Nepal

There are approximately 96,500 Bhutanese refugees registered in seven camps in Nepal’s Jhapa and Morang districts. Refugees began entering Nepal in late 1990; the influx peaked in the first half of 1992. Since the beginning of 1998 no new arrivals have been accepted by His Majesty’s Government of Nepal (HMGN). The refugees, who are mostly ethnic Nepali speaking groups from the southern plains of Bhutan, fled their country in fear of the enforcement of new citizenship laws and the “one nation, one people” policy of cultural assimilation in the late 1980’s. Eight official ministerial-level talks have been held between the Bhutanese government and HMGN without any effective resolution being achieved thus far.

In general, the health and nutritional situation in these camps is adequate. The nutritional situation of children has been stable over recent years; the most recent survey in June estimated the prevalence of wasting at 9.9%, which is lower than the national prevalence in Nepal. Growth monitoring and supplementary feeding programmes are well established. The most recent report from UNHCR states that (CMR) for the month of October and November 1999 were 0,11/10,000/day and 0.09/10,000/day respectively (UNHCR -14/12/99).

UNHCR/CDC adolescent nutrition survey

UNHCR/CDC conducted a nutritional survey on adolescents aged 10-19 years in October in order to assess the prevalence of low BMI and micronutrient deficiencies (see annex). The survey was partially initiated in response to reports of high prevalences of angular stomatitis (AS) in the camps (see RNIS 27). The reported rise in prevalence followed the withdrawal of the blended food component of the ration. AS may be caused by riboflavin deficiency and the study attempted to assess the relationship between riboflavin and various food groups with AS.

The methodology involved medical examinations and the extraction of venal blood as well as anthropometric measurements and questionnaires. Anthropometric measurements were also obtained from 200 adults aged 20-39 years. The preliminary findings described below do not include the results of the blood analyses.

· Based on WHO BMI-for-age references, 36.1% of the adolescents had low BMI: Younger adolescents had higher prevalences of low BMI than older adolescents. BMI was adjusted for level of maturation, which reduced the prevalence of low BMI to 33.6%. The authors of the report questioned the validity of using the BMI and the WHO cut-offs as an indicator of protein-energy malnutrition in adolescents in this population.

· One third of the adult population had low BMI (<18.5 kg/m²); 2% were severely malnourished (BMI<16kg/m²). If MUAC and BMI were used in conjunction to define malnutrition, the prevalence was reduced to 21%, including 2% severe malnutrition. Comparable data from the adult Nepali population are unavailable; however, the prevalence of malnutrition among adults in other South Asian populations may be similar or higher. Again, the validity of the BMI and MUAC cut-offs employed were questioned by the authors.

· The prevalence of anaemia in adolescent females above age 11 was 33%. This level of anaemia among women of reproductive age is of concern. As expected, menstruating females had a higher prevalence of anaemia than males. Forty-three percent of female adolescents aged 16-17 years were anaemic as were 34% of females aged 18-19 years. Women who enter pregnancy with adequate iron stores have a greater chance of completing their pregnancy without developing iron deficiency.

· Very few survey subjects had detectable goitre (a clinical sign of iodine deficiency). The prevalence of goitre is higher in the indigenous Nepali population. This may in part be due to the routine distribution of iodised salt in the general ration. Although a large proportion of adolescent survey subjects reported night blindness (29%), none had Bitot’s spots, a clinical sigh of severe vitamin A deficiency. The laboratory testing on the serum collected will provide definitive information about the level of vitamin A deficiency among adolescent Bhutanese refugees in Nepal.

· The role of riboflavin deficiency as a causative factor in AS in these camps must await the laboratory testing of the blood specimens, AS was found in 28.7% of the adolescents examined. This is a relatively high prevalence. Although a large proportion of the lesions seen were acute, there were few accompanying lesions such as superinfection with other bacteria or viruses. AS was associated with other non-specific signs and symptoms of riboflavin deficiency such as cheilosis, tongue pain, and abnormal tongue on examination. AS was not related to mouth ulcers, oral thrush, or symptoms of neural neuropathy, which are not part of the syndrome of riboflavin deficiency. AS was also more common in those who ate less dairy products and eggs (foods high in riboflavin). The functional significance of AS itself is not well understood.

Recommendations and priorities:

· Continue to monitor the nutritional status of the population.

From the survey on adolescents:

· If the goal of organisations providing food and health services to this population is to eliminate all protein-energy malnutrition for adults and adolescents and the WHO cut-offs for the definition of malnutrition are considered acceptable, then the amount of kilocalaries provided to adults and adolescents should be increased.

· Given that the prevalence of anaemia is highest among female adolescent refugees, who are capable of child-bearing, health resources should be targeted specifically at prevention or treatment of anaemia among females aged twelve years and above.

· Definitive recommendations regarding AS must await the results of the laboratory testing. Nonetheless, anecdotal impressions and observation of survey subjects do not indicate that AS poses a serious health threat to individuals.

· A more thorough evaluation of the nutritional and non-nutritional effects of including blended foods in the ration should be carried out before recommendations on the re-inclusion of the blended food component can be made.

Overall, the Bhutanese refugees in Nepal are not considered to be at high risk of malnutrition (category IIc).