International Notes Nutritional Assessment of Children in Drought-Affected Areas -- Haiti, 1990

From January through June 1990, a drought occurred in the Caribbean nation of Haiti. To determine whether the nutritional status of young children had been affected by drought-related reductions in food supply, in September 1990 a nutrition survey was conducted in the five departments most affected (Nord-Ouest, Nord, Nord-Est, Artibonite, and Centre) of Haiti's nine departments (Figure 1).

A multistage 30-cluster survey was conducted using sampling methods modified from the CDC rapid nutrition assessment surveys procedure (1) because of limitations in population estimates. A preliminary weighted analysis of prevalence and confidence intervals was performed using SESUDAAN, a computer software program for analyzing complex sample survey data (2). The Epi Info version 5.0 (3) nutritional anthropometry computer software program was used to calculate height-for-age (Ht/Age), weight-for-height (Wt/Ht), and weight-for-age (Wt/Age) z-scores; percentiles; and percentages of median values.

The growth status of 967 children aged 3.0-59.9 months was evaluated to estimate the prevalence of low Ht/Age (an indicator of chronic undernutrition), low Wt/Ht (an indicator of acute undernutrition), and low Wt/Age (4). A cutoff point of less than -2 standard deviation units from CDC's National Center for Health Statistics/World Health Organization (CDC/WHO) reference median (z-score less than -2, or the 2.3rd percentile) was used to classify low Ht/Age, low Wt/Ht, and low Wt/Age (5).

The overall prevalences of low Ht/Age and Wt/Ht among the children surveyed was 40.6% and 4.2%, respectively (Table 1). The prevalence of low Wt/Ht was higher among children aged 12.0-23.9 months; however, this is partially accounted for by a disjunction in the CDC/WHO growth reference curve that results in an overestimation of the prevalence of low Wt/Ht for this age group (6). Approximately 34% of all children surveyed had low Wt/Age.

When compared with the CDC/WHO reference population, the z-score curves for Ht/Age and Wt/Age in Haitian children aged 24.0-59.9 months were dispersed (Figure 2). The Wt/Age distribution for Haitian children indicated the high prevalence of low Ht/Age rather than low Wt/Ht (Figure 2). In addition, the entire distributions of Ht/Age and Wt/Age were shifted to the left of the reference by nearly 1.8 z-score units, indicating that chronic undernutrition was prevalent and generalized among young children in the drought-affected areas of northern Haiti. Reported by: Child Health Institute of Haiti; Ministry of Health of Haiti. US Agency for International Development/Haiti. Pan American Health Organization/World Health Organization. Div of Nutrition, Center for Chronic Disease Prevention and Health Promotion; Technical Support Div, International Health Program Office, CDC.

Editorial Note

Editorial Note: When compared with the prevalence of undernutrition in other less developed countries (7), the prevalence of chronic undernutrition in Haiti was moderate to high (Table 1). Long-term protein-energy deprivation is a major cause of chronic undernutrition in children; however, recurrent infections and micronutrient deficiencies can also contribute to growth retardation (8). The estimated prevalence of low Wt/Ht represented a moderate level of acute undernutrition when compared with the prevalence of low Wt/Ht in other less developed countries (7). Unlike low Ht/Age, a greater than 10% prevalence of low Wt/Ht is regarded as a severe condition, often observed during famines.

Although not directly comparable, the prevalence estimates from this survey are similar to estimates obtained from the 1978 Haiti Nutrition Status Survey (9). However, because of the 12-year lapse between the two surveys, it is not possible to determine whether the situation was stable, better, or worse during the last few years. Data from ongoing surveillance or frequent surveys are necessary to determine secular trends in nutritional status.

The 1990 survey results do not suggest a famine situation existed in Haiti. However, because low or abnormal anthropometric findings are a late indicator of inadequate nutrition and because the present anthropometric data indicate a moderately malnourished population, the results of the survey indicate that the population had little reserve capacity to withstand food shortages and that any further deterioration of nutritional status could result in increased morbidity and mortality. Recommended nutrition interventions to prevent the emergence of such a crisis include increasing food availability and consumer purchasing power and providing seeds to farmers. The immediate distribution of food to high-risk persons (e.g., young children and pregnant women) and the establishment of a reliable system for monitoring nutritional levels in areas considered at risk are additional options.

In consultation with Haitian public health officials and relief organizations, CDC assisted in developing a sentinel nutrition surveillance system that includes the monthly collection of information on rainfall patterns, agricultural production, food prices, and child weight. Data from this system are being analyzed in Haiti and should contribute to a famine early-warning system for the country.

References

1. CDC. Nutrition assessment manual. Revised ed. Atlanta: US Department of Health and Human Services, Public Health Service, 1990.

2. Shah BV. SESUDAAN: standard errors program for computing of standardized rates from sample survey data. Research Triangle Park, North Carolina: Research Triangle Institute, 1981.

3. Sullivan K, Gorstein J. Programs for nutritional anthropometry. Chapter 23. In: Dean AD, Dean JA, Burton AH, Dicker RC. Epi Info, version 5: a word processing, database, and statistics program for epidemiology on microcomputers. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1990.

4. United Nations. How to weigh and measure children: assessing the nutritional status of young children in household surveys: preliminary version. New York: United Nations Department of Technical Cooperation for Development and Statistical Office, 1986.

5. Hammill PVV, Drizd TA, Johnson CL, Reed RB, Roche AF, Moore WM. Physical growth: National Center for Health Statistics percentiles. Am J Clin Nutr 1979;32:607-29.

6. Dibley MJ, Goldsby JB, Staehling NW, Trowbridge FL. Development of normalized curves for the international growth reference: historical and technical considerations. Am J Clin Nutr 1987;46:736-48.

7. Carlson BA, Wardlaw TM. A global, regional and country assessment of child malnutrition. New York: UNICEF Programme Division, 1990. (Staff working papers no. 7).

8. Waterlow JC. Current issues in nutritional assessment by anthropometry. In: Brozek J, Schurch B, eds. Malnutrition and behavior: critical assessment of key issues. Lausanne, Switzerland: Nestle Foundation, 1984:77-90.

9. Agency for International Development. Haiti Nutrition Status Survey: 1978. Washington DC: US Agency for International Development, Development Support Bureau, Office of Nutrition, 1979.

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