title: Observational bias during nutrition surveillance: results of a mixed longitudinal and cross-sectional data collection system in Northern Nigeria.
abstract: BACKGROUND
  The Sahel is subject to seasonal hungry periods with increasing rates of malnutrition. In Northern Nigeria, there is no surveillance system and surveys are rare. The objectives were to analyse possible observational bias in a sentinel surveillance system using repeated mixed longitudinal/cross-sectional data and estimate the extent of seasonal variation.
  
  
  METHODS
  Thirty clusters were randomly selected using probability proportional to size (PPS) sampling from Kazaure Local Government Area, Jigawa State. In each cluster, all the children aged 6-59 months within 20 randomly selected households had their mid-upper arm circumference measured and were tested for oedema. The surveys were repeated every 2 or 4 weeks. At each survey round, three of the clusters were randomly selected to be replaced by three new clusters chosen at random by PPS. The seasonal variation of acute malnutrition was assessed using cyclical regression. The effect of repeated visits to the same cluster was examined using general linear mixed effects models adjusted for the seasonal change.
  
  
  RESULTS
  There was a significant seasonal fluctuation of Global Acute Malnutrition (GAM) with a peak in October. With each repeat survey of a cluster, the prevalence of GAM decreased by 1.6% (95% CI: 0.4 to 2.7; p = 0.012) relative to the prevalence observed during the previous visit after adjusting for seasonal change.
  
  
  CONCLUSIONS
  Northern Nigeria has a seasonal variation in the prevalence of acute malnutrition. Repeated surveys in the same cluster-village, even if different children are selected, lead to a progressive improvement of the nutritional status of that village. Sentinel site surveillance of nutritional status is prone to observational bias, with the sentinel site progressively deviating from that of the community it is presumed to represent.
authors.affiliation: Epicentre, Paris, France. Emmanuel.GRELLETY@epicentre.msf.org
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Grellety
authors.forename: Francisco J
authors.initials: FJ
authors.lastname: Luquero
authors.forename: Christopher
authors.initials: C
authors.lastname: Mambula
authors.forename: Hassana H
authors.initials: HH
authors.lastname: Adamu
authors.forename: Greg
authors.initials: G
authors.lastname: Elder
authors.forename: Klaudia
authors.initials: K
authors.lastname: Porten
mesh_terms: D001132:Arm / Q000473:pathology; D002675:Child, Preschool; D016000:Cluster Analysis; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007223:Infant; D008137:Longitudinal Studies; D008297:Male; D044342:Malnutrition / Q000453:epidemiology*; D015999:Multivariate Analysis; D009549:Nigeria / Q000453:epidemiology; D009749:Nutrition Surveys; D009752:Nutritional Status; D015588:Observer Variation; D015995:Prevalence; D012621:Seasons; D018571:Sentinel Surveillance