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Leidman E, Humphreys A, Greene Cramer B, et al. Acute Malnutrition and Anemia Among Rohingya Children in Kutupalong Camp, Bangladesh. JAMA. 2018;319(14):1505–1506. doi:10.1001/jama.2018.2405
Nearly 700 000 ethnic minority Rohingya people have crossed the border between Myanmar and Bangladesh after violence in Rakhine State, which escalated in August 2017, joining an estimated 200 000 who fled in earlier waves of displacement since the 1990s. The population of 2 preexisting refugee camps and surrounding makeshift settlements have more than doubled with the new influx. Concerns have been raised about the nutritional status of the Rohingya children.
To assess the health and nutritional status of children aged 6 to 59 months, we conducted a cross-sectional population-representative survey in the Kutupalong refugee camp from October 22 through 28, 2017. Households were randomly selected from a list updated the week preceding data collection. Weight, height, mid–upper arm circumference (MUAC), and presence of bilateral pitting edema were measured using standard procedures.1 Weight-for-height z score (WHZ) and height-for-age z score (HAZ) were calculated based on 2006 World Health Organization (WHO) growth standards.2 Two definitions of global acute malnutrition (GAM) and severe acute malnutrition (SAM) were investigated because both can be criteria for admission to treatment programs. GAM was defined as a WHZ less than −2 or MUAC less than 125 mm. SAM was defined as WHZ less than −3 or MUAC less than 115 mm. All acute malnutrition categories additionally included children with edema. Chronic malnutrition was defined as an HAZ less than −2. Anemia screening was conducted by measuring hemoglobin (Hb 301, HemoCue) and classified according to WHO cutoffs.3 Children aged 6 to 23 months (the target group for fortified food distributions) consuming at least 4 of 7 food groups during the day preceding the survey were classified as receiving minimum dietary diversity.4 Respondents self-reported registration as refugees with the United Nations High Commissioner for Refugees. Wilson score CIs and results of the Pearson χ2 test were used to compare registered and unregistered children. Two-sided tests were considered significant at a P value of less than .05. The US Centers for Disease Control and Prevention determined this study was exempt from human subjects research review because it collected data for programmatic purposes.
Of the 269 children aged 6 to 59 months included, 121 (45.0%) were females, mean age was 31.9 months (SD, 15.3), and 148 (55.0%) were registered refugees. Of the unregistered children, 116 (95.9%) arrived in Bangladesh since August 25, 2017. One family declined participation.
Prevalence of GAM and SAM as assessed by WHZ were 24.3% (95% CI, 19.5% to 29.7%) and 7.5% (95% CI, 4.9% to 11.2%), respectively. The prevalence of acute malnutrition was not significantly different comparing unregistered and registered children (Table). MUAC identified 5.9% (95% CI, 3.7% to 9.4%) of children as having GAM and 0.7% (95% CI, 0.2% to 2.7%) as having SAM. The prevalence of chronic malnutrition was 43.4% (95% CI, 37.6% to 49.4%) and not significantly different between unregistered and registered children (P = .23).
Prevalence of anemia was 47.9% (95% CI, 42.0% to 53.9%) and not significantly different among unregistered and registered children (52.5% [95% CI, 43.6%-61.3%] for unregistered children vs 44.2% [95% CI, 36.4%-52.3%] for registered children; P = .18). Of children aged 6 to 23 months, 9.8% (95% CI, 5.4% to 17.1%) reported consumption of minimally diverse diets and 56.4% (95% CI, 46.7% to 65.7%) reported receiving fortified foods in the 2 weeks preceding the survey. The proportion of children reporting receipt of fortified foods was significantly higher among registered refugees (23.4% [95% CI, 13.6%-37.2%] for unregistered children vs 85.2% [95% CI, 73.4%-92.3%] for registered children; P < .001) (Table).
In this sample of Rohingya children in Kutupalong refugee camp, prevalence of GAM and anemia exceeded the global emergency thresholds of 15% and 40%, respectively, irrespective of their length of stay.5
Consistent with previous research from Bangladesh and Myanmar, discordance in the prevalence of acute malnutrition by WHZ and MUAC was found, which suggests a need to revise national treatment protocols to include admission of children with low WHZ in addition to low MUAC.6 High prevalence of anemia and poor dietary diversity highlight the need to provide more diversified family rations, expand supplemental fortified food distributions, and support continued breastfeeding.
Given the emergency context, this study was designed with a small sample size to provide rapid results, a key limitation. Nutritional outcomes may differ in other camps; however, the similarities in nutritional outcomes comparing registered and unregistered children in this study suggest a need for multisectoral efforts targeting all Rohingya in Bangladesh.
Accepted for Publication: February 19, 2018.
Corresponding Author: Eva Leidman, MSPH, Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Rd, MS E33, Atlanta, GA 30329 (firstname.lastname@example.org).
Author Contributions: Ms Leidman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Leidman, Toroitich-Van Mil, Wilkinson, Bilukha.
Acquisition, analysis, or interpretation of data: Leidman, Humphreys, Greene Cramer, Wilkinson, Narayan, Bilukha.
Drafting of the manuscript: Leidman, Bilukha.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Leidman, Humphreys, Greene Cramer, Bilukha.
Obtained funding: Toroitich-Van Mil, Wilkinson, Narayan.
Administrative, technical, or material support: Leidman, Greene Cramer, Toroitich-Van Mil, Wilkinson, Narayan, Bilukha.
Supervision: Leidman, Humphreys, Toroitich-Van Mil, Wilkinson, Bilukha.
Conflict of Interest Disclosures: The authors have completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Action Against Hunger (ACF), the United Nations High Commissioner for Refugees (UNHCR), World Food Programme (WFP), United Nations Children's Fund (UNICEF), Save the Children, or the US Centers for Disease Control and Prevention.
Additional Contributions: We thank Mohammad Lalan Miah, MSc (ACF), for contributions in training teams; Tamanna Ferdous, MPH, PhD (Save the Children), for contributions in study design; members of the Nutrition Sector Assessment Sub-Working Group, including UNICEF, UNHCR, ACF, Save the Children, WFP, and the Nutrition Sector. None of the individuals acknowledged received additional compensation for contributions to the study.
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