Improved surveillance prevents excess mortality: the Gode experience

Summary of published paper¹

A study on the epidemiology of the famine in Gode district of Ethiopia has just been published. The primary objectives of the study (which was carried out by SCF USA with support from UNICEF and the Centre for Disease Control and Prevention) were to estimate mortality rates, determine the major causes of death and estimate the prevalence of malnutrition among children and adults for the population of Gode district. A two-stage cluster survey involving 595 households (4032 people) was conducted from July 27th to August 1st which included anthropometric measurements and 8-month retrospective mortality data collection.

The operational scenario

During 1999 data from Early Warning Systems (EWS) in many regions of Ethiopia indicated that both food security and the nutritional situation were deteriorating rapidly. WFP estimated that 10 million people needed food assistance. The Somali region with its largely agro-pastoral and pastoral communities had lost a large proportion of their livestock due to drought and was the worst affected area. In addition, in early 2000, measles cases began to be reported. It was not until April 2000 however, when media attention began to focus on the town of Gode, that a large scale international humanitarian response was triggered. Interventions included food aid and selective feeding programmes and resulted in populations becoming concentrated around major sites of humanitarian services. In May 2000 some UN agencies reported that the situation, although serious, was not a famine and that mortality was under control. Later, the WFP claimed that a widespread famine was averted by the rapid humanitarian response. However, up until the SCF USA/UNICEF/CDC study there was no data to support or refute this statement.

In Gode, during the drought of 2000, the majority of malnourished children who died (73%) also had another disease such as measles or diarrhoea. Malnutrition alone was reported as the cause of death for only 27% of children.

Malnutrition can be the most serious public health problem in emergencies and may be a leading cause of death, whether directly or indirectly. Malnourished children (or people) are at higher risk of infection and those who are ill are more likely to become malnourished. This pattern is known as the infectionmalnutrition cycle.

Source: Causes of death due to wasting, Gode district, Ethiopia Dec '99 to Jul '00. Salama and Assefa, July 2000.

Findings of the Study

From December 1999 to July 2000, the CMR in Gode was approximately 6 times higher than the prefamine baseline and 3 times higher than the accepted cut-off for the definition of the acute phase of a complex emergency (0.5/10,000/day). Given other reports it is probable that this reflected the situation in other districts within the zone. Wasting alone or in combination with four major communicable diseases (i.e. measles, diarrhoea, malaria and respiratory tract infection) was the most common cause of mortality in Gode district. More than half the deaths were in children younger than 5 years.

However, a relatively large proportion of deaths occurred among children aged 5-14 years whose baseline mortality rates would be expected to be far lower. These results underscored the importance of considering relative increases in age-specific mortality as well as absolute mortality.

Mortality rates were highest in December 1999 and January 2000 coinciding with the highest rates for famine related displacement. Both displacement and mortality rates decreased until reaching a low in April 2000. After interventions began in Gode (from April to May 2000), more people moved to intervention sites such as Gode town. Communicable diseases contributed to a significantly higher proportion of deaths in the period after major interventions began, suggesting that the population concentration and poor hygiene and sanitation conditions at intervention sites may have contributed to disease transmission.

Mortality rates for children under 5 years had been high early on so that prevalence rates for severe wasting among children in July 2000 were likely to be subject to survival bias and thus underestimated. Under such circumstances, the assessment of adult nutritional status may contribute to a better understanding of community nutritional status.

The overall prevalence rates for undernutrition among adults aged 18-59 years using unadjusted BMI was 1.5-2 times higher than for wasting among children aged 6 months to 5 years (49.3% for adults using a BMI cut-off of 18.5 kg/m2 and 29.1% for children aged 6-59 months using weight for height <-2 Z scores). If these rates were valid then higher death rates amongst adults would have been expected. This suggests that the adjusted BMIs (using the Cormic Index) calculated in the study provided a more plausible estimate of adult undernutrition (22.7%).

Older persons were frequently left alone during the famine in Gode as younger adults left home to search for suitable pasture or for food aid. The study showed a high prevalence of undernutrition among older persons and may partially account for the relatively large proportion of deaths among this group. Using adjusted BMIs and a cut off point of 18.5 Kg/m2 an estimated 13% of men and 30% of women respectively were undernourished.

Study limitations

There were a number of methodological limitations with the study. These included:

• households in which all members had died could not be included in the study;
• as there was no functioning surveillance system there was reliance on verbal reports on morbidity, cause of death and vaccination status of children.

Recommendations:

Most deaths were associated with wasting and major communicable diseases and occurred before the humanitarian intervention began. The response by humanitarian partners was delayed and inadequate, consisting primarily of food aid and selective feeding at a few central locations. The intervention may have increased disease transmission and mortality by attracting non-immune malnourished people to central locations. In such situations less centralised community based programmes for selective feeding need to be considered.

Despite low measles vaccination coverage and an ongoing measles epidemic from December 1999 to July 2000, a measles vaccination campaign with coverage sufficient to stop the epidemic was not implemented in Gode district until August 2000. Measles vaccination, in combination with vitamin A distribution is a life-saving intervention that needs to be implemented immediately in all types of complex emergencies. Vaccination coverage should be above 90% and extended to children up to 12-15 years old².

Nutrition and mortality data should be collected and analysed during famines. Such data may also challenge the assumption that only children under 5 are at higher risk. In Gode the lack of anthropometric data on adults, particularly older persons, resulted in them not being targeted for selective feeding programmes despite their vulnerability.

The use of adjusted BMI is recommended for adults and allows comparison with international cut-offs^3,4. Such measurements should be repeated and results validated against mortality and functional health outcomes in other famines and among other ethnic groups. After this method is further validated, a database of baseline mean BMIs and Cormic indices for populations regularly affected by famines should be collated for future reference and computer software to perform relevant calculations should be developed for field surveys.

Conclusion

No specific international agency has a mandate for overseeing surveillance systems, designing programmes based on such data nor for coordinating humanitarian agencies in non-refugee complex emergency affected populations. As a result these activities were inadequately performed in the Somali region of Ethiopia during this crisis. Ultimately national governments are responsible for such activities but may lack the resources. In the absence of structural change in the humanitarian system to address this lack of mandate, entirely preventable loss of life is likely to continue to occur on a large scale during complex emergencies.

¹Salama.P, Assefa.F, Talley.L, Spiegel.P, van der Veen.A and Gotway.C (2001) Malnutrition, measles, mortality and the humanitarian response during a famine in Ethiopia: Journal of the American Medical Association, Vol 286, No 5, pp 563- 571.

²Medecins Sans Frontieres. Refugee Health: An Approach to Emergency Situations. London, England, Macmillan Education Ltd; 1997.

³See Field Exchange Issue 13 'Assessment of adult malnutrition' for a summary of the special meeting on this topic at the SCNs 28th session held in Nairobi, April 2001.

⁴ Collins S., Woodruff B., Duffield A., Assessment of Adult malnutrition in emergencies. ACC/SCN July 2000.