EC, SIDA, UKAID, DFID, ITALIAN COOPERATION, SDC, UNICEF, UNHCR, CHF

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1 FSNAU Food Security and Nutrition Analysis Unit - Somalia March-April 2011 OVERVIEW Map 3: Estimated April 2011 Nutrition Situation Current Nutrition Situation An analysis of historical data from similar seasons, was conducted to forecast the likely situation for April 2011, as illustrated in Map 1. This shows Sool Plateau of Bari Region in the Alert phase, with the rest of Somalia in Serious to Very Critical phases. Findings from a nutrition survey conducted in Mogadishu in April 2011, and a rapid nutrition assessment in Shabelle, regions in February-May 2011 reflect a Critical nutrition situation in these population groups. The nutrition situation in Shabelle riverine, Juba Pastoral, and parts of Sool Plateau (Bari region), appears likely Critical-Very Critical. Food Security Situation: The food security situation remains as projected during the post Deyr 2010/11 analysis with an estimated 2.4 million people in crisis. However, the effects of the ongoing drought, deteriorating purchasing power, rampant conflict and limited humanitarian space continue to aggravate the situation in most parts of the country. The Jilaal (January-March) 2011 season was particularly harsh, with a long spell of dry conditions for almost 9 months, following failure of the 2010 short rains, due to the La-Nina effect. The outcome has been severe water crisis with extremely high prices of water, low cereal availability and an upward trend of food prices, depleted pasture, deteriorated livestock condition, increased cases of livestock deaths, displacements and increased destitution in central regions. Nevertheless, according to the April 2011 FSNAU/FEWSNET Climate Data Update, commencement of Gu 2011 rains is observed in most parts of the country, especially in Bay, Juba and Shabelle regions, and is likely to lead to improved water availability, pasture and browse conditions, and eventually provide recovery to animals after the dry spell. According to the April 2011 FSNAU/FEWSNET Market Data Update, the prices of locally produced cereals increased by percent across the main markets of all regions apart from Lower Juba (9% increase for the white maize price). The price increments in the current hunger period are substantially higher than the same time last year due to dwindling grain stocks held by producers and traders, high demand, rising transport costs, as well as stock hoarding by retailers and farmers due to uncertainty in the Gu 2011 harvest. Since April last year, the red sorghum prices have more than doubled ( %) in all regions of the Sorghum Belt. The white maize prices are also considerably higher than a year ago in producing regions of Shabelle (73%) and Juba (92%). These circumstances have exacerbated the precarious household food access in Somalia. Details of the food security, market and climate update, are accessible at Overview 1 Mogadishu Nutrition Survey 4 Shabelle Rapid Nutrition Assessment 6 Juba Rapid Nutrition Assessment 7 Nutrition Survey Guidelines 8 Bari Rapid Nutrition Assessment 8 Child Dietary Diversity And Milk Feeding Frequencies 9 Effects Of Drought In M & L Shabelle Regions 10 Mogadishu: Findings from a nutrition survey conducted in Mogadishu in April 2011, in which 902 children aged 6-59 months were assessed, indicate a Critical nutrition situation, with a global acute malnutrition (GAM), (WHZ scores <-2 or oedema) of 15.2% ( ) and a severe acute malnutrition (SAM) (WHZ score <-3 or oedema) rate of 1.7% ( ). The 90 days retrospective crude and under five death rates reported are 1.81 ( ), and 2.2 ( ), indicating a Serious situation according to WHO classification. The main causes of death reported through respondent s recall were through accidents/physical injuries, diarrhoea and other illnesses. The nutrition information from health facility reports shows a high and stable proportion of malnourished children (>20%). (Figure 1). According to the April 2011 FSNAU Market Data Update, local cereal prices increased significantly (26-35%) when compared to the previous month. However, imported food commodity prices remained stable in April. As poor households are mainly dependent on locally produced foods, the high price increases their limited access, and is a risk factor to the Critical nutrition situation. Ongoing response activities which also mitigated the nutrition situation include 4 stabilization centers run by ACF (2), SOS (1), BPHCC (1), 33 sites with targeted supplementary feeding programs (TSFP), 51 sites with outpatient therapeutic care (OTP), and one blanket supplementary feeding program site. These are undertaken by UNICEF and WFP in collaboration with Oxfam Novib/Saccid, ACF, Concern Worldwide, with local non-governmental organizations namely, Sorrdo, Jumbo, Muslim Aid, Hacda, SEA, Zam zam, SRCS, SOS, Dawa, and Wardi. (Source: IASC Nutrition Cluster 3W Matrix Who does What Where, Feb 11). The FSNAU is managed by FAO and funded by the EC, SIDA, UKAID, DFID, ITALIAN COOPERATION, SDC, UNICEF, UNHCR, CHF and HRF

2 Lower and Middle Shabelle Regions: Results from two rapid mid upper arm circumference (MUAC) assessments conducted in April 2011 in which 2,200 children from 20 accessible villages in Lower Shabelle agro-pastoral and riverine populations, indicate 21.7% ( ), and 19.1% ( ) respectively, of the assessed children as acutely malnourished ( MUAC <12.5 cm or oedema). In the Middle Shabelle region, rapid MUAC assessment findings in the agro-pastoral, and riverine livelihood zones in which 2,200 children were assessed indicates 25.3% ( ) and 21.6% ( ) respectively of the assessed children as acutely malnourished children. The nutrition information from health facilities in Shabelle agro-pastoral areas shows a high proportion of acutely malnourished children (>20%), with a decreasing trend since January 2011 (Figure 2). The number of admissions of acutely malnourished children into selective feeding programs shows an increasing trend since February 2011 ( ). Integrated analysis of these findings indicates a likely Very Critical nutrition situation in the assessed villages, and reflects a deterioration from the Deyr 2010/11 nutrition phase. A detailed nutrition survey is scheduled for June According to the FSNAU/FEWSNET Market Update, April 2011, maize prices are 73% higher than a year ago. However, cattle prices declined in most markets whereas milk, cereal and diesel prices escalated at varying levels. Stability in wage rates and rising cereal prices over the month of April 2011 reduced the terms of trade by about half of its levels a year ago. This negatively impacted on food access during this period, thereby aggravating the nutrition situation. Gu rains have been reported in Shabelle regions and are likely to mitigate water and pasture stress. (Source, FSNAU/ FEWSNET Climate Data Update April 2011). Ongoing response activities that mitigated the nutrition situation in Lower Shabelle include: one stabilization center (SC) managed by MSF-CH, and three managed by COSV, with support from UNICEF. Additionally, there are 51 OTP sites, 10 TSFP and 1 BSNP, run by UNICEF and WFP in collaboration with Sorrdo, Jumbo, Concern Worldwide, Muslim Aid, SRCS and SWISSO-Kalmo. In Middle Shabelle, there are two stabilization centers run by Saccid (Adale) and Intersos (Jowhar), 36 OTPs managed by Intersos, Saccid, Mercy USA and Muslim Aid, and eight TFSP sites. (Source: IASC Nutrition Cluster 3W Matrix Who does What Where, Feb 11). Middle and Lower Juba Regions: A rapid MUAC assessment conducted in February 2011 among 3,432 children from 31 villages, indicated a likely sustained Very Critical nutrition situation in the assessed pastoral and agro-pastoral populations. The proportions of the acutely malnourished children, with MUAC < 12.5 cm or oedema, is 15.0% and 15.6% respectively and 3.1% and 3.6% being severely malnourished (MUAC <11.5 or Oedema) respectively. However the riverine livelihood populations indicates a likely Critical nutrition situation, with the proportion of children acutely malnourished (MUAC <12.5 cm or Oedema) as 14.6% and severely malnourished as 3.2% (MUAC <11.5 cm or oedema). This shows a slight improvement 1 from the Very Critical nutrition situation reported 1A tally sheet was used during data collection. Hence the confidence intervals are unavailable Pitting of bilateral oedema - Juba riverine, FSNAU, Feb 2011 in the Deyr 10/11 season, mostly attributable to off-season crop production and milk availability due to in-migration of livestock health interventions. Health facility reports show a high (>20%) but decreasing trend of acutely malnourished pastoral children since January 2011 (Figure 3 and 4). In the agro-pastoral livelihood zone, the trend is high (>20%) but stable, while in the riverine, it is high (>20%) and increasing. Data from selective feeding programs indicate a high (104 in February, 156 in March and 182 in April) and increasing trend of admissions of acutely malnourished children. An integrated analysis of this findings indicates a likely Very Critical situation across the three livelihoods, sustained since the Deyr 10/11. Prices of most monitored commodities remained generally stable in the past one month except for maize, charcoal and firewood, which accelerated from their March 2011 levels. The marginal decline in casual labor wage rate and increased maize price have dropped terms of trade between labor and maize by 15 and 68 percent from March 11 and April 10 respectively, limiting food access. Ongoing response activities which have also mitigated the nutrition situation in Lower Juba, include 2 stabilization centers in Kismayo by Muslim Aid, 6 OTP and 81 TSFP sites implemented by UNICEF in collaboration with SAF, AFREC APD, SRCS, DIAL, Muslim Aid, WRRS and Sordes. In Middle Juba, there is one stabilization center, in Marere, run by MSF-H, 4 OTP sites and 8 sites for targeted supplementary feeding program sites managed by APD, Zam zam, and SRCS. (Source: IASC Nutrition Cluster 3W Matrix Who does What Where, Feb 11). For comments related to response activities, please contact lmatunga@unicef.org or muli@un.org. Bari Region Sool Plateau Livelihood Zone: Field reports by a local agency, followed by a rapid MUAC assessment of 133 children aged 6-59 months from three villages of Bari region indicate a worrying nutrition situation with 19.5%, with a MUAC <12.5cm or oedema and 5.3% severely malnourished (MUAC <11.5 or oedema). Details are provided in this update, and a survey scheduled for June Health facility data from the assessed area shows high (>15%) and fluctuating trend of acutely malnourished children being screened. Preliminary integrated analysis of the situation in Sool is therefore likely Very Critical. 2

3 FSNAU Nutrition Survey Plans for the Gu 2011 Season FSNAU, in collaboration with partners is scheduled to conduct 34 nutrition surveys, based on the standard two stage cluster sampling methodology, during April and July The target populations are eight internally displaced persons settlements, and 26 rural livelihoods both in the north and south central Somalia. Currently, seven surveys are ongoing in Somaliland (Hargeisa, Burao, Berbera IDPs), and Puntland (Bossaso, Qardho, Garowe and Galkayo IDPs), in partnership with the Ministries of Health. In addition FSNAU, is scheduled to conduct nutrition and household food security surveys in at least seven urban centers. Mogadishu survey was undertaken in April 2011, while studies are scheduled in Hargeisa, Boroma, Berbera, Bossaso, Garowe and Galkayo, to estimate both the nutrition and household food security situation in these urban population groups. The remainder of the surveys are scheduled as per the plan in Table 1. National Immunization Days (NIDs) Somalia marked the 4 th anniversary of being polio-free on 25 th March 2011, after joint polio immunization campaigns spearheaded by health authorities at national and local levels, in collaboration with WHO, UNICEF, other polio eradication partners and the Somali communities. To maintain high immunity of children under the age of five, two rounds of National Immunization Days (NIDs) were planned for this year, the first round in the week of th March For more information, visit the Somalia Health Cluster on SPECIAL STUDIES Knowledge, Attitudes and Practices (KAP) study on Fish Consumption FSNAU is currently undertaking a KAP study on fish consumption in Somalia. The main purpose of the study is to gain a full understanding on the common practices, attitudes and beliefs on fish consumption in Somalia, and the level of knowledge the community has on the health and nutritive benefits of fish consumption. This information will then be used as a basis for developing relevant communication strategies promoting the consumption of fish. In addition the information will be used to supplement baseline fisheries livelihood information that is currently being collected in Somalia, in order to design appropriate interventions in the fisheries sector. The specific study objectives are: 1. To determine the main types and forms of fish consumed by communities in Somalia. 2. To determine the main types and forms of fish consumed by various groups (e.g. gender, age-groups, socioeconomic groups) in Somalia. 3. To identify the main factors affecting or influencing fish consumption among the communities. 4. To gain understanding on the cultural beliefs, practices and attitudes regarding fish consumption in Somalia. 5. To determine the preferred/popular storage, preparation and cooking methods used in preparing fish. Table 1: Summary of Nutrition Surveys Nutrition Survey Planned Period Status 1 Togdheer Pastoral June-July Planned 2 West Golis/Guban Pastoral June-July Planned 3 Agro-pastoralists-NW & Togdheer June-July Planned 4 Sool Plateau June-July Planned 5 Hawd of Sool/Togd/Galbeed June-July Planned 6 East Golis/Gebbi/Kakar Pastoral June-July Planned 7 Nugal Valley Pastoral June-July Planned 8 Coastal Deeh - NE July 2011 Planned 9 Coastal Deeh - Central July 2011 Planned 10 Hawd Livelihood July 2011 Planned 11 Addun Livelihood July 2011 Planned 12 Cowpea - Central July 2011 Planned 13 NW Urban (Hargeisa, Berbera, Boroma) June-July Planned NE urban (Bossaso, Garowe, Galkayo) June-July Planned NW IDPs (Hargeisa, Burao, Berbera) May 2011 On-going 22 NE IDPs (Garowe, Galkayo, Bossaso) May 2011 On-going 25 Hiran Pastoral June-July Planned 26 Hiran Riverine June-July Planned 27 Hiran Agropastoral June-July Planned 28 Shabelle riverine May-June Planned 29 Shabelle Agropastoral May-June Planned 30 Shabele IDP May-June Planned 31 Mogadishu City April Completed 32 Bakool Pastoral June-July Planned 33 Bakool Agropastoral June-July Planned 34 Bay Agropastoral June-July Planned 35 Gedo Riverine June-July Planned 36 Gedo Agropastoral June-July Planned 37 Gedo Pastoral June-July Planned 38 Juba Riverine June-July Planned 39 Juba Agropastoral June-July Planned 40 Juba Pastoral June-July Planned Multiple Indicator Cluster Survey (MICS) - UNICEF The UNICEF led multiple indicator cluster survey (MICS) is currently ongoing in Somalia. In April-May 2011, the study was undertaken in Puntland, while plans are underway for Somaliland from June-July The objectives are: 1. To provide up-to-date information on the situation of women and children in Somalia 2. To furnish data needed for progress towards MDGs and other internationally agreed goals. 3. To contribute to improvements of data and monitoring systems in Somalia. Infant and Young Child Feeding (IYCF) A meta-analysis of data from 22 nutrition assessments conducted in 2010 by FSNAU, on two indicators measuring infant and young child feeding: child dietary diversity and number of milk feeds, among children aged 6-24 months in Somalia, shows that child dietary diversity and the level of milk consumption are key determinants of both wasting and stunting indices. This highlights the necessity to continue collection and analysis of the data as proxy indicators of the nutrition situation. A detailed report is presented within this publication. Study findings will be shared on completion of the study. 3

4 FSNAU Monthly Nutrition Update March - April 2011 Mogadishu Nutrition Survey: Findings show Critical Nutrition Situation in the conflict-stricken Somalia Capital Figure 1: HIS Acute Malnutrition Trends in Mogadishu MCHs Mogadishu, the capital city of Somalia, has remained in a state of civil unrest and the epicentre of conflict, since January This conflict has had an impact on the general health and well being of the population in the town. The last nutrition survey in the town was conducted in 2004 and reported a GAM and SAM rate of 13.8% ( ) and 3.2% ( ) respectively, while the under five and crude mortality rates reported were 0.7 per 10,000/day, and 0.5 per 10,000/day. Due to the high level of insecurity experienced in the town, it has been very difficult for FSNAU and partners to conduct regular surveys and in-depth nutrition surveillance activities. Consequently the nutrition information collected from the area has been mainly through rapid MUAC nutrition assessments. Between 18th 26th April 2011, FSNAU/UNICEF, ACF with partners namely, WFP, SAACID,SORDO, MURDO, TRG, SRCS, CBO (Hamarweyne, Hamarjabjab and Waaberi) and ZAM ZAM with support from local authorities, conducted a SMART nutrition assessment in six districts1 in Mogadishu. Using a two-stage probability proportionate to size (PPS) sampling methodology, a total of 902 children aged 6-59 months were assessed from 502 households, while 737 households were assessed for mortality from a total of 35 clusters in the six districts. The survey collected anthropometric, morbidity and mortality data. Proportion of malnourished children per. Mov. Avg.(2010) 2 per. Mov. Avg.(2011) Jun May Apr Mar Feb Jan 0.0 MOGADISHU Results from the nutrition survey indicate a Critical nutrition situation in Mogadishu town, with a global acute malnutrition (WHZ scores <-2 or oedema) of 15.2% ( ) and a severe acute malnutrition rate of 1.7% ( ). The 90 days Mother with child during the Mogadishu nutrition survey, retrospective crude and under five death rates reported are FSNAU April ( ), and 2.2 ( ), both rates being above the emergency threshold according to WHO classification and indicating a Serious situation. The main causes of death reported through respondent s recall were accidents/physical injuries, diarrhoea and other illnesses2. The FSNAU Post Deyr 10/11 integrated nutrition analysis, generally classified the nutrition situation of the populations in Mogadishu town as likely Very Critical. Data from rapid MUAC assessments conducted in December 2010 reported a global acute malnutrition (MUAC <12.5 or oedema) rate of >15%; in addition data from the health facilities3 in the area reported a high and stable trend in the number of acutely malnourished children. The current data from the health facilities in the area from the month of January to April 2011 indicates high and stable numbers of acutely malnourished children (Figure 1). High morbidity rates in a population predispose the population to malnutrition; in Mogadishu, a high proportion of the children assessed in the survey had reportedly fallen ill two weeks prior to the survey, the total with reported rate of morbidity reported is 37.7%. The proportion of children reported to have suffered from diarrhoea in the 2 weeks prior to the assessment is 11.8%, while those reportedly suffering from pneumonia and measles is 12.6% and 1.9% respectively. The measles immunization and vitamin A supplementation status for the assessed children in the 6 months prior to the assessment is well below the recommended Sphere standards (24.5% and 70.5% respectively), increasing the children s susceptibility to disease (Table 2). Qualitative data collected during the survey indicates some of the main factors affecting the nutritional status of the population as: increased incidences of diarrhoea and measles, reduced purchasing power of households, less income opportunity due to the closure of the Bakara market, households from the drought- affected surrounding rural areas have come to Mogadishu looking for opportunities, population displacements due to conflict in parts of the town, very limited humanitarian intervention space, high cereal prices for both local and imported commodities, in addition to the disruption of regional markets due to high taxation from the local authorities. Currently there are selective feeding programmes being undertaken by several partners in the town (see page 1). ACF is conducting feeding programmes in 4 districts, data from their programmes indicate an increasing number of acutely malnourished children being admitted to the programmes. 1 Wadajir, Dharkenley, Hamarweyne, Hamarjabjab, Waaberi and Hodan 2 Diabetes, heart failure, TB, whooping cough, hypertension, etc 3 Medina, Waberi, Hamarweyne and Hamarjabjab 4

5 Table 2: Summary of Results for Mogadishu Nutrition Survey (N= 902) Indicator N % (CI) Total number of Clusters assessed 35 Total number of Households assessed for children 502 Total number of Households assessed for mortality 737 Total number of Children assessed Child Malnutrition Global Acute Malnutrition (WHO 2006) Severe Acute Malnutrition (WHO 2006) Oedema Global Acute Malnutrition (NCHS) Severe Acute Malnutrition (NCHS) Global Acute Malnutrition (WHM<80% or oedema - NCHS) Severe Acute Malnutrition (WHM<70% or oedema - NCHS) Severe to Moderate Acute Malnutrition by MUAC (<12.5 cm or oedema) Severe Acute Malnutrition by MUAC (<11.5 cm or oedema) Proportion of children Stunted (HAZ<-2) Proportion of children Underweight (WAZ<-2) Child Morbidity Children reported ill in the previous 2 weeks Children reported with diarrhoea in 2 weeks prior to assessment Children reported with ARI within two weeks prior to assessment Children reported with febrile illness in 2 weeks prior to assessment Children reported with suspected measles within one month prior to assessment Child Immunization status Children immunized against measles By Recall By Card Children reported to have received vitamin A supplementation in last 6 months Mortality Under 5 Death Rate (U5DR) as deaths/10,000/ day* Crude Death Rate (CDR) as deaths/10,000/ day Table 3: Quality checks for survey data Location Criteria Missing/ Overall sex Flagged data ratio Overall age Dig Preference distribution score-weight Dig Preference score-height SD WHZ Skewness WHZ Kurtosis WHZ Poisson Distribution Mogadishu Nutrition Survey Category Good Acceptable Poor Good Acceptable Acceptable Good Good Unacceptable Score

6 WFP is conducting wet feeding activities, In addition UNICEF through OXFAM/SAAID and other partners 1 are providing feeding and health programmes to the population. Although these efforts are assisting in mitigating the situation, it is not sufficient, scaling up of health and nutrition related programmes are essential given the effects of the persistent conflict in the town and its resultant negative impact on the food security, health and nutritional well being of the population. There are also a large number of internally displaced populations living in the area, these populations have integrated with the local residents and face the same challenges of the urban poor. Overall, the nutrition situation in Mogadishu is Critical, and the population remains highly vulnerable due to the persistent conflict in the town which has a direct impact on household income, food security, health and nutritional well being of the population. Poor access to health facilities in the town is also an instigating factor. Disease outbreaks such as measles and acute watery diarrhoea have a direct impact on the health and nutritional status of the children. Chronic underlying factors such as poor child care and feeding practices, inadequate sanitation facilities and lack of access to safe drinking water will remain as long term challenges to the health and nutrition well- being of the population. It is therefore imperative to closely monitor the well being of the population, and to continue interventions targeting the underlying causes of food insecurity and disease in the region. SHABELLE RAPID NUTRITION ASSESSMENT Between 31 st March and 7 th April 2011, FSNAU conducted a rapid nutrition assessment in 40 purposively selected villages (based on access) in Middle and Lower Shabelle regions. This was a follow up assessment to determine the nutrition situation in the area, following the Deyr 10/11 integrated nutrition assessment and analysis which was not conclusive due to data quality concerns. Using Mid upper Arm Circumference (MUAC) measurements, a total of 4,395 children, from the entire Shabelle region were assessed. From each livelihood zone in Middle and Lower Shabelle, 10 villages were selected and 110 children (aged 6-59 months) assessed per site. Figure 2: HIS Acute Malnutrition Trends in Shabelle Findings indicate that the proportion of children at risk of acute Agropastoral MCHs (Source: COSV/MSF-S) malnutrition, with MUAC <12.5 cm or oedema, as 21.7% ( ) and 19.1% ( ) in the Lower Shabelle agro-pastoral and riverine populations respectively. In the Middle Shabelle region, the proportion is 25.3% ( ) and 21.6% ( ) among the agro-pastoral and riverine populations respectively. No cases of oedema were reported among the assessed agropastoral populations, however, 10 cases (0.9%) were reported among the assessed in Lower Shabelle riverine population and one (0.1%) in the Middle Shabelle riverine population ( See table per. Mov. Avg.(2011) 2 per. Mov. Avg.(2010) for a summary of the results). The nutrition information from Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec health facility reports shows a high and decreasing proportion of malnourished children (>20%). (Figure 2). These results indicate a likely Very Critical nutrition situation in the assessed population groups, a likely deterioration from the previous nutrition situation of Deyr 10/11. The likely Very Critical nutrition situation is mainly attributed to the impact of limited food access including reduced milk consumption and poor dietary diversity. In addition, information from health facility data indicates high cases of morbidity with measles, acute watery diarrhea (AWD) and whooping cough. These factors combined with the chronic issues affecting malnutrition such as poor child care and feeding practices and lack of adequate and appropriate access to safe water, health and sanitation facilities further aggravate the poor nutrition situation. According to the April 2011 FSNAU Food Security and Nutrition Bulletin, the water situation in the area is critical, with several boreholes and shallow wells drying up, and extreme overcrowding at the water points. The agro-pastoral livelihoods are the most affected by the drought in the region, they are losing livestock either through mortality or sales at lower prices to purchase food. Table 4: Summary of Rapid Assessment Findings in Lower and Middle Shabelle regions Agro-pastoral N= sites 238 (21.7%) Lower Shabelle Riverine N= sites 210 (19.1%) Agro-pastoral N= sites 278 (25.3%) Middle Shabelle Riverine N= sites 237 (21.6%) Proportion of assessed children with MUAC <12.5 cm or oedema CI: CI: CI: CI: Proportion of assessed children with MUAC < (3.3%) 61 (5.5%) 106 (9.6%) 125 (11.4%) cm or oedema CI: CI: CI: CI: Oedema 0 (0.0%) 10 (0.9%) 0 (0.0%) 1 (0.1%) Proportion of malnourished children 1 SORDO, HACAA,ZAM ZAM,SEA,DAWA 6

7 In addition to MUAC, a high proportion of the assessed children (about 25-30%) in Middle Shabelle riverine and agro-pastoral, and 40-47% in Lower Shabelle were reported to have suffered from an infection in the preceding two weeks to the assessment. The reported causes of morbidity in Middle Shabelle livelihoods were fever (about 10-12% ), and diarrhoea (9-12%) in the riverine and agro-pastoral livelihood zones. In the Lower Shabelle regions, morbidity was mainly attributed to diarrhoea (24-31%), fever (10-11% and suspected measles, (10-9%) in the agro-pastoral and riverine livelihoods respectively. Interventions geared towards improved access to food, health care services, safe drinking water and sanitation services remain a priority to prevent further deterioration of the nutrition situation in Shabelle region. This needs to be combined with rehabilitation of acutely malnourished children in the region. FSNAU will continue to monitor the situation in the region. Juba Rapid Nutrition assessment Between 21 st to 28 th of February 2011 FSNAU conducted rapid MUAC assessments in the three livelihoods of Middle and Lower Juba regions, namely pastoral, agro-pastoral and riverine. This was a follow up assessment to monitor the nutrition situation in the area, from the Deyr 10/11 integrated nutrition analysis, which indicated a Very Critical nutrition situation among the populations groups. A total of 3,432 children, (1,214 from the riverine, 1,102 from the agro-pastoral and 1,116 from pastoral livelihood) aged 6 to 59 were assessed using Mid upper Arm Circumference (MUAC) measurement. Tally sheets were used in recording of data (rather than recording of actual measurements) thereby limiting calculation of confidence intervals. Results of the rapid MUAC assessments points to Very Critical situation in the populations of the pastoral and agro-pastoral livelihoods of Juba regions. The proportion of acutely malnourished children with MUAC < 12.5 cm or oedema among the pastoral and agro-pastoral population was 15.0% and 15.6% respectively, with 3.1% and 3.6% respectively being severely malnourished (MUAC <11.5 or oedema). Among the riverine population, the proportion of acutely malnourished (MUAC <12.5 cm or oedema) children was 14.6%, including 3.2% severely malnourished children (MUAC <11.5 cm or oedema) (Table 5). The nutrition information from health facility reports shows a high and stable proportion of acuteley malnourished children (>20%) in the agro-pastoralists, but high and decreasing trend in the pastoralists (Figures 3 and 4). Integrated analysis of findings indicates a Very Critical nutrition situation, though with slight improvements in the riverine since the Deyr 10/11 assessment. (see table 5 for a summary of the results). Figure 3: HIS Acute Malnutrition trends in Juba Agropastoral Figure: 4 HIS Acute Malnutrition trends in Juba Pastoral MCHs MCHs Proportion of malnourished children per. Mov. Avg.(2010) 2 per. Mov. Avg.(2011) Proportion of malnourished children per. Mov. Avg.(2010) 2 per. Mov. Avg.(2011) 0.0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Overall the results show a likely sustained Very Critical nutrition situation among the populations in the three livelihoods due to the impact of Deyr 10/11 rainfall failure and followed by the abnormally extended dry Jilaal (January-March) season. The sustained worrying nutrition situation is also attributed to the reduced access to cattle and camel milk due to poor livestock body condition, following the impact of drought. In addition, limited food access and reduced income among the pastoral and agro-pastoral population remains a challenge. Furthermore, the chronic underlying causes of malnutrition which include inadequate health services, high morbidity, poor infant and young child feeding practices, lack of access to safe drinking water and poor dietary persist in the area aggravated the poor nutrition situation. The slight improvement noted among the riverine population is likely attributed to the availability of the off-season crop, fruits and vegetable from the riverine communities and the mutual benefit from milk access from cattle that have in-migrated to the riverbanks for fodder and water. According to the FSNAU quarterly brief April, 2011, the off-season harvest, mainly maize, sesame and cowpea, was harvested in the riverine livelihood of Juba regions, from the desheks (depression areas) and pump irrigated farms in Jammame, Jilib, Buale and Sakow districts. The current off-season harvest in desheks is a result of natural floods in May 2010, which recharged most of the desheks thereby bringing opportunities for two rounds of off-season crop production (Sep 10 and Mar 11). In addition to that there is an income from the sale of fodder and TFC and OTP intervention programs targeting the severely malnourished children at the riverine areas. Table 5: Summary of Rapid Assessment Findings in Juba regions Riverine (N= 1214; 11 sites) Agro-pastoral (N=1102; 10 sites) Pastoral (N= 1116; 10 sites) Proportion of assessed children with MUAC <12.5 cm or oedema 178 (14.6%) 173 (15.6%) 168 (15.0%) Proportion of assessed children with MUAC <11.5 cm or oedema 3.2% 35 (3.1%) 40 (3.6%) Oedema 9 (0.7%) 5 (0.4%) 2 (0.2%) 7

8 Nutrition Survey Guidelines and Data Management Workshop Based on Epi-info-Ena In line with the FSNAU and nutrition cluster objective to enhance capacity in early warning of government institutions and partners, FSNAU conducted a 3 day training workshop for the key partner members of the Somalia Nutrition Cluster in Nairobi from 16 th to 18 th March A total of 17 participants, consisting of 2 UN, 7 international NGOs and 8 local NGOs took part in the training. The overall aim of the workshop was to empower the partners to conduct nutrition surveillance activities using the standardized guidelines endorsed by the cluster members. The training covered different parts of the nutrition survey process including survey planning, data collection, entry, processing and analysis. Other aspects emphasized in the workshop included sampling techniques, quality control of data, anthropometric measurements and age determination. The participants were also provided with practical sessions on data management and analysis using the EPI Info and ENA software, including how to create data entry templates, data cleaning and processing, and computing indices. Different methodologies were used during the training comprising of: power point presentations, demonstrations, group discussions and questions and answers sessions. Participants self evaluation pre and post training indicated significant improvement in their understanding of the key areas covered. Prior to the training most participants indicated having a limited understanding of certain survey methodologies and data management, however they had fair knowledge in areas of survey planning, data interpretation and presentation. The post training evaluation indicated that the participants improved their knowledge on all the areas covered. RAPID ASSESSMENT IN AFFECTED AREAS IN SOOL PLATEAU, BARI REGION On 26 th April 2011, FSNAU received a worrying report from a local NGO in Puntland, claiming increased human and animal mortality arising from food insecurity and disease in Baq baq and surrounding villages. In an effort to ascertain the situation, FSNAU conducted an exhaustive rapid Mid Upper Arm Circumference (MUAC) assessment with focus group discussions in the affected villages on 3 rd and 4 th May A total of 133 children (aged 6-59 months), from the three affected villages of Baqbaq, Usuguse, and Elmadobe in Sool Plateau of Bari Region were assessed. Findings indicate that the proportion of acutely malnourished children with MUAC < 12.5 cm or oedema is 19.5%, with 5.3% severely malnourished (MUAC <11.5 or oedema), and 3 (2.3%) cases of oedema were reported. The nutrition information from health facility reports shows a high and fluctuating proportion of acutely malnourished children (>15%). (Figure 5). Though not representative of the livelihood, these results indicate a likely Very Critical nutrition situation in the assessed affected population, a likely deterioration from the previous nutrition situation. The likely Very Critical nutrition situation is mainly attributed to the negative effects of the drought from previous poor rains, the reason which has resulted in limited access to food, poor dietary diversity and reduced milk consumption. In addition, qualitative information from the area indicates livestock deaths, increased destitution, and reduced number of meals consumed. These factors combined with the chronic issues affecting malnutrition such as lack of adequate and appropriate access to safe water. At present, water access is affected by high prices with the cost of one drum of water ranging from SoSh (US$ ) compared to SoSh 20,000-30,000 at the same period last year; and constrained access to basic services in the area - only Usgure village has a recently opened health post. The other villagers have to go through a difficult terrain to reach Allula/Kandala or Qardho further aggravates the poor nutrition situation Interventions geared towards improved access to food, health care services, safe drinking water and sanitation services remain a priority to prevent further deterioration of the nutrition situation in Baqbaq, Usuguse and Elmadobe in Bari region. This needs to be combined with rehabilitation of acutely malnourished children in the area. FSNAU will continue to monitor the situation in the entire livelihood. Increased livestock mortality in Sool plateau, Bari Region, FSNAU April 2011 Figure 5: HIS Acute Malnutrition Trends in Sool Plateau of Bari Region Proportion malnourished (%) per. Mov. Avg.(2010) 2 per. Mov. Avg.(2011) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 8

9 The Association between Child Dietary Diversity and Milk Feeding Frequencies with Acute Malnutrition in Somalia Introduction The impact of infant and young child feeding (IYCF) practices on the nutrition and health status and the extent to which an individual or population is meeting the recommended feeding standards can be clearly demonstrated if the appropriate IYCF indicators are used in assessments. In view of this, FSNAU has, over the years, been refining the methods of data collection and analysis of IYCF data. In 2010, FSNAU modified the nutrition assessment questionnaire for comprehensive nutrition surveys to include child dietary diversity and milk feeding frequencies indicators. This article presents the findings of a meta data analysis of the two new IYCF indicators from a total of twenty two assessments using the Population Proportionate to size sampling methodology conducted during the Gu (April-June) and Deyr (October-December) seasons of 2010 by FSNAU and partners. Data analysis A total of 3,883 children aged 6-24 months were identified from the database, of whom 15.2% were acutely malnourished (WHZ 4 <-2 or oedema) while 23.4% were stunted (HAZ 5 <-2). A median of 2.5 food groups out of a list of eight 6 food groups and a median milk feeding frequencies of 3.0 (a range of 0-5 times) was consumed by the assessed children. When analyzed against the recommended minimum feeding threshold of four food groups and two milk feeding frequencies, majority (81.7%), of the children consumed milk at least two times in a day as recommended. On the other hand, only 15.9% of the children were fed on a diet that comprised of the recommended four or more food groups. This shows a high milk consumption but poor dietary diversity. Table 6 gives a summary of the findings. Table 6. Summary of Findings of IYCF Data Analysis (2010) Variable N % Total children assessed Proportion Acutely Malnourished (WHZ<-2 or 591 oedema) 15.2 Mean weight-for-height z-score ±1.32 Proportion stunted Mean weight-for-height z-score 1.038±1.26 Proportion consuming four food groups in 617 a day 15.9 Median food groups consumed 2.5 Further statistical analysis shows that child dietary diversity Proportion consuming milk for two times in 3175 a day 81.7 (number of food groups consumed) is significantly associated with both WHZ-scores and HAZ-scores, where consumption of a Median food groups consumed 3.0 higher number of food groups is associated with improved WHZ and HAZ scores (p<0.01). Even after controlling for breastfeeding status, the association remained significant, implying that besides breast milk, children in this age group need to consume many food groups to prevent both wasting and stunting. Similarly, increased frequency of milk consumption is associated with a corresponding increase in WHZ score (p<0.01), (Table 6). The strength of the association (τ) increases when breastfeeding status is controlled, showing the importance of breastfeeding on the nutrition status of the children. Further, the results show the important nutritional role played by milk among children in the Somali population. However, milk feeding frequency is not significantly associated with HAZ (p=0.06), but when the breastfeeding status is controlled, a significant but negative association is observed (p=0.025). This relationship requires further investigation but may suggest the presence of other confounding factors not accounted for in the analysis, such as quality of the milk feeds, illness, or frequency of breastfeeding. 4 Weight for Height Z scores 5 Height for Age Z scores 6 Cereals, Milk,Meat/fish, Legumes, White roots/tubers, Yellow orange fleshed tubers/vitamin A rich vegetables, Vitamin A rich fruits, other vegetables and fruits Table 7: Associations between Child dietary diversity and Milk feeding frequency with malnutrition Variables Nutrition Indicators Correlation (Kendall s tau_b) p Value Food groups WHZ-scores * HAZ-scores * Milk feeding frequency WHZ-scores * HAZ-scores Dietary Diversity Four food groups < Four food groups Dietary Diversity Four food groups < Four food groups Milk frequency for non breastfed children Two times < Two times Milk frequency for non breastfed children Two times < Two times *Indicates significant association Proportion malnourished RR (95% CI) p Value Proportion Wasted (WHZ<-2) 108 (17.5%) ( (14.8%) Proportion Stunted (HAZ<-2) 155 (25.1%) ( ) 756 (23.1%) Proportion Wasted (WHZ<-2) 225 (14.5%) ( ) 125 (17.7%) Proportion Stunted (HAZ<-2) 310 (20%) 42 (13.2%) 1.5 ( ) 0.004* 9

10 On the contrary, analysis of the association between the proportion of wasted (WHZ<-2 scores or oedema) and stunted (HAZ<-2 scores) children, with the proportion of those meeting the recommended thresholds of at least two milk feedings and a minimum of four food groups in a day, shows mixed results (Table 7). There is no statistically significant association between the proportion meeting the dietary diversity threshold both with global acute malnutrition (GAM) rate, and global stunted (p>0.05). However, there is significant association between the milk feeding frequency threshold with stunting (p<0.01), but not with wasting (p>0.05). The lack of association between these indicators when using categorical thresholds and the proportions of the wasted and stunted children may imply that these thresholds are not sensitive measures for the minimum required milk feeding frequencies and number of food groups for Somali population. In conclusion, the meta data analysis shows that the number of food groups, and frequency of milk consumption are key determinants of both WHZ and HAZ scores. It also justifies the need for continued collection and analysis of these important indicators of IYCF practices. The categorical thresholds for the required minimum number of food groups and milk feeding frequencies are not sensitive and may need to be reviewed to levels that are specific and sensitive to the Somali context. CASE STUDY: Effects of the Drought on Households in Middle & Lower Shabelle regions The population of the agro-pastoral districts namely Walanweyne and Qoryoley are among those severely affected by the drought in the region. The lack of adequate rainfall in the area resulted in below normal crop production last season and the abnormal out migration of livestock to the riverine areas in search of water and pasture; this increased the pressure for resources in the area. Households in the agro-pastoral area are reporting reduced livestock herd sizes, as a result of the drought, as is the case with Filay Adan. Adan Ali, Filay s father owned a large herd of over 100 cows, but that s no more. We are only left with two cows now, says Filay. Filay is currently living alone with her acutely malnourished son, her sisters and brothers have left the village to seek casual labour opportunities in the town. We have lost many animals and due to this we are not able to purchase food and get milk like we used to, water is also a big problem in the area, she says. Even the remaining two cows are just hand- fed and worse, there is a great fear of wide outbreak of diseases if it rains due to the high rate of livestock death even though the rains are still sporadic. There are many families in the same situation as Adan s family, experiencing the negative impact the drought has had on the livelihoods of populations in the area. The lack of safe clean water, reduced household income and consumption of milk are some the main factors affecting poor food access and poor nutrition situation in the area. Malnutrition rates indicate a likely Very Critical nutrition situation in the region. The situation is worsened by diminished access to humanitarian health and nutrition services provided by international organization this lead to limited access to basic health services and lack of medical supplies to the few existing MCH in the region. Immediate interventions that aim at rehabilitating malnourished children such as Filay s son in addition to interventions to mitigate the negative impact of the drought on the population s livelihood is imperative. MURDO a local NGO in the region has carried out some water trucking in the area, and has also set up a feeding programme for acutely malnourished children in Qoryoley hospital. Acutely malnourished mother and child in Shabelle, FSNAU April 2011 CAPACITY BUILDING As part of the capacity development strategy, FSNAU conducted four trainings in the months of March, April and May 2011 targeting different groups of nutrition professionals and partners. The aim of these workshops was to empower the participants to conduct nutrition assessments using the standard international nutrition guidelines (SMART), and to equip them with skills to conduct basic data analysis and interpretation. FSNAU Nutrition Cluster Partners: A three day partners training on nutrition assessments and data management based on SMART methodology was conducted in Nairobi, with 17 participants from agencies working in Somalia in March Academic Institutions: o University of Hargeisa: A two day data management training was provided to medical students at the University of Hargeisa in April o University of Nairobi: Msc. Nutrition Students in April 2011on Nutrition Surveillance and Information Systems o Kenyatta University: Msc. Nutrition Students in May 2011 Nutrition Surveillance and Information Systems Recent FSNAU publications: FSNAU Technical Series Report, Nutrition Situation Post Deyr 2010/11, February 2011 FSNAU Technical Series Report, Post Deyr 2010/11, March 2011 FSNAU/FEWSNET Market Data Update, April 2011 FSNAU/FEWSNET Climate Data Update, April 2011 FSNAU Food Security and Nutrition Brief, April 2011 NOTE: The above publications and releases are available on the FSNAU website: 10