Nutritional survey and retrospective mortality assessment - Denan, Ogaden , Ethiopia

Originally published


MAY 16-18, 2000
Pascale Delchevalerie, Michel Van Herp, An Willems


A retrospective mortality and nutritional survey was conducted in the camp and the town of Denan from May 16-18, 2000.


  • To quantify the global and severe malnutrition among children aged 6 to 59 months in the camp and the town of Denan.
  • To identify high risks groups.
  • To evaluate the coverage of the feeding programmes.
  • To estimate the mortality in the community over the previous months.
  • To evaluate the measles coverage of children under 5 years.


The standard methodology of UNHCR/WFP/MSF was followed, a two stage cluster sampling was used. The sample size was defined according to an expected prevalence of malnutrition of 40% . A degree of 3,5% as precision and 5% risk of error. In the camp and the town, 30 clusters of at least 25 children were completed. Inclusion criteria : children between 6 to 59 months , or a length between 65 cm and 110 cm. Data collection were age, sex, weight, height, Muac, oedema, measles vaccine given by card and measles given by history, attendance in TFC or SFC. Results for weight and height index values are based on the Reference Population Table of the NCHS/CDC/WHO 1982.

A retrospective mortality survey was also done in all the houses visited (even the ones without children under five). Data collected were status, resident or displaced (1), number of persons above five years , number of children less than five years, number of deaths under five and above five years since the end of last Ramandan ( 08/01/2000).


1) Nutritional survey

Sample size : 765 children
% Boys : 50,5 %
% Girls : 49, 5%
Sex ratio B:G 1,02:1

Anthropometric Indices
95% CI*
< -2 z-scores or oed. = GAM**
< -3 z-scores or oed. = SAM**


[47.8 - 58.1]
[9.6 - 14.2]
Percent. Of the Median
< 80% or oedema =GAM
< 70% or oedema =SAM


[35.8 - 45.5]
[4.1 - 7.9]

* 95% confidence intervals with calculated cluster effect
** GAM= global acute malnutrition - SAM =severe acute malnutrition

2) Retrospective Mortality

Sample size : 3934
Families interviewed : 691
Under 5 population : 818
% under 5’s : 21%
Average people per family : 5.7

Under five MR
(7,9- 9,9)
( 25,2 - 29,7)

3) Measles coverage

Measles coverage confirmed by vaccine card : 44,6% (37,6-51,6)
Measles coverage confirmed by history : 26,7% ( 20,6- 32,8)
Not vaccinated : 28,8% (24,3 - 33,2)


  • The prevalence of the global and severe malnutrition observed is extremely high.
  • The retrospective crude mortality rate is catastrophic and is most probably due to malnutrition and the measles epidemic in the area.
  • The measles coverage surveyed by both card and history is 71,2% which is not satisfactory.

  • To provide an adequate ration, qualitatively and quantitatively, through the general food distribution programme already in place by ICRC and DPPC/WFP in the affected areas.
  • Reduce mortality by continuing the therapeutic feeding programme to treat severely malnourished individuals and the supplementary programme for moderately malnourished individuals.
  • To repeat a nutritional survey in 3 months to assess the trends in the nutritional status.
  • To set up a nutritional and epidemiological surveillance system.
  • Support to the existing health structure to reduce morbidity and mortality.
  • To continue the vaccination of the non vaccinated children at the screening point in the TFC and SFC.
  • To organise a measles immunisation day in Denan, for the children between 6 months and 15 years, with the support of the existing health structure.
  • Reinforcement restocking programmes, seed distribution, tools supply and supply adequate livestock drugs .
  • Investment should be made in seeking long term solutions for a potable water supply in this area.


1.1 Context

The Ogaden which is now administered by the Somali National Regional State V lies to the South East of Ethiopia, bordering Somali, Kenya and Djibouti. This area is renown for it’s instability since the Somali-Ethiopian war in the 1970’s with continuing conflict influenced by secessionist groups and regional wars. At the present time the area insecure, restricting activities for all international actors in the area. The main armed actors in this region are the ONLF ( Ogadenese National Liberation Front) and the Al-Itihad (fundamentalist Group) however there is also a high risk from bandits and with the high level of military presence (Ethiopian Army) there are frequent attacks on both civilian and military targets.

MSF-B has been present in Ethiopia since 1985. Initially the focus of their programme were emergencies , including a presence in the Gode region from 1991-1996, but in recent years projects have become more development orientated. At the present time MSF B is present in Region V, Somali State , in the regional capital, Jijiga where they run a tuberculosis programme. Up until February this year MSF B was also present in the Degah Bur zone , working in rural health and water, but due to a critical incident in February this programme was suspended.

In January 2000 an urgent international appeal was launched by the Ethiopian government with regard to the threat of a nation-wide famine due to the failure of rains in recent years. Thus MSF decided to study the nutritional situation in Gode area where it was already present. The first team was evacuated following the security incident in Degah Bur zone. However MSF clearly recommended an intervention for both the malnourished and an ongoing measles epidemic that the team had clearly identified during their short the first week of February. Due to the security risk , it was clear that MSF could not be permanently present but that they could assist in the Zonal Health Bureau in a mass measles vaccination campaign. At the same time other local actors assured the DPPC task force in Addis Abeba that they would take in charge the malnutrition and water supply problem.

A two person team was sent immediately to Ethiopia and Gode and they started the training of medical personnel and launched the measles vaccination campaign on 15th of Feb. This campaign covered Gode zone and ended on the 21.03.00. This campaign achieved 39% coverage of the expected target population (quoted at 120.000 persons at the beginning of the campaign) and 45.9% of children under five years of age, for measles vaccination and Vitamin A distribution. At the same time all children between 6 months and five years also had a MUAC taken - this showed a severe malnutrition problem of 13% in this population(<110muac/oed = 3618 children measured), with 19.4% (110-125muac=5415 children) suffering from moderate malnutrition and 21% at risk(126-135muac=5809 children) - thus over 50% of the under five population with a serious risk. It was also clear that the other actors in the area were having difficulty to cope with the population requirements. Again the recommendation of the team was an immediate nutritional intervention in the Gode zone, where priority should be given to Denan, Gode and Imey areas.

Following a third and final assessment mission in early April it was decided that there was a reasonable security situation in the Gode which can allow MSF to have a team permanently presence in the Gode zone.

Taking this into consideration MSF launched a programme with three main actions:

1. A nutritional intervention to treat the severe and moderately malnourished.

2. Set up a nutritional and epidemiological surveillance system.

3. Support to existing Primary Health Care structures

1.2 Demographic data

Denan has changed considerably over the past months with a large population movement towards the town. The initial population estimated at 9.000 people in the town has shown to have increased to 9.906 just before the survey , with an under five population of 2.890 children(29.2%).

There is also a displaced camp at the outskirts of the town (this camp started in January 2000) which was initially (26/04) estimated at 7.000 persons, but just before the survey it had reached 12,919 persons (2). The under five population was counted 4.534 children (35.1%)

1.3 Food distribution

Since November the DPPC (3) started with general food distributions in Denan town and for some of the surrounding villages. This food distribution was 1200 Kcal per person, and consisted of a dry ration of wheat flour only. As the general food distribution was not considered to be sufficient, it was agreed by the DPPC and ICRC that a supplementary general food distribution was necessary. ICRC therefore started this supplementary distribution to the population (target population of the programme: 200.000 people) consisting of 10 kg Famix and 2 litre of oil per person. This brings the ration of these 200.000 people to 2000 Kcal per person.

The DDPC is planning a distribution of 10 kg wheat per person at the end of May 2000.

1.4 Nutritional services

MSF Belgium began activities in Denan end of April 2000 with a therapeutic feeding centre and a supplementary feeding centre. In the beginning of May a second therapeutic feeding centre was opened.

At the time of the survey , 2 TFC’s were open with an attendance of 532 children. In the SFC there was an attendance of 2131 children per week.

All severely malnourished children below 70% weight for height, children with oedema or a MUAC < 110mm (4) are admitted in the therapeutic feeding centre. Severely malnourished adults /elderly are also admitted based on MUAC and clinical status.

In the TFC the children are fed intensively until they reach W/H > 80% (5). Basic medical care and individual follow up is given to all children in care.

All children with W/H between 70% and 80% (including children discharged from the TFC) are admitted to the supplementary feeding centre and receive a dry ration of BP5 on a weekly basis. These children are discharged when they reach 85 %W/H for two consecutive weeks.

1.5 Medical information

There is a primary health care post in Denan town, which is run by an Auxiliary Nurse form the Zonal Health Bureau of Gode Zone. With the increase in the population, the health post needs additional support. UNICEF gave a first donation of drugs to the health centre at the beginning of May. At present MSF in collaboration with the Zonal Health Bureau is preparing a support mechanism to the health post. This support will include clinical supervision and drug distribution. This will include the assurance that all the population will have access to free care and medication.

Lethality rate observed in both TFC’s from 26/04/2000 till 21/05/2000 :

  • 18 deaths / 532 children admitted = 3,4.%

Morbidity data observed in both TFC’s from 26/04/2000 till 21/05/2000 where

532 children were admitted :

- 102 measles cases
- 53 cases of bloody diarrhoea
- 23 cases of strong suspicion of tuberculosis

1.6 Livestock

Due to the four year old drought in this area the predominantly nomadic population and their families have been moving towards general food distribution points as fail to find water and their animals die. At the beginning of May it started to rain although this rain came too late for the Ogaden. The livestock is already dead and many families are now destitute depending on general food distributions. The period required for this population to recuperate, livestock recovery, conception, gestation and sufficient milk production will take at least several months.

1.7 Water situation

Feeding centres

Water supply to the feeding centre is organised from a riverbed well 12 km North West from Denan village.

Due to heavy rains this well flooded leaving Denan without watersupply as of 3 May. Water trucking from Gode became impossible the next day so a combination of different strategies assured watersupply to the feeding centre:

1. Installation of water transport facilities and a water treatment unit at 2 km from the feeding centre using assisted sedimentation to treat very turbid run-off rainwater. At the same time, rehabilitation of 2 existing flood free wells was initiated.

2. Installation in the feeding centre of a water storage stock of 50 m3 and a rainwater collection system.

The usual hygiene and sanitation infrastructures were installed in the feeding centre and a team of hygiene promoters assured the correct use of these infrastructures.

IDP Camp

A very basic emergency sanitation program for the IDP camp adjoining

Denan village was started up including:

1. Lobby for distribution of non-food items by ICRC

2. Installation of trench latrines and a hygiene education program run via the CHW network.

3. Supply safe water from the MSF water treatment unit to assist OWS with the general water supply

4. Donate MSF bladders and tapstands to assist SCF with the general water transport and distribution


The objectives of the survey were :

  • To quantify the global and severe malnutrition among children aged 6 to 59 months in the camp and the town of Denan.
  • To identify high risks groups.
  • To evaluate the coverage of the feeding programmes.
  • To estimate the mortality in the community over the previous months.
  • To evaluate the measles coverage of children under 5 years.

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