SCIENTIFIC INQUIRER: What prompted your group to undertake the study of malnutrition among Rohingya refugee children in Bangladesh?

EVA LEIDMAN*: Nearly 700,000 Rohingya people crossed the border to Cox’s Bazar Bangladesh in August 2017 following violence in Myanmar. They joined an estimated 200,000 who had fled in earlier waves since the 1990s. The mass displacement created a need for better evidence regarding the nutritional situation of Rohingya in Cox’s Bazar to inform the ongoing humanitarian response. The CDC-led study “Acute Malnutrition and Anemia among Rohingya Children in Kutupalong Camp, Bangladesh” was a joint initiative by partners providing nutritional services for the Rohingya, including UNICEF, the United Nations High Commissioner for Refugees (UNHCR), Action Against Hunger (ACF), Save the Children, the World Food Program (WFP), the Nutrition Sector, together with the Government of Bangladesh. CDC is providing technical assistance to the Ministry of Health and other partners on the management of the public health aspects of the Rohingya crisis. CDC staff with expertise in refugee health and public health emergency response management are engaged in refugee camp health assessments, strategies for reducing disease risks, and the establishment of health information and management systems.

SCINQ: Can you explain the difference between global acute malnutrition and severe acute malnutrition? How does it relate to the children you studied?

EL: Global acute malnutrition (GAM) is a measure of acute malnutrition that includes both severe acute malnutrition (SAM) and moderate acute malnutrition (MAM). Severe acute malnutrition is the most extreme form of malnutrition, requiring urgent treatment to survive.

Prevalence of GAM among children aged 6 to 59 months of age is used to benchmark the severity of a crisis, whereby a prevalence greater than 15% is considered an emergency by World Health Organization classifications.

Two definitions of GAM and SAM were investigated in our study because both can be criteria for admission to treatment programs. GAM was defined as a weight-for-height z score (WHZ) less than −2 or mid–upper arm circumference (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 (swelling of the legs).

SCINQ: Was there a difference between refugees who had been at the camps longer than the more recent ones?

EL: An important finding of our study was that 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. In other words, we did not observe a difference between refugees who had been in the camp prior to the August 2017 influx and those who had more recently arrived.

Based on the findings of the study, we recommended that ongoing humanitarian activities target all Rohingya in the region, irrespective of their registration status and length of stay in the camps.

SCINQ: Why is there such a significant malnutrition problem?

EL: Our study was conducted during the acute phase of the emergency. Many of the Rohingya households included in the study had arrived in Bangladesh during the week preceding the survey. The population of two pre-existing refugee camps, Kutupalong and Nayapara, had more than doubled with the new influx. Anecdotally, we know Rohingya walk several days in harsh conditions to arrive in Bangladesh, often with limited access to food, safe water and shelter.

The causes of malnutrition are multi-sectoral, and questions regarding causality are difficult to answer with a cross-sectional survey (our study design), however, this context helps explain the emergency levels of acute malnutrition observed.

SCINQ: How can your findings be used by aid groups to address the situation on the ground? Do your findings indicate areas where they can shift their focus?

EL: There are many ongoing efforts to improve the situation. Partners have built additional treatment centers for children with acute malnutrition. National treatment protocols have been revised to expand admission criteria, as we recommended. Efforts are ongoing to provide more diversified family rations and expand coverage of supplemental fortified food distributions. Given the scale of the humanitarian situation, the response needs to be multi-sectoral to address the observed high prevalence of malnutrition.

Additionally, there is a need to continue monitoring the situation. CDC lead author on this study, Eva Leidman, has returned to Bangladesh and is there now working together with a large group of nutrition partners responding in Cox’s Bazar to conduct a second assessment of nutritional status among Rohingya in the camps.

* Lead author, Eva Leidman, MSPH, is an epidemiologist in the Emergency Response and Recovery Branch, the CDC’s Center for Global Health

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