Whole of Syria (WoS) Nutrition Sector Bulletin

Transcription

1 Whole of Syria (WoS) Nutrition Sector Bulletin July - December 2017; Issue 4 Inside this issue: Sector highlights Sector achievements Situation overview Key facts p01 p02 p03 Activity Update P3-4 Sector response p5-7 Response in besieged and hard to reach areas Eastern Ghouta Response p08 p09 Success stories P10- Coordination Experiences 11 p12 Challenges and response p13 PMR Upcoming Activities Key contacts p14 p15 P15 Approximately 75,000 girls and boys aged 6-59 months are acutely malnourished. 840,000 girls and boys aged 6-59 months suffer from micronutrient deficiencies. 2.9 Million girls and boys under 2 years of age require optimal feeding to ensure optimal nutrition. Sector Highlights A total of 2,618,702 boys and girls under five and pregnant and lactating women (PLW) were reached by preventative and therapeutic nutrition interventions between January and December 2017, from them 145,196 boys, girls and women are living in UN declared besieged areas and 823,351 in hard to reach (HTR) areas. The nutrition sector partners stepped up their response in Northeast Syria, reaching 227,235 boys and girls under five and PLW with preventative and therapeutic nutrition interventions from January to December. An inter-agency convoy entered the UN declared besieged area of East Ghouta in November with 2400 cartons of high-energy biscuits, 2,280 cartons of lipid nutrition supplement, 401 cartons of ready to use supplementary food, 290 cartons of ready to use therapeutic food, 20,080 packages of micronutrient powders as well as medications used in the protocol for the treatment of acute malnutrition. Four SMART surveys were conducted in the second half of 2017: July in Idleb Governorate; August in the Al Bab area of Aleppo Governorate and in the Lajat area of Dar a Goverorate; November in the UN declared besieged location of Eastern Ghouta. A nutrition surveillance system from cross-border hubs (Jordan and Turkey) began releasing data in July with 83 health facilities reporting from seven governorates. Additional nutrition surveillance sites began collecting data in October in Dar a and in Eastern Ghouta in December. By the end of December 2017, 95 health facilities were collecting data on nutrition indicators and reporting monthly to the EWARN system covering 695 communities million USD appeal was approved for the nutrition sector as part of the 2018 Syrian Humanitarian Response Plan (HRP). The HRP plan was finalized during this quarter, fully endorsed by the Humanitarian Coordinator and presented in December to the Ministry of Health in Syria for final endorsement. 22 participants actively participated and completed a five-day cluster coordination training in October facilitated by the Global Nutrition Cluster in collaboration with WoS. 17Turkey hub partners sent 19 participants to the training with 3 nutrition sector coordinators joining from three hubs. Four nutrition partners responded to IDPs displaced from Southern Idleb and Northern Hama via 11 rapid response mobile teams to accelerate the curative and preventative nutrition activities. In December, a total of 3,707 boys, girls and PLW were screened for malnutrition using MUAC. All identified acute malnutrition cases were treated and 615 PLW received IYCF counselling. For the first time in Syria, an IYCF barrier analysis has been completed. In September, the data collected from two IYCF barrier analysis assessments were analysed in order to inform and strengthen the IYCF programming efforts for nutrition partners. The assessment examined the determinants of three key IYCF and maternal nutrition behaviors 1) exclusive breastfeeding, 2) diet diversity during complementary feeding and 3) consuming an extra meal during pregnancy. Capacity building of the nutrition sector partners for the barrier analysis methodology was completed prior to commencing the assessment. As part of the WoS nutrition architecture, all hub nutrition coordinators participated in a three-day face-to-face WoS team meeting with the participation of sub-national focal points from Aleppo, Tartous, Rural Damascus, Qamishli and Homs. 1.5 Million pregnant and lactating women require access to nutrition services. Figure 1: Rapid response team, Sarmada Camp and Abu Dhuar, Dec 2017

2 WoS Nutrition Sector Bulletin Page 2 Sector achievements at WoS level from January to December 2017 Map 1 1,542,257 children under five (105% of the target for 2017) and 296,237 pregnant and lactating women (PLW) (33% of the target for 2017) were screened for acute malnutrition. 1,025,960 children under 5 (88% of the target for 2017) received lipid-based nutrient supplements (LNS) or high energy biscuits and 799,698 PLW (89% of the target for 2017) received infant and young child feeding (IYCF) counselling. 1,887,470 children under five and PLWs received micronutrient supplementation (71%). This includes 436,104 children under five that received multiple micronutrient powders, and 1,326,087 children under five that received vitamin A supplementation. 34,741 children under five were identified and treated for acute malnutrition. This included 9,428 children under five for severe acute malnutrition and 25,313 children under five for moderate acute malnutrition. In addition, 8,512 PLW received treatment for acute malnutrition. Through a capacity building initiative, the sector trained 2,778 health workers on CMAM and 2,584 health workers and community outreach/volunteers on IYCF. In close collaboration with the Damascus, Turkey and Jordan hubs, 145,196 children under five and PLW in besieged areas and 823,351 children under five and PLW in hard-to-reach areas, were provided with essential nutrition support including preventative and treatment of acute malnutrition through inter-agency convoys (see Map 5). Finalization, endorsement and dissemination of the strategic advisory group (SAG) and assessment working group (AWG) terms of reference for the WoS architecture, as well as a document on the Guiding Principles for Harmonizing Data Validation and Advocacy Messaging.

3 WoS Nutrition Sector Bulletin January March, Page Page 3 3 Situation Update from July to December 2017 Although the level of Global Acute Malnutrition (GAM) among under five boys and girls in the majority of the assessed locations was found to be within acceptable levels, there are still pockets in the Lajat area in Dar a Governorate where the recently conducted SMART surveys detected poor levels of acute malnutrition and the East Ghouta enclave where the November SMART survey 997,804 detected serious levels of acute malnutrition. The SMART surveys of 2017 in UN-declared besieged and hard-to-reach areas indicate poor to serious levels of chronic malnutrition. IYCF practices in assessed locations remain suboptimal and are all below pre-crisis levels. The sector severity ranking for 2018 considers seventeen nutrition-specific and sensitive indicators from other 690,918 sectors such as Food Security, WASH and Health in addition to three cross cutting indicators related to access, intensity of hostilities and population movement to highlight the priority geographic areas to inform the subsequent response. The severity of the situation in the northeast of Syria appears to be greater than in the rest of the country and requires special attention. Across Syria, 66 of 270 sub-districts are found to be facing critical problems and in need of immediate humanitarian assistance (these sub-districts are located in Aleppo, Al Hasakeh, Ar Raqqa, Dar a, Deir-ez-Zor, Hama, Homs, Lattakia, and Rural Damascus governorates). In addition, 121 of 270 subdistricts are categorized with severe problems (these sub-districts are located nationwide except for As-Sweida and Quneitra) and require urgent humanitarian assistance. The remaining 83 sub-districts were ranked with major problems and likewise require humanitarian assistance. In light of ongoing displacement, anticipated returns, problematic access to health services and food, high food prices, diminishing employment opportunities and low service coverage nutrition partners are forecasting more under-nutrition cases in UN-declared besieged and hard-to-reach areas as well as conflict affected areas. Consequently, the sector ranks all UN-declared besieged and hard-to-reach areas as 'critical'. Activity Update from July to December 2017 Lifesaving Interventions 25 new nutrition treatment centres (Community Based Management of Acute Malnutrition CMAM) opened in this half of the year. 4 opened in Dar a Governorate, 3 fixed and 4 mobile clinics in East Ghouta, 3 in Hassekeh Governorate covering the IDP camps and 11 mobile clinics responded to cover the IDP reception centers in NW Syria. Currently 257 CMAM centres operate throughout Syria (215 Syria hub, 6 Jordan hub, 36 Turkey hub) to provide specialised therapeutic and/or supplementary nutrition treatment. Four nutrition partners responded to the waves of IDP movement into and within NW Syria with 11 rapid response mobile teams to accelerate the curative and preventative nutrition activities for children and PLW. Nutrition Information Systems The Syria hub supports a nutrition surveillance system integrated within 603 MoH health facilities that screens children under five using anthropometry measurements such as weight, height, middle upper arm circumference (MUAC) and bilateral, nutrition oedema. While the Early Warning Alert and Response Network (EWARN) collects MUAC data from 95 health facilities on nutrition indicators covering 695 communities with reports issued on a monthly basis. New surveillance sites began in Dar a and Quneitra in October and in Eastern Ghouta in December. The data collection for an IYCF barrier analysis study was conducted in July and August from the Jordan and Turkey hubs. An initial Training of Trainers (TOT) was conducted with five trainers and then a cascade training immediately followed, with 15 data collectors and 2 supervisors being trained in North Syria and 10 data collectors and 2 supervisors trained in South Syria. The information collected and analyzed should help all nutrition sector partners gain knowledge about the actual feeding practices, beliefs and attitudes, barriers and motivating factors regarding IYCF practices in these areas of Syria. For each behavior studied, at least 45 Doers and 45 Non-Doers participants were sampled, and one-on-one interviews were conducted with each participant. The sector plans to incorporate the findings to support partners to improve their nutrition programming, specifically to review and update messages that are delivered to women. The final report will be released in the first quarter of In an effort to integrate nutrition indicators in food security assessments, the nutrition sector conducted remote nutrition assessment trainings for food security and nutrition partners. 31 participants from 5 partners in the Jordan hub and 14 participants from 7 partners in the Turkey hub participated in these trainings in the second week of November in order to integrate MUAC measurements in the third round of outcome monitoring supported by the food security sector. The results should be available in the first quarter of In August 2017, a SMART survey was conducted in the Lajat area (35 communities of Izra and As-sanamayn) of Dar a Governorate indicating a prevalence of global acute malnutrition based on weight-height z-scores at 7.8% ( % C.I.), GAM measured via MUAC at 5.5% ( % C.I.) and the prevalence of stunting based on height-for-age z-scores is at 27.5% ( % C.I.).

4 WoS Nutrition Sector Bulletin January March, Page Page 4 4 Activity Update from July to December 2017 In August 2017, a SMART survey was conducted in Al Bab District of Aleppo Governorate. The validated results indicate a prevalence of GAM based on weigh-height Z-scores in children 6 59 months at 3.1% ( % C.I.). The prevalence 997,804 of stunting based on height-for-age Z-scores is 25.6% ( % C.I.). In November 2017, a SMART survey was completed in the UN Declared besieged location of Eastern Ghouta 690,918 in Rural Damascus Governorate indicating a proportion of global acute malnutrition (GAM) (<-2 z-score and/or oedema) is 11.9% ( % CI). The proportion of children with moderate acute malnutrition (MAM) (<-2 z-score and >=-3 z-score, no oedema) is 10.3% ( % CI), and the proportion of children with severe acute malnutrition (SAM) (<-3 z-score and/or oedema) is 1.6% ( % CI). The survey also found the proportion of young children (< 24 months) with GAM to be significantly higher than for other age groups. The data quality was acceptable and the results indicate a deterioration in the nutrition situation among children under the age of five years old since the last SMART nutrition survey in January Six nutrition partners mobilized to scale-up the nutrition response, which was an increase from the two partners conducting nutrition activities in this area since January A nutrition surveillance system was initiated in December within 9 health facilities and 4,362 girls and boys were screened for acute malnutrition in December and those identified with acute malnutrition were referred to 19 available health clinics offering curative and preventative nutrition services with 24 newly trained health workers. Emergency Nutrition Network s Field Exchange Issue 56 (available from 56_Web_110118_onlineversion.pdf) included three articles from the WoS coordination team. The WoS coordinator and cocoordinator documented the history, strengths, weaknesses and ways forward for coordination at WoS level in the article found on page 79 titled: Experiences of the Whole of Syria Coordination for Nutrition. The nutrition cluster coordinator in Turkey wrote the article Development and Added Value of the Nutrition Cluster in Turkey found on page 11 which explains some of important value added activities for this past year. This includes but is not limited to generating nutrition information and gap analysis to inform response plans; harmonising reporting tools as well as developing, implementing and monitoring an infant and young child feeding in emergencies (IYCF-E) strategy. The nutrition sector coordinator based in Damascus wrote the article, Experiences of Nutrition Sector Coordination in Syria found on page 25. He explains in this article how access to the affected population has improved through negotiated, inter-agency, cross-line convoys that are cooperatively planned with cross-border operations, reducing duplication and maximising synergies. More information on the experiences from three different viewpoints can be found in the full articles within Field Exchange 56. Coordination In August, 2017, all hub nutrition coordinators participated in a three day face-to-face WoS team meeting with the participation of sub-national focal points from Aleppo, Tartous, Qamishli and Homs. The team reviewed the 2017 sector response and operational gaps and then identified strategic priorities and indicators for 2018 and the way forward. The sector actively participated in the Integrated Food Security Phase Classification (IPC) exercise in collaboration with the Food Security Sector in Turkey, Damascus and Jordan. The exercise included a 4 day training and 5 day analysis to classify areas. A total of 9 members of the nutrition sector participated in this exercise across the hubs. Capacity Building A technical support mission was conducted by the WoS sector coordinator to the Damascus hub. Both the WoS coordinator and the Syria hub sector coordinator supported sub-national sector meetings in Tartous and Homs Governorates as well as a national sector meeting. Eight participants from the Damascus hub nutrition sector attended a five day training on Infant and Young Child Feeding in Emergencies (IYCF-E) facilitated by Save the Children and the WoS Nutrition Sector Coordinator in Sudan. The participants included four sub-national sector focal persons from Homs, Aleppo, Tartous and Qamishli Governorates, and the national sector coordinator, in addition to three staff from NGOs partners. Following the five day training, 4 orientation sessions were completed for nutrition sector partners at field level in three of the four represented Governorates. 6 IYCF-E orientation sessions are planned at national and hub level coordination forums for quarter one of 2018.

5 WoS Nutrition Sector Bulletin Page 5 Achievements of the Jordan hub from January to December 2017 Map 2 From January to December 2017, the Jordan sector partners reached 75,859 children under five and pregnant and lactating women (PLWs) in 69 communities of accessible locations in the south and northeast of Syria with both preventative and therapeutic nutrition interventions. 28,664 children under-five and 7,705 PLWs were screened for acute malnutrition using MUAC. 1,078 children under five were identified with acute malnutrition: 206 children had severe acute malnutrition (SAM) and 872 had moderate acute malnutrition (MAM). All identified cases were referred to one of the six static health facilities or 1 mobile unit providing lifesaving CMAM services in Dar a and Quenitra and enrolled in the relevant therapeutic or supplementary feeding programme. Additionally 640 PLWs were identified with moderate malnutrition and enrolled in supplementary feeding programmes in order to receive nutritional interventions. 29,935 children between 6-59 months benefited from a blanket supplementary feeding programme which provided lipid based nutrient supplements and high energy biscuits to prevent acute malnutrition. 3,913 PLW benefited from a blanket supplementary feeding program which provided high energy biscuits. 9,972 children under five and 6,165 PLW received micronutrient supplementation to prevent and treat micronutrient deficiencies. 718 children under five and 474 PLW received Vitamin A supplements In order to improve infant and young child feeding (IYCF) practices, sector partners supported counselling sessions to 15,970 PLWs on breast feeding practices and timely introduction and appropriate complementary feeding.

6 WoS Nutrition Sector Bulletin January March, Page Page 6 6 Achievements of the Turkey Hub from January to December , ,918 Map 3 From January to December 2017, the South Turkey cross border cluster partners reached 767,392 children under five and pregnant and lactating women (PLW) in 425 communities with both preventative and therapeutic nutrition interventions. A total of 486,032 children under 5 years and 56,354 PLW were screened for malnutrition. Among them, 3,522 children were treated for severe acute malnutrition (SAM), including 82 children as SAM with medical complications. Lipid-based nutrient supplements were provided to a total of 100,616 children aged 6 59 months and appropriate IYCF counselling was provided to a total of 220,680 PLWs. 964 health workers received CMAM training while 1,254 health workers received IYCF counselling training.

7 WoS Nutrition Sector Bulletin Page 7 Achievements of the Syria Hub from January to December 2017 Map 4 * Vitamin A figure not considered in the total reached calculation as it need desegregation From January to December 2017, the Damascus hub sector partners reached 1,833,474 children under five and pregnant and lactating women (PLW) in 1,116 communities with both preventative and therapeutic nutrition interventions. 897,866 children under the age of 5 have received lipid based nutrient supplements (LNS). Appropriate IYCF counselling was provided to a total of 562,357 PLW. Multiple micronutrient supplementation was provided to a total of 396,334 children under 5 years and 133,292 PLW, In addition Vitamin A was also provided 1,324,691 to children under five and 3,272 lactating women. A total of 1,026,028 children under 5 and 232,178 PLW were screened for acute malnutrition from these 16,393 were identified with acute malnutrition (5,618 children with severe acute malnutrition (SAM), 10,775 children with moderate acute malnutrition (MAM) and 6,220 PLW with MAM). The identified cases were treated for malnutrition in CMAM centers. 1,730 health workers were trained on CMAM and 1,249 health workers and community outreach/volunteers on IYCF.

8 WoS Nutrition Sector Bulletin January March, Page Page 8 8 Response in besieged and hard to reach areas in , ,918 Map 5 Service Delivery From January - December 2017, 325 UN-declared besieged and hard-to-reach areas (21 besieged and 304 HTR) were reached with nutrition interventions. 662,261 children under five and 306,286 PLW were reached with nutrition support in these besieged and HTR areas in Convoys Inter-agency (IA) cross-line operations are ongoing in the UN-declared besieged and hard-to-reach areas of Eastern Ghouta (Rural Damascus), Northern Rural Homs and Deir-ez-Zor. With nutrition support including lipid nutrient supplements, ready to use supplementary food, high energy biscuits, micronutrients for the prevention of undernutrition and therapeutic nutrition items for the treatment of acute malnutrition in outpatient and inpatient facilities. The UN IA convoy operation is facilitated by OCHA and SARC with the participation of UN agencies and the nutrition sector in the Syria hub, in close coordination with other sectors where monthly IA convoys plans are prepared by the sector (monthly plans were prepared from January August by the sector and bimonthly plans from September to December). During the process of developing nutrition sector IA convoys plans, consultations are made within the Whole of Syria for deconfliction and better coordination of the response as well as ensuring complementarity of efforts in those locations. 44 air drops were completed to Deir-ez-Zor from July September 2017 with nutrition and other relief supplies. In the last quarter of 2017, a land route was established to Deir-ez-Zor and the nutrition sector participated in an inter-agency convoy with nutrition supplies for 12,000 girls and boys under five and 550 PLW. 55 IA cross-line convoys reached besieged and HTR areas with nutrition products in 66 locations from January to December of this year (some of these convoys were only approved with a reduced number of targeted beneficiaries than the plan presented by the sector). The supplies on the cross-line convoys are estimated to cover the need for 464,292 girls and boys under five and PLW. This decline in the delivery of humanitarian supplies to besieged and HTR locations might contribute to the deterioration of the wellbeing of PLW and children under five, particularly in Eastern Ghouta.

9 WoS Nutrition Sector Bulletin Page 9 Eastern Ghouta Response Nutrition vulnerabilities and risks for children under five and pregnant and lactating women (PLW) in East Ghouta have drastically deteriorated in the second half of 2017, due to the pervasiveness of under-nutrition, particularly after the full closure of the Al Wafideen checkpoint and the subsequent reduced availability of food. The Nutrition sector conducted a nutrition SMART survey in East Ghouta in the first two weeks of November Anthropometric data were collected from 311 children between 6 59 months in 27 out of 30 clusters for this representative survey. The survey findings indicate the proportion of children between 6-59 months with global acute malnutrition (GAM) is 11.9 per cent compared to 2.1 per cent in January the highest rate recorded in Syria since the beginning of the conflict. The proportion of children with moderate acute malnutrition (MAM) is 10.3 per cent, and the proportion of children with severe acute malnutrition (SAM) is 1.6 per cent compared to 0.3 per cent in January. The survey also found that the proportion of young children (< 24 months) with GAM is significantly higher than for other age groups. The survey findings indicate that the proportion of children between 6 and 59 months with chronic malnutrition (low heightfor- age/stunted) is 36 per cent, which is higher than the prevalence rate for stunting of 30.5 per cent reported in January This serious level of stunting confirms the negative impact of the long-term deprivation that has prevented children from receiving a quality and acceptable diet, and has resulted in poor infant and young child feeding practices. Children who suffer from stunting tend to be at greater risk of illness and death. Stunting often results in delayed mental development, poor school performance and reduced intellectual capacity. At the beginning of December, twenty-four health workers were trained on CMAM protocols (inpatient and outpatient) in order to build the capacity to scale up nutrition services. Six nutrition sector partners are providing life-saving curative and preventive nutrition services in East Ghouta, through eight fixed health facilities and eleven mobile clinics covering 17 communities in three sub-districts (Duma, Harasta and Kafr Batna). Community based interventions are conducted by 78 community health workers which includes screening for malnutrition, multiple micronutrients supplementation for women and children, and infant and young child feeding (IYCF) counselling via campaigns implemented 4 times per year in 17 communities out of 23 (74%). All eight health facilities and eleven mobile clinics screen and refer women and children with acute malnutrition to the CMAM centres and provide one-to-one counselling and health education services on IYCF practices. From these health facilities and mobile clinics, five health facilities and eight mobile clinics offer the therapeutic lifesaving treatment for the acutely malnourished for children and PLWs and micronutrient supplementation for PLWs. Four of the health facilities and seven of the mobile clinics offer micronutrient supplementation for girls and boys under five. In December, nutrition partners initiated the establishment of a nutrition surveillance system in 9 health facilities covering 10 communities in Eastern Ghouta. In these sites approximately 2,988 children were screened for acute malnutrition using midupper arm circumference (MUAC) measurement. 31 children were identified with severe acute malnutrition (SAM) and 181 were identified with moderate acute malnutrition (MAM). All children identified with acute malnutrition were referred to nutrition treatment centres (CMAM) to receive treatment. Operational capacities are in place to deliver CMAM services by integrating nutrition activities in three additional fixed health facilities and two mobile clinics covering three communities, dependent on the availability of supplies. 27 CHWs will be also be trained in January on CMAM to increase the response capacity. Despite the scale up of nutrition services in December 2017, the Nutrition sector strongly advocates for unconditional and sustained humanitarian access to deliver and distribute life-saving curative and preventative nutrition supplies, food, medicine and other critical supplies without delay and on a more regular basis. These critical supplies are pivotal in protecting children from malnutrition and in treating those children already malnourished. Figure 2: Distribution of HEB to children in East Ghouta

10 WoS Nutrition Sector Bulletin January March, Page Page STORIES FROM THE FIELD Improving the Nutritional Status of Jorry Jorry is a ten-month-old girl living with her family in the Karak community of southern Syria. Sana, her mother, noticed that her growth was much slower and her height and weight lower when compared with her sister at the same age. She gave Jorry breast 997,804 milk substitutes (baby milk formula) which she thought would help to improve her growth, but she noticed no improvement. Sana visited many doctors in As-Sweida and Dar a to seek advice about her daughter s health and nutritional status. Jorry had length, weight and head circumference measurements corresponding to a five-month-old girl. The doctors recommended laboratory 690,918 tests to investigate underlying medical issues but the blood, urine and stool tests all came back normal. One doctor advised Sana to take Jorry to a CMAM clinic close by for treatment, but she did not take his advice. The mother relatives advised her to introduce milk formula in order to increase her appetite and weight, but when Sana tried to give her formula with a bottle, Jorry refused. In August 2017, community nutrition teams began mid-upper arm circumference (MUAC) measurements for boys and girls 6-59 months old and pregnant and lactating women at the household level by a nutrition project implemented by cross-border partners. Sana and Jorry s home was included in the targeted area of the project. Maysam and Samah, community nutrition workers (CNW), visited Sana s home in the Karak community and conducted MUAC measurements for Sana, Jorry and Jorry s sister. Jorry s MUAC measurement was 11.8 cm and classified her as moderately acutely malnourished. The CNWs knew that they needed to refer her to the nearest CMAM clinic to receive the appropriate treatment where there are trained staff on the international guidelines for appropriate treatment of moderate and severe acute malnutrition. The project provided transportation costs for the referral in order to overcome the economic access barrier to the CMAM clinic. Jorry transferred the day after the MUAC measurement to the CMAM clinic in Hrak. The nutrition officer in the Hrak CMAM clinic examined Jorry and took her MUAC, weight and height measurements. Her measurements at the clinic confirmed her nutrition status as moderately acutely malnourished and she began treatment according to the guidelines of the supplementary feeding programme (SFP) of the CMAM clinic. The mother received a two-week supply of ready-to-use supplementary food (RUSF) and instructions to give one sachet of the RUSF per day to Jorry. The CNWs visited Sana s home to check on Jorry s progress and facilitate the transport to the clinic as per the guidelines for the three-month treatment period. Maysam and Samah conducted one -on-one counselling sessions for Sana on optimal infant and young child feeding practices (IYCF) and distributed micronutrient tablets for Sana as per the nutrition programme guidelines. Jorry s nutritional status improved throughout the three-month treatment period with the last MUAC measurement recorded at 13.3 cm. The parents are very happy with her progress and the mother commented that Jorry used to be easily irritable with lots of crying and since her weight gain she is much more calm with an improved appetite. Maysam and Samah wanted to share this story as they felt that Jorry s improved nutritional status is a great success and the positive outcome is due to the multifaceted approach of the implemented nutrition project in Dara (community outreach and screening, IYCF counselling, treatment and transportation support). They stress that more attention should be given to malnutrition and IYCF in their areas of Southern Syria. Jorry s mother, Sana, shared her experience with her community and she is now encouraging other caregivers to practice what she learned from her IYCF counselling sessions with the CNWs: to exclusively breastfeed their infants up to age of 6 months and to continue breastfeeding while introducing complementary foods starting at 6 months of age. Figure 3: Jorry at discharge from the nutrition treatment program with a MUAC of 13.3 cm Dec 2017

11 WoS Nutrition Sector Bulletin Page 11 STORIES FROM THE FIELD Providing lifesaving nutrition treatment to Asmaa from Ar Raqqa Governorate Asmaa is an 18-month-old girl who fled from Raqqa Governorate early in 2017 with her mother and four brothers after the loss of her father. They settled with relatives who were also displaced to the Ras Al Ain sub-district of Hasakeh Governorate. All six of them live together in one shared room. On October 20, 2017, a nutrition sector partner reached the community where Asmaa and her family were living with mobile outreach nutrition activities. The outreach team conducted MUAC screenings for all children 6 59 months in this community and Asmaa was identified as moderately acutely malnourished (MUAC of 11.9 cm). The outreach team started her treatment according to the protocol and referred her for follow up to the fixed health and nutrition clinic in Ras Al Ain to continue the treatment by the clinic nutrition nurse. The mother and Asmaa visited the clinic two days later and the height, weight and MUAC measurement confirmed that she was moderately acutely malnourished with an admission weight of 7.5 kg. The nutritionist asked the family to bring Asmaa on a weekly basis for follow up, but the family stated they were not able due to the cost and logistics of moving from their community to the clinic. Therefore, the nutritionist gave additional quantities of the ready-touse supplementary food (RUSF) to decrease the frequency of required visits to the clinic and to overcome the access challenge. Figure 4: Asmaa s first visit to the nutrition North - east Syria Asmaa returned to the clinic approximately one month later, on November Her overall condition improved with a MUAC reading of 12.2 and a weight measurement of 7.7 kg. Two weeks later (on December 6, 2017) her MUAC measurement was 12.4 and weight measurement was 8.1 kg. Her final visit was on December 27, 2017 and her MUAC measurement was 13.0 cm and a weight measurement of 8.4 kg. The mother was happy and Asmaa more active than before according to her mother. Nutrition cross-border partners support Rapid Response Teams (RRT) to respond to newly displaced people (IDPs) in North-west Syria The Turkey hub initiated a rapid response team in response to the influx of IDPs arriving to North-west Syria. 35 nutrition workers from five partners respond via five mobile clinics. The rapid response team objectives include: Providing lifesaving nutrition supplies, such as HEB, lipid-based nutrient supplements and micronutrients supplementations; Improving wellbeing of children 6-59 months and pregnant and lactating women. Improving the wellbeing of caregivers and their infants and young children through providing a safe and supportive space for caregivers, thus enabling them to appropriately care for and feed their children. Target Group: children (0 59 months) and pregnant and lactating women The activities of the RRT include: -Immediate nutrition screening of children under five (5) and PLW and referral of acutely malnourished cases for treatment to CMAM center after providing ration for one week. -Providing Blanket Supplementary Feeding for children from 6-59 months to prevent acute malnutrition and micronutrient deficiencies in collaboration with the food security sector; -Support for infant and young child feeding including: Provision of key IYCF messages / information Meeting basic needs e.g. provision of infant clothing and nappy changing Psychosocial support (integrate with MHPSS services) Provision of cups / promotion of feeding (for artificial feeding and complementary feeding) Referral to medical, mental health, child protection and other services Here is a story from one of the team members. Jomaa is a seven month old boy who arrived to the Sarmada reception center on August 5 th, 2017 with his mother. The RRT team screened Jomaa for his nutrition status using MUAC, by which he was identified as moderately acutely malnourished (MAM) with MUAC of 12.2 cm. The RRT started his treatment according to the protocol and referred him for follow up to the fixed CMAM clinic in Tayba. The RRT made sure that in addition to the proper treatment provision, the mother was provided with the required nutrition counseling about complementary feeding appropriate for the age of Jomaa and the rationale for adhering to treatment and follow-up. Jomaa arrived at the fixed CMAM center one week later (on August 12, 2017) where his MUAC measurement was repeated, and indicated improvement up to 12.4 cm. The nutritionists commended the mother and encouraged her to continue the treatment and the follow-up. The third visit was on August 19 th, 2017 and Jomaa had made a remarkable improvements. He was full of activity and had a MUAC measurement of 13.2 cm. He remained in the supplementary feeding program (SFP) until he was discharged cured on September 16, Figure 5: Jomaa s first visit and day of discharge in Sarmada, Sep. 2017

12 WoS Nutrition Sector Bulletin Page 12 Coordination Experiences Multi-hub Coordination for Northeast Syria Northeast Syria comprising Al-Hassakeh, Ar-Raqqa, Deir-ez-Zor and parts of Aleppo Governorates has experienced approximately 538,000 people displaced, with many reporting displacement multiple times. The number of IDPs in planned camps, informal settlements, transit sites, collective centres or transit centres as of December 2017 is 79,324. The continued hostilities resulting in extensive displacement has resulted in hampered access to nutrition and health services as well as overburdened host community health facilities. The WoS coordination mechanism has actively engaged in efforts to support the Northeast Syria response from multiple hubs to provide an integrated package of nutrition services to this area of Syria. In 2017, coordination among the three hubs (Qamishli, NES, Turkey) was facilitated by the WoS team by conducting monthly gap and coverage analysis after consultation with the nutrition coordinators in the three hubs. This contributed to the mobilization and guidance of 17 nutrition partners. The communication amongst cross-border partners in NE Syria has been improved by having a dedicated focal point for food security and nutrition deployed by an NGO in October This NE Syria focal point integrates the food security and nutrition response while coordinating with the other hubs through the WoS. Map 6 :BENEFICIARIES REACHED FROM 1-31 OCTOBER 2017 The information management officer for WoS compiles the data from multiple hubs and creates detailed maps for coordination purposes as well as a simplified, anonymized map for easy reference and public dissemination (see Map 6). WoS Coordination & Strategy Face-to-Face Meeting The face to face meeting is one of the quarterly communication modalities for the WOS nutrition team which comprises sector coordinators, IM officers and sector co-coordinators from the three hubs (Damascus, Amman and Gaziantep). The purpose of the meeting was to discuss common strategic issues, conduct joint reviews, and plan for the coming year/s. Through this mechanism, the communication at the WOS nutrition sector level maintains its smooth, transparent and inclusive status. The last meeting took place in March 2017, back to back with the nutrition and food security meeting. This one was planned in the context of the joint preparation for the HNO and HRP 2018 processes. In order to ensure a more inclusive process, bottom up planning, coherence and consistent nutrition response approach and better coordination during the strategic planning this year, and in addition to being a capacity development exercise, this meeting went one step further to including the sub-national focal points from Aleppo, Tartous, Homs, and Qamishli as well as the health and nutrition officer for the Damascus hub. These sub-sector focal points are on the front line of leading the nutrition response in their respective areas. The main objectives of this meeting -Review the sector response from January to June Agree on the data sources for the nutrition severity ranking. - Agree on the strategic priorities for 2018 and the main indicators - Identify strategic and/or operational gaps and agree on the way forward. Figure 6 :WOS nutrition team in face to face meeting Beirut Lebanon, Aug 2017

13 WoS Nutrition Sector Bulletin Page 13 Challenges The decline in the delivery of humanitarian supplies and the lack of monitoring of the already delivered supplies to besieged and HTR locations might contribute to the deterioration of wellbeing for girls and boys under five and PLW, particularly in East Ghouta. Response to challenges Coordination between the two operational hubs for East Ghouta was strengthened and led by the WoS coordinators. The sector developed key advocacy messages, generated evidence with SMART surveys/surveillance sites and continues to coordinate amongst the two hubs to ensure that the delivered supplies are distributed to correct partners in an efficient manner. Difficulty in monitoring program quality due to the limited capacity of partners despite regular training. The sector will focus on training for CMAM quality improvement in The sector developed validation protocols and will provide orientation on the protocols in 2018 to partners. Violations of the international code of marketing of breastmilk substitutes continue to be of major concern in Syria as unsolicited breastmilk substitutes (BMS) are reportedly distributed without following proper mechanisms and procedures. These violations hinder IYCF efforts at the community and health care levels. The nutrition sector was notified in regards to three violations of the international code of marketing of breastmilk substitutes. The untargeted distribution of BMS substitutes was stopped in a timely way due to prompt feedback, dialogue, training and orientation to the partners from the sector.

14 WoS Nutrition Sector Bulletin January March, Page Page Periodic monitoring reports Periodic monitoring report January-December ,804 Target Achievement 690,918 Health Workers trained on CMAM and IYCF 3,500 4, % Children 6-59 months, treated for SAM and MAM 34,781 35, % Children 6-59 months, PLWs receiving micronutrients 1,048, ,716 58% PLWs counselled on IYCF 500, , % Children 6-59 months screened for malnutrition 865,384 1,171, % Children 6-59 months Receiving LNS 915,249 1,807, % Figure 7 Periodic monitoring report January-December 2017 Target Achievement Health Workers trained on CMAM and IYCF 5,500 5,362 97% Children 6-59 months, PLWs treated for SAM and MAM 81,335 43,253 53% Children 6-59 months, PLWs receiving micronutrients 2,647,682 1,887,470 71% PLWs counselled on IYCF 893, ,698 89% Children 6-59 months, PLWs screened for malnutrition 2,355,361 1,838,494 78% Children 6-59 months Receiving LNS 1,169,282 1,025,960 88% Figure 8 In 2017, the target population for all nutrition sector indicators were dramatically increased. Training on CMAM and IYCF for health workers is close to the target for the 12 month period. Micronutrient interventions, counselling on IYCF, screening and children receiving LNS are at acceptable levels as compared to the target. The coverage for SAM and MAM treatment are less than anticipated. Reasons for this could include: - A majority of SAM and MAM cases live in HTR and besieged areas where limited active finding can be conducted due to limited staff and volunteers - Continual displacement of the population in these areas disrupting treatment - Insecurity in the HTR and besieged areas preventing SAM and MAM cases from accessing treatment centers. - Overestimation of target population and underreporting

15 WoS Nutrition Sector Bulletin Page 15 Upcoming Activities for January to June of 2018 January February March April May June January 14 22; SMART nutrition survey manager training Damascus, Syria February 19 20; First High Level Technical Assessment Consultation Meeting for crisis-affected populations in the Middle Eastern Region Amman, Jordan Plan for SMART survey in Raqqa City SMART survey for Menbij and Abu Qalqal sub-districts as well as parts of Al-Khafsa subdistricts of Aleppo Governorate Regional SMART nutrition survey manager training Location TBA WoS face-to-face consultation workshop : Focus HNO SMART survey for Tell Abyiad, Ein Issa and Suluk sub-districts of Raqqa Governorate February 25 March 1; Regional SMART nutrition survey manager training Amman, Jordan Face-to-Face WoS meeting Plan for nutritional surveillance in Tabqa Review severity ranking and PMR Nutrition Surveillance pilot 5 facilities in Menbij, Abu Qalqal and part of Al-Khafsa subdistricts of Aleppo Governorate SMART survey for Jarablus sub-district of Aleppo Governorate Review sector calculation methods Finalization and publication of the Smart survey results for Al Bab District Nutrition Surveillance in 5 additional facilities in Menbij, Abu Qalqal and part of Al-Khafsa sub-districts of Aleppo Governorate to total 10 sites. Finalization and publication of the Barrier Analysis of Infant & Young Child Feeding and Maternal Nutrition Behaviors among IDPs in Northern and Southern Syria Key contacts Title / Responsibilities WoS Sector Coordinator and Jordan Hub Coordinator WoS Sector Co-Coordinator Amman Action Against Hunger Jordan Hub Sector Co- Coordinator WoS Information Management Officer Location Organization Focal Point Amman UNICEF Saja Abdullah sabdullah@unicef.org Lindsay Spainhour Baker lbaker@me.acfspain.org Amman SRD Marwa Alsubaih malsubaih@srd.ngo Amman UNICEF Shabib Alqobati salqobati@unicef.org Syria Hub Coordinator Damascus UNICEF Muhiadin Abdullahi mabdulahi@unicef.org Syria Information Management Officer Damascus UNICEF Lana Al-Maradni lalmaradni@unicef.org Turkey Hub Coordinator Gaziantep UNICEF Wigdan Madani wmadani@unicef.org Turkey Hub Co-Coordinator Gaziantep PAC Mona Maman nutrition@pac-turkey.org Turkey Hub Information Management Officer Nutrition Website Gaziantep PAC Abdullah Al Esmail nutrition.imo@pac-turkey.org