Rapid MUAC assessment summary 10 June 08 by skatzz

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									           Summary Report of the Mid Upper Arm Circumference (MUAC) Rapid
                         Assessment in Cyclone affected Areas

                     Supported by- National Nutrition Centre/ MOH and UNICEF

1. Introduction
Many townships in Yangon and Ayeyarwady divisions of Myanmar were declared by the
authorities as disaster areas after the cyclone Nargis struck the country on 2nd & 3rd May
2008. Concern was raised that, as a result of the cyclone, levels of acute malnutrition
particularly among children may rise as a result of poor availability of and access to food,
potential increase in disease and disrupted infant and child care. Given the pre crisis
prevalence of acute malnutrition in Ayeyarwady and Yangon division (measured by weight
for height z score) of 9.8% and 7.8% respectively and severe acute malnutrition 2.9% and
0.4% respectively (MICS 2003) a rapid deterioration in nutritional status was feared. In order
to provide some rapid information on the situation UNICEF, in collaboration with the
National Nutrition Centre (NNC) of the DOH, conducted a rapid assessment of the nutrition
situation of under-5 children residing in the relief camps estimated to be those most affected
by the cyclone. The assessment was conducted from 17th May to 23rd May 2008
Because the sample in this assessment was intentionally selected from the relief camps in the
most severely affected disaster townships, the results cannot be generalized to the total
population of the country nor the whole cyclone-affected area. The analysis below presents
overall estimates as well as group specific estimates not to generate precise prevalence
estimates but rather to roughly indicate the magnitude of the nutrition problem in severely
affected population.

2. Objectives of the Assessment:
   2.1. General objective:
        To roughly estimate the nutritional status and vulnerability of children aged 6-59
        months who are residing in the relief camps in Ayeyarwady and Yangon divisions.

 2.2. Specific objectives
       To make a rough estimate of prevalence of acute malnutrition rates using MUAC
       To gain basic information on infant and young child feeding practices
       To identify reported 2 week incidence of diarrhoea & ARI in young children in camps
       To identify iodized salt usage

3 . Methodology and Data Collection
Assessment sites were selected from the worst affected townships and included Twantay,
Kungyangon, Hlaingtharyar and Dagon Myothit (North) townships in Yangon division and
Laputa, Bogalay, Pyapon and Myaumgmya townships in Ayeyarwady division.
It was not possible to select camps within these townships based on probability proportionate
to population size as had been planned due to lack of accurate figures and lack of access to
some of the camps. Therefore convenience sampling had to be used to cover the camps
where access was available.
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The sample size of children was calculated based on a formula for a simple proportion using
an expected acute malnutrition rate of 3%, a precision of 2%, with a confidence level of 95%.
These parameters lead to a minimum sample size of 291 which was further increased to 400
in order to account for the design effect of cluster sampling. Thus 20 children per cluster and
20 clusters were planned in each division. When it came to the fieldwork more camps
became accessible in the Ayeyarwady division therefore the number of clusters was
increased to 30.

Within the camps children were selected by taking a random starting point and then moving
to the nearest household until 20 children had been measured in each camp.
Surveyors were four public health nurses from the National Nutrition Centre of the
Department of Health who had been well trained on measuring the MUAC and conducting
community nutrition surveys. A rapid refresher training was given by the health specialist
from Health and Nutrition Section of UNICEF Yangon.
Single-colour coded insertion tape was used and the MUAC was measured to the nearest 0.1
cm. Interpretation of MUAC was as follows for all children 6-59months of age:

        MUAC < 11 cm : Very low = acute severe malnutrition
        MUAC 11-12.4: Low = acute moderate malnutrition
        MUAC 12.5-13.4: At-risk
        MUAC >/=13.5: Normal
Bilateral oedema was also checked for and classified as severe acute malnutrition when
found.

4. Quality of the data:
1.   The distribution of MUAC measurements appears reasonably normal.
2.   The distribution of the decimal for the MUAC measurements is clustered around the .0
     and .5 decimal indicating teams were rounding the actual MUAC measurements. This
     leads us to question the quality of the data. However we cannot know if this rounding
     was systematic – i.e. always rounding down, or always rounding up.
3.   The distribution of the children’s ages is also clustered around whole years (12m, 24m
     etc.) indicating that ages were rounded and again leading to questions of the accuracy
     of the data.
4.   Data was not entered by cluster or by team therefore neither the numbers of children
     sampled in each cluster nor the quality of the data by team can be cross checked.
5.   The standard deviation (not accounting for clustering) of MUAC measurements is 1.16
     The standard deviation for the WHO standard population in the same age group (12-47
     months) is 1.18. This demonstrates that there is probably little random error in the
     MUAC measurements.

Given the limitations of the data, confidence intervals have not been calculated.


5. Summary of Findings:
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5.1. Study population
The entire sample consists of 1316 children between 6 months and 59 months (832 in
Ayeyarwady division and 484 in Yangon division). Boys and girls were equally included in
both divisions. Boys constituted 51.7% in Ayeyarwady and 51.4% in Yangon division. The
age distribution was similar for both Divisions. (see Annex 1.)

5.2 Acute malnutrition
The estimated prevalence of acute malnutrition in the sample was 6.5% and 3.9%
respectively for Ayeyarwady and Yangon Division. The proportion of children with MUAC
below 11 cm was less than 1% in both Divisions. No cases of oedema were found in the
study sample.

A substantial proportion of children had MUAC within the range of "at-risk" (17.4% in
Ayeyarwady and 14.7% in Yangon). The highest percentage of children with low MUAC
(<12.5cm) and those with "at-risk" MUAC were in the 6 to 23 month age group. Distribution
of children's MUAC by township indicated little difference in prevalence between townships
sampled. (see Annex 2.)

5.3. Infant and Young Child Feeding
More than 90% of infants between 6-11 months were reported to be breastfed. Nearly 80% of
children between 12-17 months in Yangon division and nearly 90% in the same age group in
Ayeyarwady were reported to be still breastfed. Prevalence of breastfeeding was reported to
drop only after the age of 24 months. (see Annex 4.)
The majority (85% Ayeyarwady, 91% Yangon) of infants 6 to 12 months old were receiving
complementary foods. Among children between 7 and 12 months, the majority of children
were fed two times a day (54% in Ayeyarwady and 67.7% in Yangon), however in
Ayeyarwady 25% of children in this age group were only eating 1 meal a day. After one year
of age, the majority of children in both Divisions (Ayeyarwady 95.4%, Yangon 99.3%) were
reported to be eating 2 or more meals a day. However in Ayeyarwady only one third of
children were getting three or more meals a day. (See Annex 4).
5.4. Morbidity
30.6% (255/832) of care givers in Ayeyarwady division and 24% (116/484) of care givers in
Yangon Division reported that their child had experienced diarrhoea within the last 2 weeks.

36.4% (303/832) of care givers in Ayeyarwady and 43.2% (209/484) in Yangon division
reported that their child had experienced cough in the last 2 weeks.

5.5. Iodized salt consumption
All 15 salt samples in Yangon were iodized. Both iodized and non-iodized salt were
available in Ayeyarwady division with only 13 out of 21 salt samples iodized.

6. Discussion and Recommendations
The estimated levels of acute malnutrition using MUAC for children 6-59 months old in the
most cyclone affect areas in Ayeyarwady and Yangon divisions found during this assessment
                                               4

(6.5% and 3.9% respectively) were not alarming. However, it is important to bear in mind
that these estimates cannot be compared to available data on pre crisis prevalence as the
MICS results were based on WHZ (weight for height Z scores).

The numbers of children in the ‘at risk’ category in Ayeyarwady and Yangon (17.4 and
14.7% respectively) according to this assessment are worrying and illustrate the need for
approaches to prevent these children from slipping into the malnourished categories.
Measures to improve food availability, provide sufficiently energy dense foods for young
children, protect appropriate infant feeding, and ensure environmental sanitation and
adequate health care services will be vital for preventing a deterioration in the nutritional
situation.

Higher estimates of malnutrition in the younger age group (6-23 m) in this rapid assessment
is in conformity with the MICS 2003. However this pattern may also be due to the fact that
the use of a single MUAC cut-off selects a larger proportion of younger children.
Nevertheless as a MUAC of <11.0cm is highly associated with mortality, irrespective of age,
the higher estimates of malnutrition in this age group illustrate the need for action in the area
of promoting appropriate infant feeding and particularly in the provision of appropriate
complementary foods.
High prevalence of breastfeeding with long duration is an encouraging finding as this will
benefit the nutritional status of infants and young children. It is very important to maintain
this status by supporting mothers both practically, psychologically and with nutritional inputs
to continue to breastfeed. This is particularly important due to the disruption and stress which
the population have experienced and should include prevention of mass distributions of
breast milk substitutes which may undermine breastfeeding and place infants at risk.

Most children were fed only two daily meals. Even though frequency of daily meals
generally increased after one year of age it is still necessary to encourage giving young
children 3 or more meals a day and ensure that the foods being given can provide their
nutrient needs.
Ayeyarwady division produces large quantity of sea salt and thus non-iodized salt is
available in many places especially those near the sea coast. Measures should be taken to
ensure that salt in food rations are adequately iodized, to control salt factories more strictly
and to promote local iodization for small salt producers.
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ANNEX 1. Study Population

Table 1. Distribution of children by sex (Ayeyarwady Division).

        Township                  boys #                Girls #             Total #
 Laputa                           137 (52.9%)            122 (47.1%)         259 (100%)
 Bogalay                          100 (47.4%)            111(52.6%)          211 (100%)
 Pyapon                            43 (49.4%)             44 (50.6%)          87 (100%)
 Myaungmya                        150 (54.5%)              12545.5%          275 (100%)
 Total                            430 (51.7%)           402 (48.3%)          832(100%)

Table 2: Distribution of children by sex (Yangon Division)

        Township                  boys #                Girls #             Total #
 Twantay                           53 (52.5%)             48 (47.5%)         101 (100%)
 Kungyangon                        45 (48.5%)             48 (51.6%)          93 (100%)
 Hlaingtharyar                    140 (52.4%)            127(47.6%)          267 (100%)
 Dagon (N)                         11 (47.8%)              12(52.2%)          23 (100%)
 Total                            249 (51.4%)           235 (48.6%)          484 (100%)


Table 3: Distribution of children by age (Ayeyarwady)

   Township            6-23m              24-35m             36-47m         48-59m          Total
 Laputa               103 (39.8%)          47 (18.1%)         48 (18.5%)     61 (23.6%)    259 (100%)
 Bogalay               53 (25.1%)          48 (22.7%)         61 (28.9%)     49 (23.2%)    211 (100%)
 Pyapon                34 (39.1%)          16 (18.4%)         18 (20.7%)     19 (21.8%)     87 (100%)
 Myaungmya             82 (29.8%)          59 (21.5%)         64 (23.3%)     70 (25.5%)    275 (100%)
 Total                272 (32.7%)        170 (20.4%)         64 (23.0%)    199 (23.9%)     832 (100%)

Table 4: Distribution of children by age (Yangon Division)

   Township            6-23m              24-35m           36-47m           48-59m          Total
 Twantay               29 (28.7%)          22 (21.8%)       25 (24.8%)       25 (24.8%)    101 (100%)
 Kungyangon              27 (29%)          22 (23.7%)       18 (19.4%)       26 (28.0%)     93 (100%)
 Hlaingtharyar         78 (29.2%)          50 (18.7%)       73 (27.3%)       66 (24.7%)    267 (100%)
 Dagon (N)              7 (30.4%)           9 (39.1%)        3 (13.0%)        4 (17.4%)     23 (100%)
 Total                141 (29.1%)        103 (21.3%)      119 (24.6%)      121 (25.0%)     484 (100%)


ANNEX 2. Nutritional Status

Table 5. Summary of nutritional status

   MUAC (cm)                Nutritional status           Ayeyarwady Division          Yangon Division
                                                              #              %           #             %
 >/= 13.5 cm        Normal                                  633            76.1        394          81.4
 12.5 – 13.4 cm     At risk of malnutrition                 145            17.4         71          14.7
 11 – 12.4 cm       Moderate acute malnutrition              49             5.9         18            3.7
 <11 cm             Severe acute malnutrition                 5             0.6          1            0.2
No child in Ayeyarwady division nor in Yangon division had oedema.
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Table 6: Prevalence of acute malnutrition by age

             Yangon             Ayeyarwady
Age            Total               Total
(m)           #        %           #        %
6-23         10     7.1%          38      14%
24-35         8     7.8%          10     5.9%
36-47         1     0.8%           2     1.0%
48-59         0     0.0%           4     2.0%
Total        19    3.9%           54     6.5%

Table 7. Distribution of MUAC by township (Ayeyarwady division)

   Township              <12.5             12.5-13.4              =>13.5              Total
                         #       %          #        %            #       %            #    %
 Laputta                23       8.8       41       15.8        195      75.3        259 100
 Bogalay                 9       4.3       37       17.5        165      78.2        211 100
 Pyapon*                 2       2.3       21       24.1         64      73.6         87 100
 Myaungmya              20       7.2       46       16.7        209      76.0        275 100
 Total                  54    6.5%        145 17.4%             633 76.1%            832 100

Table 8. Distribution of MUAC by township (Yangon division)
   Township              <12.5           12.5-13.4             =>13.5            Total
                         #       %         #        %          #         %         #   %
 Twanty                  5       5.0      16      15.8        80      79.2      101 100
 Kungyangon*             2       2.2      11      11.8        80      86.0        93 100
 Hlaingtharyar         10        3.7      40      15.0      217       81.3      267 100
 Dagon Myothit           2       8.7       4      17.4        17      73.9        23 100
 (N)*
 Total                 19     3.9%        71 14.7%          394 81.4%           484 100
        * care needed when interpreting these findings due to the small sample size.

ANNEX 3. Infant and Young Child Feeding

Table 9. Prevalence of breastfeeding by age group

Division               6-11 m                 12-17 m                  18-23 m                 =>24 m
                        #      %                #      %                 #      %                #     %
Ayeyarwady          81/86     94.2        135/145     93.1           36/41     87.8        226/560    40.4
Yangon              45/46     97.8          49/53     92.5           33/42     78.6         51/343    14.9

Table 10. Frequency of daily meals by age group

                6m                      7-12 m                                     Above 12 m
                 #          Not       1        2       =>3        Not       1          2        3        >3
                (%)         yet     time     times    times       yet     time       times    times    times
Ayeyarwady         18         24        35       75         5       14        17        418      207       19
                (100)      (17.3)   (25.2) (54.0)       (3.6)     (2,1)    (2.5)     (61,9) (30.7)       (2.8)
Yangon              5           6        8       44         7         0        3        167      221       23
                (100)       (9.2)   (12.3) (67.7)     (10.7)      (0.0)    (0.7)     (40.3) (53.4)       (5.6)

								
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