBI
Rachel SAUTREAU
Mogadishu, Somalia
June 30th 2000
Anthropometrical Survey
IDP Camps in Mogadishu
Somalia
17 - 27 June 2000

CONTENTS
Page 3: Acknowledgements
Page 4 – 6: Summary
Page 7 – 8: Introduction
Page 9: Objectives
Page 10 - 11: Methodology
Page 12 - 13: Data Collection
Page 14: Indicators and Guidelines Used
Page 15 - 24: Results
Page 25 – 27: Discussion
Page 28: Recommendations
ANNEX 1: Map of Mogadishu (available only with printed version).
ANNEX 2: Background Statistics and Information on Mogadishu (from ACF)
ANNEX 3: List of population and names of all IDP camps in Mogadishu
ANNEX 4: IDP camps used for cluster selection in the Nutritional Survey
ANNEX 5: Schedule and selected clusters
ANNEX 6: Explanation of Normalisation Tests
ANNEX 7: Forms and Charts used in the Nutritional Survey
ANNEX 8: Events Calendar
ANNEX 9: Results of the previous Nutritional Surveys conducted by ACF
since 1994
ANNEX 10: Collection of Mortality Statistics for the Survey
2

ACKNOWLEDGEMENTS
The Action Contre la Faim (ACF) Nutrition team would like to offer thanks to the
following people for assisting them, and without whom this survey would not have been
possible:
- ACF Mogadishu Logistics and Security Teams
- ACF Health Education Team
- ACF Paris Nutrition Staff
- European Community Humanitarian Office (ECHO)
As usual ACF would like to thank, above all, the staff that have worked on the survey
and the Internally Displaced People (IDPs) in Mogadishu who welcomed us and assisted
us in performing this survey – in particular the Chairmen of the camps.
3

OBJECTIVES
SUMMARY
• To quantify malnutrition rates in children aged between 6 and 59 months in the IDP
(Internally Displaced Peoples Camps) in Mogadishu, Somalia.
• To quantify the measles vaccination coverage in the IDP camps
• To assess Therapeutic Feeding Centre coverage
• To assess the period of time that IDPs have been in Mogadishu.
• To quantify the mortality rate in the IDP camps, and the causes of mortality.
• To assess the use of latrines and the amount of water used per person per day
METHODOLOGY
This survey was carried out in the IDP camps accessible to ACF in Mogadishu between
the 17 th and 30 th of June 2000.
Classic double cluster anthropometrics survey technique was employed (30 clusters of 30
children – total 900 children surveyed).
Only children aged between 6 and 59 months were included in the survey
MALNUTRITION RATE
Global acute malnutrition and Severe Acute Malnutrition of children from 6 – 59 months
Expressed in z-scores (-2 z-scores
for Global, -3 z-scores for
Severe) and including bilateral
oedema
Expressed as a % of the Median
(between 70 and 80% for Global,

FEEDING CENTRE COVERAGE
Feeding Centre coverage: 0 %
PERIOD OF DISPLACEMENT:
IDPs < 3 months
IDPs 3 – 6 months
IDPs 6 – 12 months
IDPs greater than 1 year
MORTALITY RATE
Number and Percentage
2 (0.2 %)
6 (0.6 %)
21 (2.1 %)
992 (97.1 %)
Mortality Rate of Children under five years: 7.08 / 10 000 / day
Causes of Mortality: Diarrhoea: 55.6%
Measles: 2.5%
ARI: 6.2%
Malaria: 2.5%
Others / Unknown: 28.4%
Mortality Rate of Adults: 0.67 / 10 000 / day
Causes of Mortality: Diarrhoea: 65.5%
Measles: 0%
ARI: 0%
Malaria: 0%
Others / Unknown: 34.5 %
USE OF LATRINES / AVERAGE QUANTITY OF WATER USED PER FAMILY:
IDPs using latrines: 90%
Mean quantity of water used per person per day: 12.46 Litres
5

RECOMMENDATIONS
• An evaluation into the effective area of coverage of the 4 TFCs in the city would assist
in defining the future need for 4 TFCs in the city given the comparatively low rate of
malnutrition found.
• Active case finding and screening should be increased to ensure the early reference of
the severely malnourished to the TFC.
• At a minimum, a further nutritional survey should be undertaken on the same
population in November 2000 – before the next Cholera outbreak. In addition, it
would be useful to perform a survey on the Resident population of the town if at all
possible.
• Access to, knowledge of, and the quantity of free simple medical assistance (Health
Posts, ORS points etc.) needs to be increased.
• Evaluate, strongly supervise and if necessary re-orientate Health Education Activities.
• Increase supervision of Vaccination activities.
• Perform regular statistically viable surveys of the vaccination coverage and mortality
on a two monthly basis.
• Improve supervision of Health Education activities and evaluate the impact of the
Health Education given.
• The system of the collection of information about the movements of population into
the city of Mogadishu should be reviewed.
• The use of the 125mm cut-off point with the muac to indicate Global Acute
Malnutrition should be studied further in a maximum of Anthropometrical Nutrition
Surveys.
6

INTRODUCTION
Mogadishu needs little introduction. Since the collapse of the Somali State in 1991, and
the withdrawal of the United Nations forces in 1995 Mogadishu has been in a state of
anarchy and chaos. The town is effectively split into 2, with the North and South
separately controlled. In addition there is an enclave called Medina in the Southern
controlled area. A map of Mogadishu is enclosed as Annex 1. Since this time there has
been a steady decrease in the presence of Humanitarian Organisations in Mogadishu. At
the time of writing, ACF is the only Humanitarian Organisation left in Mogadishu with a
permanent Expatriate presence in both the North and the South of Mogadishu.
ACF has been operating in Somalia since 1990. The present programme in Mogadishu
includes 4 Therapeutic Feeding Centres (TFCs) in the city – at Medina, Towfiq, Hodan
and Forlanini (in the North). In addition there is an ongoing Water and Sanitation
Programme that works in the IDP camps around the city on latrine construction, and the
chlorination of wells. ACF also has an Expanded Programme of Immunization (EPI)
team working in the IDP camps in the South of Mogadishu. Finally, Health Education
teams are active both in the South and the North in the IDP camps.
This Nutritional Survey is the first statistically relevant anthropometric nutritional survey
to be conducted in Mogadishu since 1995. It is hoped that the results of this Nutritional
Survey will help provide some ideas about the impact of some of the programmes that
Agencies have been running since that time, and suggest ways of developing projects in
the future.
The survey took place between the 17 th and 27 th of June 2000 in the Internally Displaced
People (IDP) camps accessible to Action Contre la Faim (ACF) in and around both North
and South Mogadishu. These IDP camps represent around 57% of the total population of
IDPs in Mogadishu.
An obvious result of the lack of Humanitarian Presence in Mogadishu, is that it proved to
be difficult to find background information about the current Humanitarian situation of
the IDPs in Mogadishu. The following agencies (amongst others) were contacted by ACF
prior to this survey in order to obtain further background information about Mogadishu:
- Food Security Alert Unit (FSAU)
- United Nation Co-ordination Unit (UNCU)
- Food and Agricultural Office (FAO)
- United Nations World Food Programme (UNWFP)
- Save the Children Fund United Kingdom (SCF/UK)
In addition, over the last few years ACF has collated some information on Mogadishu.
This information includes information on TFC attendance, the numbers of reported
Influxes and Outflows from the IDP camps, and the presence of contagious diseases in
the IDP camps visited by the ACF Health Educators. This information has been used to
7

help in the interpretation of results of the Nutritional Survey and has been included in
Annex 2.
The Nutritional Survey took place at the time when the 1 st rainy season was in process
(the ‘Gu’ season). This year the rains have arrived in Mogadishu, as in everywhere else in
the country. As the population of Mogadishu has become increasingly reliant on
agricultural activities, this may have some significance in the survey results, as it
correlates with a time of a traditional ‘Hunger Gap’ – i.e. the period prior to harvesting.
Market prices of sorghum and maize, stable parts of the diet of the population, have
increased during the period prior to the Nutritional Survey by around 3%. This first half
of the year (January – June), is in addition, corresponding with the period of time when
there is the majority of the admissions into the ACF TFCs (see Annex 2).
The Cholera outbreak was just starting to tail off during the Nutritional Survey. This
assumption corresponded with both the traditional period for the end of the Cholera
outbreak, and the statistics for the Cholera Treatment Centres in the town (all of which
were reducing).
Although its extremely difficult to say with any certainty, a hypothesis could be made
that the IDP population is likely to be more vulnerable than the normal resident
population of the town of Mogadishu. Their income generating activities are limited (See
Annex 2 – for income generating activities of IDPs and how much each activity pays).
What better possibilities for employment that there are in the city are generally taken by
the resident population. (Ref: Broudic, C., 1997, Socio – Economic Context of the
Vulnerable Population in Mogadishu, Nairobi, ACF).
In ACFs 4 TFCs in Mogadishu, IDPs are twice as likely to frequent the TFCs as residents
of Mogadishu (IDPs comprising approximately 20% of the population make up globally
45% of the admissions in the 4 TFCs).
The IDP population was consequently chosen as the target group for the ACF Nutrition
survey for the following reasons:
- Security and Access, the presence of ACF in these camps for an extended
period of time meant that they were considered safe to visit.
- Overall, this group was considered to represent a part of the population that
was likely to be affected by malnutrition.
Population figures for Mogadishu vary considerably depending with who they are
discussed. ACF based its population figures on available information from the Elders, the
ACF Water and Sanitation team, and, the ACF Health Education team. The IDP
population of Mogadishu has built up considerably over the last 10 years. Their reasons
for displacement are varied, but drought, famine and war have all had an important part
to play in the last few years.
It was estimated that 237,000 people live in the IDP camps in and around Mogadishu;
approximately 135,000 of them (57% of the IDP population) were included in the survey.
8

OBJECTIVES
• To quantify malnutrition rates in children aged between 6 and 59 months in the IDP
(Internally Displaced Peoples Camps) in Mogadishu, Somalia.
• To quantify the measles vaccination coverage in the IDP camps
• To assess Therapeutic Feeding Centre coverage
• To assess the period of time that IDPs have been in Mogadishu.
• To quantify the mortality rate in the IDP camps, and the causes of mortality.
• To assess the use of latrines and the amount of water used per person per day
9

METHODOLOGY
The target population for the survey was children aged between 6 and 59 months. This
age group is considered to be particularly vulnerable to malnutrition.
1. Survey Design
Classic two-stage cluster sampling was used for the survey. A total of 30 clusters of 30
children aged 6 to 59 months old were selected in order to provide an estimate of the
prevalence of malnutrition with a minimum 5% confidence.
2. Sampling methodology
Initially a sampling framework was constructed from which a representative sample
could be drawn from. Population figures were collected from a variety of sources (ACF
Water and Sanitation Team, ACF Health Education Team Statistics and IDP camp
Elders). Only camps that were accessible to ACF were included in the sampling
framework. Annexes 3 and 4 details those camps the camps and their populations that
were included in the survey as well as those that could not be included.
The percentage of children less than 5 years was then estimated at 20% and the
cumulative target population determined. For each section of the town the estimated
population, and the estimated number of children under 5 was then listed. The cumulative
population of children under 5 years old was then calculated by adding at each stage of
the list the number of children under 5 years to the total of the number of children under 5
years in the previous section(s) of the town.
Thirty clusters were randomly selected. The cluster interval was calculated by dividing
the total cumulative population under five years old by the number of clusters: (22962 /
30 = 765). A random number was then chosen between one and the cluster interval using
a random number table to have a starting number (51) for the first cluster. The following
29 clusters were selected systematically by adding the cluster interval number to the
previous cluster. Details can be found in Annex 5.
Once this list had been completed, the ACF Health Education team visited each chosen
cluster prior to the day of the survey to inform the people about the survey, the purpose of
the survey, and to ask that the population of the cluster stay at home on the day of the
survey.
The second stage of sampling was carried out in the cluster. In general, one member of
the team went to the centre of the chosen area with the chief of the community and threw
a pencil to determine a direction and all the households following this direction were
visited and all the children found in the houses between 6 and 59 months, and between 65
and 110 cm, were screened. However, due to the nature of the IDP camps in Mogadishu
10

this was not always possible, and alternative methods of selecting the second stage of the
sampling had to be used.
Some of the clusters were buildings, with the whole cluster split between the three or 4
different floors of the building, the roof of the building, and the area outside of the
building. In this case, all these areas were given a number. A random number was then
drawn and the area that had the same allocated number as the random number was used
for the sample, and then the second stage of sampling was carried out in this area (as
described above). If the area was exhausted of children before the required 30 had been
reached, a further area was randomly selected.
In other clusters the choice of direction was limited to 2, as the cluster stretched, for
example, along the side of a road.
If a child was absent, contrary to standard Nutritional Survey techniques, the team did not
make an appointment to come back and see the child. This was because of the security
constraint of limited movement and time on the ground to a minimum. However, if the
child was in the hospital or Therapeutic Feeding Centre the team visited the child there
and recorded his measurements – but only if this structure was accessible for ACF
Expatriate supervised teams. If the limit of the section was reached before completing the
cluster, the team returned back to the centre of the cluster and the second stage of
sampling was started again.
In the event that insufficient children were found in the selected camp, the nearest camp
to the selected camp was visited and the outstanding number of children surveyed from
this site using the same methodology as outlined above.
3 teams were used to collect the survey data. Each team comprised of a qualified ACF
Expatriate Nurse Nutritionist for the supervision, a Registrar to record the details and ask
the supplementary questions, and 2 Measurers to take the anthropometric measurements.
A week of training prior to the survey was completed with the teams. This training was
focussed on the correct taking of anthropometric measurements. In the last 3 days,
Normalisation tests were completed with the staff to ensure an optimal precision was
obtained. (Annex 6 details how these tests are undertaken and how the results are
interpreted).
11

Data Collection
The forms used to collect the information are included as Annex 7.
Age: was recorded with the help of a local calendar of events (see Annex 8). Only
children between the ages of 6-59 months were included in the survey. If the age could
not be ascertained only the children between 65 and 110 cm were included in the survey.
Weight: Children were weighed without clothes using a 25 kg Salter scale (precision of
100g).
Height: Each child was measured using a height board (precision of 0.1 cm). Children
less than 85 cm in height had to be measured lying down. Children equal to or more than
85 cm were measured standing up.
Mid upper arm circumference (MUAC): This was measured to the nearest 0.1cm. The
MUAC was measured at the mid point of the left upper arm.
Oedema: Only children with bilateral oedema on the lower limbs were recorded as
having nutritional oedema.
Mortality: This was taken retrospectively. Each family was asked the composition of
their family in two parts – those family members less than 5 years, and those family
members more than 5 years. The family was then asked how many people had died in the
last three months – for both the under 5 years of age, and those over 5 years. The 3-month
period was easy to define because ‘Atha’ (an important religious event) had finished
almost exactly 3 months ago on the 16 th March 2000.
If the family was without a child of less than 5 years, even though no anthropometric
information could be obtained, the family was still asked if they had had a child who had
died during the last 3 months and this information was collected.
The overall mortality was calculated by taking the total number of dead and multiplying
this figure by 10,000. This figure was then divided by the total population 3 months
previously. Finally it was divided again by 98. Ninety-eight represented the average
number of days from ‘Atha’ to the survey. As the survey took place over a relatively
long period of time (9 days - due to the security constraints), the number of days between
‘Atha’ and the 5 th day of the survey was calculated (98).
If a family said that their child had died, the team asked the family to explain what the
signs and symptoms were of the child’s illness before he/she died. The team then
compared this information with the simple case definitions below.
Diarrhoea: More than 3 liquid stools per day.
Measles: Spots, Fever, Mouth Infection, Chest Infection, Eye Infection (more than 3
signs considered enough to identify the cause as Measles).
12

ARI: (Acute Respiratory Infection). Cough, Shortness of Breath, Fever
Malaria: High Fever, Coma
Malnutrition: Anorexia, loss of weight, oedema
Others: All other causes
Measles vaccinations: For all children from 9 to 59 months the mothers were asked for
vaccination cards. The vaccination card was then checked. If no vaccination card was
available, the mothers were asked if their child had been immunised against measles.
Length of time in Mogadishu: The 4 periods of time that were used fitted in with
significant local events to enable the team to say accurately how long the families had
been displaced for. The 4 periods of time considered were up to 3 months (this correlated
with the time from ‘Atha’ to the day of the survey, 3 – 6 months (this correlated with the
period of time between ‘Atha’ and the end of ‘Ramadan’), 6 – 12 months (this correlated
with the period of time between ‘Ramadan’ and ‘Mawlid’) and greater than 12 months
(this correlated with the period of time after ‘Mawlid’).
Frequentation of the ACF Therapeutic Feeding Centre: Those children who were
found in the criteria of severe malnutrition were considered not to frequent the ACF
Therapeutic Feeding Centre. Only when a child was not be found at home and was found
instead at the TFC and was still in the criteria of severe malnutrition was he considered to
frequent the centre.
Latrine Use: Families were simply asked whether they used a latrine or not.
Water Consumption: The quantity of water per day used by the entire family was
estimated by families and recorded. As the number of people in the family was recorded
in the mortality data, it was possible to work out the average personal consumption.
13

Indicators and guidelines used
Acute malnutrition rates were estimated from the weight for height index values. Weight
for height index was calculated using National Centre for Health Statistics as a reference.
This is considered the most appropriate index to quantify wasting in a population in
emergency situations where acute forms of malnutrition are the predominant pattern. The
expression in Z-scores has a true statistical meaning and allows inter-study comparison.
The percentage of the median is commonly used to identify eligible children for feeding
programmes.
Guidelines for the results expressed in Z-Score:
• Severe acute malnutrition is defined by W/H < -3 SD and/or oedema
• Global acute malnutrition is defined by W/H < -2 SD and/or oedema
Guidelines for the results expressed in percentage of the reference median:
• Severe acute malnutrition is defined by W/H < 70 % and/or oedema
• Global acute malnutrition is defined by W/H < 80 % and/or oedema
Mid Upper Arm Circumference (MUAC) is a useful tool for rapid screening of children
at a higher risk of mortality. MUAC changes only marginally between 12 and 59 months
of age (75 to 110 cm height group) and therefore does not need to be related to the age. It
is a reliable indicator of the muscular status of the child and is mainly used to identify
children with a high risk of mortality. The cut off values can vary according to authors;
the following figures were used for this survey:
• Low risk of mortality: MUAC ≥ 120mm
• Moderate risk of mortality: 110 mm ≤ MUAC < 120 mm:
• Severe risk of mortality: MUAC < 110 mm
Admission and discharge criteria in Action Contre la Faim feeding centres:
Therapeutic Feeding W/H < 70% of the median
and /or bilateral oedema
and /or Muac < 11 cm for height ≥75 cm
Supplementary Feeding W/H < 80% of the median
and /or 11 85% for 2 consecutive weighing
Absence of bilateral oedema 15 days
MUAC > 12 cm
Ascending weight curve
W/H > 85% for 2 consecutive weighing
MUAC > 12 cm
Ascending weight curve

RESULTS
The data processing and analysis were carried out using the programme EPI-INFO 5.0.
The calculation and the analysis of the anthropometrical indications were carried out
using the EPINUT programme. All children between 6 and 59 months were recorded and
analysed.
1. Distribution by age and sex
TABLE 1: DISTRIBUTION BY AGE AND BY SEX
AGE CLASS BOYS GIRLS | TOTAL SEX RATIO
N % N % | N %
___________________________________________|______________________
06-17 124 54.6% 103 45.4% | 227 25.2% 1.20
18-29 154 58.6% 109 41.4% | 263 29.2% 1.41
30-41 105 57.1% 79 42.9% | 184 20.4% 1.33
42-53 95 52.8% 85 47.2% | 180 20.0% 1.12
54-59 22 47.8% 24 52.2% | 46 5.1% 0.92
___________________________________________|______________________
TOTAL 500 55.6% 400 44.4% | 900 100.0% 1.25
The results show that there were a higher number of boys than girls included in the
survey. For every 5 boys sampled, only 4 girls were surveyed.
2. Nutritional status
The global acute malnutrition rate expressed as a Z-Score was 12.9% (95% Confidence
Interval (CI: 10.0 – 16.5 %), including 2.0 % of severe malnutrition (CI: 1.0 – 3.9 %).
Expressed as a percentage of the median, the overall global acute malnutrition rate was
9.0 % (CI: 6.5 – 12.2 %), including 1.6 % (CI: 0.7 – 3.3 %) of severe malnutrition.
Z-SCORE 2.0 %
(1.0 – 3.9 %)
% OF MEDIAN 1.6 %
(0.7 – 3.3 %)
SEVERE GLOBAL
15
12.9 %
(10.0 – 16.5 %)
9.0 %
(6.5 – 12.2 %)
Among the severely malnourished 6 cases of Oedema were found during the survey.

Weight for height index distribution
F
r
e
q
u
e
n
c
y
30
25
20
15
10
5
0
-4.75
-3.75
-2.25
-0.75
0.75
2.25
3.75
Z-SCORE
The distribution of weight for height index expressed in Z-score, in comparison to the
reference curve, appears to the left of that of the reference population. This shows that the
nutritional status of the children in the displaced camps is lower than that of the reference
population. The mean weight for height index expressed as Z-score is -0,99 with a
standard deviation of 0,90.
16
5
Reference
Sex Combined

Height for Age Distribution Curve
F
R
E
Q
U
E
N
C
Y
25
20
15
10
5
0
-4.75
-3.75
-2.25
-0.75
0.75
Z-SCORE
The distribution of height for age index expressed in Z-score, in comparison to the
reference curve, appears to the left of that of the reference population. This shows that the
long-term nutritional status of the children in the displaced camps is lower than that of
the reference population. The mean height for age index expressed as Z-score is –1.71
with a standard deviation of 1.28.
3. Anthropometric analysis
2.25
3.75
3.1 Distribution in Weight for Height Z-scores
TABLE 2: WEIGHT/HEIGHT: DISTRIBUTION BY GROUP OF AGE IN Z SCORES
=-3&=-2 STD OEDEMA
N n % n % n % n %
___________________________________________________________
06-17 227 6 2.6% 23 10.1% 196 86.3% 2 0.9%
18-29 263 4 1.5% 35 13.3% 222 84.4% 2 0.8%
30-41 184 1 0.5% 23 12.5% 159 86.4% 1 0.5%
42-53 180 1 0.6% 14 7.8% 164 91.1% 1 0.6%
54-59 46 0 0.0% 3 6.5% 43 93.5% 0 0.0%
___________________________________________________________
TOTAL 900 12 1.3% 98 10.9% 784 87.1% 6 0.7%
17
5
Reference
Sex Combined

TABLE 3: WEIGHT/HEIGHT: DISTRIBUTION BY HEIGHT IN Z SCORES
Global acute malnutrition
Severe acute malnutrition
Total children Children < 80 cm
n=900 n=400
12,9 %
(CI: 10.9%-16.5%)
2,0 %
(CI: 1.0%-3.9%)
18
16,0 %
(CI: 11.3%-22.2%)
3,3 %
(1,3%-7,1%)
TABLE 4: WEIGHT/ HEIGHT: DISTRIBUTION BY AGE IN Z SCORES
Global acute malnutrition
Severe acute malnutrition
6-59 months 6 - 29 months
n=900 n=400
12,9 %
(CI: 10.9%-16.5%)
2,0 %
(CI: 1.0%-3.9%)
14,7 %
(CI: 10.6%-20.0%)
2.9 %
(1,2%-6.1%)
In tables 2, 3 and 4 it can be seen that younger children are more prone to both Global
Acute Malnutrition and Severe Acute Malnutrition. The comparison was made using both
the height and the age of the children. A height of less than 80cm usually implies an age
of less than 2 years.
TABLE 5: WEIGHT/HEIGHT INDEX VS. OEDEMA (Z SCORES)
OEDEMA
-2Z
MARASM/KWASH KWASHIORKOR
YES 3 0.3% 3 0.3%
MARASMUS NORMAL
NO 110 12.2% 784 87.1%

4.2 Distribution in % of the Median
TABLE 6: MALNUTRITION BY AGE EXPRESSED AS % OF MEDIAN
=70%&=80% OEDEMA
N n % n % n % n %
____________________________________________________________________
06-17 227 2 0.9% 19 8.4% 204 89.9% 2 0.9%
18-29 263 4 1.5% 24 9.1% 233 88.6% 2 0.8%
30-41 184 1 0.5% 17 9.2% 165 89.7% 1 0.5%
42-53 180 1 0.6% 6 3.3% 172 95.6% 1 0.6%
54-59 46 0 0.0% 1 2.2% 45 97.8% 0 0.0%
____________________________________________________________________
TOTAL 900 8 0.9% 67 7.4% 819 91.0% 6 0.7%
TABLE 7: WEIGHT/HEIGHT: DISTRIBUTION BY GROUP OF AGE IN % OF
MEDIAN
Global acute malnutrition
Severe acute malnutrition
6-59 months 6 - 29 months
n=900 n=400
9.0 %
(CI: 6.5%-12.2%)
1.6 %
(CI: 0.7%-3.3%)
19
10.8 %
(CI: 7.3%-15.7%)
2.0 %
(0.7%-5,0%)
TABLE 8: WEIGHT/HEIGHT INDEX vs. OEDEMA (% OF MEDIAN)
80%
MARASM/KWASH KWASHIORKOR
YES 3 0.3% 3 0.3%
OEDEMA
MARASMUS NORMAL
NO 75 8.3% 819 91.0%

4.3 Distribution of brachial circumference (MUAC)
4.3.1 MUAC vs. Height
The MUAC distribution versus the height among the target population is shown below.
The following cut-off points for the height are used: 75 cm as an average for a 1 year old
child, 90 cm for children of 3 years old, and 110 cm for children of 5 years old.
TABLE 9: MUAC VERSUS HEIGHT
MUAC

WHZ < -3 Z
STD
-3STD

Children should be considered as vaccinated only when a card proves that the vaccination
has been given. Unverified information from the mother stating that her child has had
measles cannot be confirmed and therefore cannot be considered as statistically
significant information. When the unverified information of the mother is taken into
account the total is 73.4% of the children vaccinated.
6. Coverage of Nutrition Programmes
The coverage of Feeding Centre programmes is estimated through comparing the number
of severe malnourished children in Therapeutic Feeding programmes the day of the
survey with the number of children found with severe acute malnutrition found in the
survey, according to the ACF criteria (i.e. admission in feeding centre W/H < 70% of the
median and/or oedema and/or MUAC

8. Mortality rate and Causes of Mortality
The overall mortality was calculated by taking the total number of dead and multiplying
this figure by 10,000. This figure was then divided by the total population 3 months
previously. Finally it was divided again by 98. Ninety-eight represented the average
number of days from ‘Atha’ to the survey. As the survey took place over a relatively
long period of time (9 days - due to the security constraints), the number of days between
‘Atha’ and the 5 th day of the survey was calculated (98).
The total number of recorded deaths over the last 98 days was 81 for the children underfive
years of age, and 29 for the population over five years of age (see Annex 10).
The mortality rate for under-five children was calculated as being 7.08 / 10,000/ day in
the IDPs camps. This rate is very high, as a rate of more than 1 / 10,000 / day is
considered above the norm. The reasons for mortality are cited below:
CAUSE NUMBER % OF TOTAL DEATHS
DIARRHOEA 45 55.6
MEASLES 2 2.5
ARI 5 6.2
MALARIA 2 2.5
MALNUTRITION 4 4.9
OTHER 23 28.4
TOTAL 81 100
The mortality rate for the population over 5 years of age was calculated as being 0.67 /
10,000 / day in the IDPs camps. This rate is high for a population above 5 years of age.
The reasons for mortality are cited below:
CAUSE NUMBER % OF TOTAL DEATHS
DIARRHOEA 45 65.5
MEASLES 2 0
ARI 5 0
MALARIA 2 0
MALNUTRITION 4 0
OTHER 23 34.5
TOTAL 81 100
Note that in both cases Diarrhoea is the most important cause of mortality and represents
well over half of all the recorded deaths.
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9. Use of latrines and average quantity of water used per person per day.
For the latrine usage, families were simply asked whether or not they used latrines, and a
simple ‘yes’ or ‘no’ answer recorded.
No of sampled people using latrine: 919 (90%)
The average quantity of water used per person was calculated by asking the family for the
total quantity of water they used and dividing it by the number of people in the family:
Average quantity of water used per person per day: 12.46 Litres
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Anthropometrical Results
DISCUSSION
The Nutritional Survey results would indicate that the nutritional situation amongst the
IDPs in Mogadishu is still poor – although not catastrophic. At the same time additional
information collected in the survey indicates an extremely high rate of mortality amongst
young children. The two pieces of information could in fact be complimentary. Children
who are malnourished have a higher risk of mortality – having less resistance to
infections and a poorer ability to cope with them when they do catch them.
Younger children (i.e. those between 65cm and 80cm or those between 6 and 29 months)
appear to be more at risk of severe malnutrition than older children. One possible
explanation for this is that a lack of health education has meant that parents have poor
breastfeeding and weaning habits, making these children particularly vulnerable. A
further possibility is that these children are generally physiologically more vulnerable to
infections and illnesses than older children. One likely consequence of these infections is
a drop in Nutritional Status – more energy being required to fight the infections coupled
with a potential loss of appetite.
It proved to be difficult even with the assistance of an Events Calendar and strong
Expatriate supervision to gain truly valid information about the age of the children in
certain cases. However, even given this difficulty the Height for Age distribution curve
would indicate that stunting is a significant problem. This could be expected, given the
context of civil war and the breakdown of central authority that the IDPs have been living
in for the last 5 years.
As usual there is a difference in the rate of malnutrition when a comparison is made
between the Z score results and the % of the Median results. However in both cases the
situation is poor.
Although no statistical comparison can be made between clusters, it was observed that
malnutrition appeared to not be universal in the IDP camps. Camps in South Mogadishu
appear to be in a worse state than those in the North.
The IDP camps sampled are those where ACF has access – for referral to Therapeutic
Feeding Centres, for Health Education sessions, and for Water and Sanitation work.
Some other camps are being accessed by other agencies. But globally, it would be fair to
say that the camps that were sampled are generally better supported than other camps
around the city. Consequently, there is a high probability that the situation in those camps
not sampled by ACF is worse than that outlined above.
The hypothesis has been put forward that the population of the IDP camps surveyed was
one of the groups of the overall Mogadishu population that was considered the most
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vulnerable to malnutrition. It would be interesting to pursue this theory further in the
future by performing a further Nutritional Survey on the town population of Mogadishu.
The last major Nutritional Survey to cover the IDPs (see Annex 10) was completed
almost exactly 5 years ago between the 7 th and 20 th June 1995 (performed by ACF). The
Global Acute Malnutrition rate (in Z scores) was 26.3% (CI: 22.3% - 30.8%). The Severe
Acute Malnutrition rate (in Z scores) was 5.4% (CI: 3.5% - 8.1%). Although there has
been a significant drop since this time (13.4% drop in Global Acute Malnutrition and
3.4% in Severe Acute Malnutrition), there still remains a considerable problem.
There is agreement between different agencies working in Somalia (Nutrition Working
Group, 1999, ‘Nutrition Survey – Recommendations for Somalia’, Nairobi) that a MUAC
of less than 125mm is equivalent to Global Acute Malnutrition. In this Nutrition Survey
145 children (16.1%) were found with a MUAC of less than 125mm. Only 62 (42%) of
these 145 children had in addition a corresponding weight for height score of less than 2
Z scores. It would appear that using the MUAC of less than 125mm as a criterion of
Global Acute Malnutrition is:
- In this sample raising the overall Global Acute Malnutrition Rate by 24.8%
- Corresponds on an individual basis with the Statistically correct Z scores only
42% of the time.
Vaccination Coverage
The correct vaccination coverage for measles is low. This is the normal situation at the
moment in Somalia. Yet at the same time, the coverage appears to be particularly when
account is take of the fact that ACF have been conducting an ongoing measles
vaccination campaign (see Annex 2) which would indicate a far greater % of the
population has been properly vaccinated than the survey indicates. It is interesting that a
larger number of people said that there child had been vaccinated but were unable to
produce the vaccination card. No firm explanation can be offered for this difference.
5 years ago, in June 1995, the confirmed vaccination coverage for measles was 39.8%. It
now stands at 10%. This is a massive reduction in confirmed coverage, and highlights the
difficulties in undertaking vaccination activities in the context of Mogadishu. At the same
time it has to be considered a weakness of the ACF vaccination team.
Length of time displaced
97.1% of the IDPs have now spent at least one year in Mogadishu. This does not
correspond at all with the figures for the population influxes that ACF Health Education
team collects each month (see Annex 2), which would indicate a much higher influx of
new IDPs into the city over the last 12 months (around 10% of the population). The
conflicting nature of these results would suggest that there is a need to review how this
information is being collected on the ground.
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Mortality
In global, the overall figure for mortality is extremely alarming. The fact that 55% of the
mortality is due to Diarrhoea, and that latrine coverage is 90%, can only enhance this
alarm. Some possible explanations, which could partially explain this, include the
following:
- The mortality was taken during the last three months, which corresponded
with the peak in the Cholera outbreak and it is notable that Diarrhoea
represents at least 55% of all the mortality. No attempt was made in the
survey to differentiate between Common Diarrhoea and Cholera.
- The overall impact of Health Education activities (many focussed on Hygiene
and Diarrhoea) conducted in the IDP camps is probably less than anticipated.
- A number of places in Mogadishu treat the main possible consequence of
Diarrhoea (dehydration) freely. There would appear to be a lack of knowledge
of their presence and purpose, or a potential problem of access to them, or
finally not enough of them available to serve the needs of the population.
- In Mogadishu it is generally accepted that the overall Sanitation situation in
the town is poor. Improvements in not just the latrine coverage, but also the
collection and disposal of rubbish, and the water distribution system would be
needed to make a better impact on the Sanitation conditions. These actions
together would probably diminish the number of cases of Diarrhoea. The
impact of one action alone (latrine building) may not be enough.
- Other diseases, such as malaria or measles, could be presenting a primary
observed symptom of Diarrhoea.
Given this high rate of mortality due to Diarrhoea, it would be useful to perform a further
Nutritional survey after the end of the Cholera season to see if this figure changes. It
would also be interesting to perform a further statistically relevant survey on mortality
alone in the near future.
Water and Sanitation
Globally, the number of people claiming to use latrines is encouraging. Only 10% said
that they did not use the toilets. The quantity of water used per person (12.46 litres) on
average is slightly above the minimum acceptable international amount (10 litres).
However, the team on the ground observed a grand difference between individual camps.
Certain camps used as little as 5 litres per person, others up to 25 litres per person.
This information above, although interesting, does not particularly reveal a lot about the
Water and Sanitation situation in Mogadishu. However, it may assist in providing ideas
for more focussed Water and Sanitation Surveys in the future.
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RECOMMENDATIONS
• An evaluation into the effective area of coverage of the 4 TFCs in the city would assist
in defining the future need for 4 TFCs in the city given the comparatively low rate of
malnutrition found.
• Active case finding and screening should be increased to ensure the early reference of
the severely malnourished to the TFC.
• At a minimum, a further nutritional survey should be undertaken on the same
population in November 2000 – before the next Cholera outbreak. In addition, it
would be useful to perform a survey on the Resident population of the town if at all
possible.
• Access to, knowledge of, and the quantity of free simple medical assistance (Health
Posts, ORS points etc.) needs to be increased.
• Evaluate, strongly supervise and if necessary re-orientate Health Education Activities.
• Increase supervision of Vaccination activities.
• Perform regular statistically viable surveys of the vaccination coverage and mortality
on a two monthly basis.
• Improve supervision of Health Education activities and evaluate the impact of the
Health Education given.
• The system of the collection of information about the movements of population into
the city of Mogadishu should be reviewed.
• The use of the 125mm cut – off point with the muac to indicate Global Acute
Malnutrition should be studied further in a maximum of Anthropometrical Nutrition
Surveys.
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