RECURSOS COMUNALES 1 NATURALEZA DE LOS BIENES

MUAC measurement in emergencies has three main uses:

1. To estimate the prevalence of acute malnutrition as a rapid alternative to W/H 2. As a first-stage screening and referral tool

3. To admit children to therapeutic feeding programs

MUAC is a simple tool that involves a single, non age-related measurement. It requires the use of an elastic band to systematically measure the mid-upper arm circumference of children between 6 and 59 months of age, using sample sizes of 900 children or more for full surveys. MUAC is often used in emergencies to estimate the prevalence of wasting across a population. For results to be valid, enumerators must be carefully trained by qualified staff on proper usage of the armband to ensure that errors in measurement due to technique and variance between enumerators are minimized. Nutrition staff must also support FSL teams on designing the sampling approach and analyzing results. Note that there is still significant controversy over whether MUAC or W/H is the best indicator of acute malnutrition for use in surveys.

MUAC is also often used as a referral or screening tool in the field to identify children who are at risk of malnutrition. To date there are no standard MUAC cut-offs for initial first-stage field screening and FSL teams need to consult with nutrition teams on the ground to identify acceptable thresholds in collaboration with Ministry of Health officials and other agencies. Cut-offs in the range of 130 or 135mm have been used.

Children with a measurement below the agreed cut-off are referred to a nutrition centre where a weight-for-height measurement and/or a new MUAC measurement is taken. Admission criteria to feeding centres until recently had been solely based on weight-for-height Z scores (WHZ) but MUAC is now a considered indicator for case definitions of acute malnutrition based on a cut-off of 115mm (as recommended by WHO/ UNICEF, measured against the WHO growth curves).

Approach Rapid MUAC screening for 768 children 6-59 months of age, using a non-scientific sample. Material One 110cm stick; MUAC bracelets; MUAC record sheets; clipboard & pen; random table.

Selection of communities

Purposive selection of 24 communities considering security and logistic issues, and so that to cross the range of situations prevailing in Jebel Marra. Purposively selected communities all had more than 20 households. Habitats were generally grouped within villages or camps for selected communities. (N1)

Selection of compounds & households within compounds

Random selection of compounds in selected communities. More specifically selected communities were divided into 4 clusters. From the centre of each cluster, a direction was selected randomly (“spinning pen” technique); the first compound was selected along this direction using a random number table; remaining compounds were taken successively by proximity, always taking the compounds on the right hand side from the entrance of the former. HHs living in these compounds were selected. If more than one HH resided in the compound, identification was made according to the residential status (resident/ IDP); if the HHs were all residents or all IDPs, a random choice was made to select 1 HH; if IDPs were living with residents, one HH from each residential status was randomly selected. (N2)

Selection of children

Systematic selection of children between 6 months & 59 months within selected households. All children between 6 months & 59 months/110 cm and living in selected houses are screened, so that to reach 32 children per community (equivalent to 8 children per cluster). Children higher than 110 cm/ reference stick were systematically removed, and age was requested to mothers before including very young children (6 months-old children were those born after August 2007). If a child was not present in the compound but was in the close surroundings, MUAC team managed to measure the child; if child was not present in the compound randomly selected and was not in the close surroundings (away for the village & practically difficult to meet him/her), the child was replaced.

Information recorded

All the following information was recorded in a MUAC record sheet:

For each community: name of community; date; screener; methodology used; household number. For each household: status (resident; IDP); date of arrival (if displaced); origins (is displaced). For each child: age (N3); months; sex; MUAC (mm); presence of oedema (N4); presence of ARI in the past 15 days; presence of diarrhoea in the past 15 days; any additional comments.

Data storage & analysis

MUAC record sheets were entered in a MS Excel database. In the frame of the analysis, MUAC were disaggregated into the following MUAC categories: < 110; 110 - 119; 120 - 135; > 135; children were as well disaggregated in 5 age groups: > 6 & <=12 months; > 12 & <= 24 months; > 24 & <= 36 months; > 36 & <= 48 months; > 48 & <= 59 months.

Miscellaneous In order to find caretakers/heads of households in the houses, the MUAC screening was conducted early morning, after having informed local authorities the former evening.

Notes

(N1) Except in the case of Huera Farik community, which was composed of one village (grouped habitat) surrounded by IDP living along the wadi (diffused habitat).

(N2) For 3 smaller communities, another methodological approach was used: all compounds were visited with all eligible children screening (referred in the database as the exhaustive approach); if the number of children exceeded the amount desired, 32 children were than randomly within the MUAC record sheet (the case of Dulda, Tabasa Garib West & Marra). In the case of Huera Farik mentioned in (N1), compounds within the grouped habitat were randomly selected, so that to screen 16 children (2 clusters were defined); IDP households living along the wadi/ diffused habitat were systematically selected, so that to screen as well 16 children.

(N3) Age - If the mother knew the birth date, determination of the age is simple: in such case, the age was recorded into the questionnaire in month; when birth dates were unknown, mothers were asked about the approximate age using the local events calendar.

(N4) Oedema - In order to determine the presence of oedema, normal thumb pressure was applied to both feet for 3 seconds; if a shallow print persisted on the both feet, then the child was presenting oedema; only children with bilateral oedema were recorded as having nutritional oedema.

Indicators Emergency Stable Situation

Minimum quantity for human consumption (drinking + cooking + hygiene)

15 liters/person/day National standard 30-60 liters/person/day

Nutrition centers Health centers

Maximum distance from water point

Number of people per water point

Maximum waiting time

30 liters/patient/day 50 liters/patient/day 500 meters

15 liters person/day 8 hours of supply: • 500people per hand pump

(16.6 l/min)

• 400 people per open well (12.5 l/min)

• 250 people per _’ tap (7.5 l/min)

15 minutes

50-220 liters/patient/day

50 meters

50 liters person/day hours of supply

• 150 people per hand pump (16.6 l/min)

• 120 people per open well (12.5 l/min)

• 75 people per tap (7.5 l/min) Household connection

No waiting time, or few minutes

Water quality

0 coli forms/100 ml

Sanitation survey indicates a low risk of possible fecal contamination

For populations of more than 10,000 people, in locations where there is a high risk of epidemics, or where there is a high occurrence of diarrheas, it is recommended to chlorinate the water and ensure a residual chlorine level of 0.5 mg per liter and less than 5 NTU turbidity.

Emergency Stable Situation

Water quality

For physic-chemical parameters, use the WHO guideline values and assess the danger of consuming the water for a short period (in emergencies), thus opening up the possibility of using other water sources. If the danger is deemed very high, the water should not be used.

Total dissolved solids should not exceed 1,000 mg/liter, or a conductivity of 2,000 µs/cm

In order to avoid negative health effects, the water should not contain chemical or radioactive contamination

Defecation areas

Latrines

Access to latrines

At least 50 m away from the nearest water point.

Trenches: 2.5 m x 0.3 m x 1 m for 100 people

First phase: 1 public latrine per 50 people

Second Phase: 1 public latrine used per 20 people

Third phase: 1 family latrine used per family

More than 50 m from the nearest water point

Less than 50 m from the house

No defecation areas

1 Latrine per family Appendix 4: WASH indicators

Appendix 5: Guidelines for Rapid Assessments